Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Affinity Skilled Living And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Down syndrome, and a pressure ulcer was left in a tilt-in-space wheelchair overnight with a Posey belt in place without a physician order. Staff and video showed the resident was not turned, repositioned, or given incontinence care for more than seven hours, despite a care plan requiring care every 2 to 4 hours. The LPN and CNA gave conflicting accounts of the overnight care, and the DON stated the device was not a restraint while the Medical Director said an order should have been obtained.
A resident with impaired cognition, bowel and bladder incontinence, and wheelchair use developed a coccyx pressure ulcer and then a worsening right buttock pressure injury. The care plan required brief changes and turning/repositioning every 2-4 hours, but surveyors found no documented evidence that these services were provided. Overnight observations, video review, and staff interviews showed the resident was left in a wheelchair for long periods with a Posey restraint, while the CNA and LPN did not provide or verify the required care.
A resident with moderate cognitive impairment, ESBL infection, and multiple wounds had physician orders for contact precautions and enhanced barrier precautions, but the record did not include a comprehensive care plan with interventions for those precautions. Staff confirmed the infection control care plan should have been initiated and continued until the precautions were resolved.
A resident with an indwelling Foley catheter, severe cognitive impairment, and diagnoses including neurogenic bladder and urinary retention was observed multiple times with the catheter drainage bag uncovered and visible from the hallway, including while in bed and eating lunch. Staff stated CNAs were responsible for placing the privacy cover, but one CNA forgot, another did not notice it, and an LPN was unsure whether the cover was in place; the DON stated the bag should have been covered to maintain dignity.
An LPN left a resident’s electronic record open in the hallway during med pass, making the resident’s personal and medical information visible to others. The resident had diagnoses including a finger fracture, cerebral infarction, and COPD, and the DON stated the screen should be minimized or closed when not in use.
A resident with Down syndrome, severely impaired cognition, and a stage 3 pressure ulcer was observed strapped into a wheelchair with a Posey belt while sleeping and unable to release the device on request. The chart lacked a physician order, monitoring instructions, skin check instructions, and documented consent or notification of the resident representative. Staff gave inconsistent accounts of the device, with the DON calling it an assistive device and the Medical Director stating an order should have been obtained.
An unsecured oxygen E-cylinder was found free-standing beside a resident’s bed and not placed in a holder, rolling safety stand, or metal rack as required by facility policy. The resident had severe cognitive impairment, aphasia, and TBI, and staff interviews confirmed the tank should have been secured and that the charge nurse was unaware the resident was on oxygen therapy.
A resident with a chronic Foley catheter had the drainage bag stored above waist level on a wheelchair arm pad during observation. An LPN did not recognize the improper placement, and RN staff, the DON, and the Medical Director stated the bag should be kept below bladder level for proper drainage; they noted that placing it above that level can prevent drainage and cause urinary retention and infection.
Failure to document fluid intake for residents on fluid restriction. Two residents with physician-ordered 1200 mL/day limits, including one with HF and renal disease and one receiving dialysis, had incomplete or missing documentation of fluids consumed at meals and during med passes. Records reviewed showed meal intake entries were inconsistent or absent, and staff interviews confirmed that the total daily fluid intake was not being documented in numerical form.
An unlocked medication cart was observed unattended in a hallway while an LPN went into a resident’s room to give meds. The LPN stated they forgot to lock the cart, and the DON stated carts are expected to be locked after meds are removed and whenever they are not in use.
Unlabeled tube feeding formula and water bags were observed for a resident receiving enteral nutrition via gastrostomy tube. The resident had severe cognitive impairment and orders for Jevity 1.5 with scheduled start time and water flushes, but the feeding was running without the resident’s name, date, or time hung documented. An LPN and the DON stated the feeding should have been labeled with the resident’s name, date, time, and ordered details.
A facility failed to maintain its infection prevention and control program when a CNA provided incontinence care to a resident with ESBL wound infection and EBP orders while wearing two pairs of gloves, no gown, and a surgical mask below the mouth. Staff were confused about which roommate was on contact precautions, the precaution signage was posted on the wrong side of the door, and interviews showed inconsistent understanding of the green dot indicator and how to identify the resident on precautions.
The facility failed to maintain an effective infection control program, with staff not adhering to contact precautions for residents with communicable diseases. A resident with MRSA was transported without proper PPE, and another resident with heel wounds lacked timely contact precaution orders. Staff did not follow hand hygiene protocols, leading to deficiencies in infection control practices.
The facility failed to provide appropriate care for residents with surgical wounds, vascular ulcers, and gastronomy tubes. A resident with an abdominal surgical incision did not receive recommended wound care, another with a vascular ulcer had unauthorized treatment, and a third with a gastronomy tube lacked orders for flushing to maintain patency. These deficiencies highlight lapses in obtaining and documenting physician orders and coordinating care among staff.
A resident with severe cognitive impairment and pressure ulcers did not receive proper care due to an inaccurately set air mattress. Despite the resident's weight being 156.2 pounds, the mattress was set at 265 pounds, contrary to the care plan and facility policy. Staff failed to identify and correct this discrepancy, potentially affecting the resident's comfort and wound healing.
A resident with impaired cognition and on oxygen therapy had a Lysol aerosol spray on their bedside table, contrary to facility policy prohibiting aerosols due to flammability. Staff were aware but did not remove it, assuming it was allowed.
A resident with hypoglycemia was not administered IV fluids at the correct rate as per physician orders, receiving 50 cc/hour instead of the prescribed 70 cc/hour. This discrepancy was observed during a survey, revealing that nursing staff did not follow the updated order, potentially affecting the resident's treatment. The attending physician noted that this could delay resolving the hypoglycemic episode.
A survey found that insulin pens on a medication cart were not labeled with the date of opening, as required. This was observed for two residents' insulin pens, which lacked documentation of when they were first used. Staff interviews confirmed the oversight, highlighting the importance of discarding insulin pens 28 days after opening to maintain effectiveness.
A resident with a documented allergy to artificial sweeteners was served sugar-free pudding and reduced-calorie syrup containing these sweeteners, despite clear physician orders and facility policies. The error was attributed to a lack of knowledge and oversight by dietary staff, as confirmed by interviews with the Food Service Director and a dietary aide.
A resident's comprehensive assessment was not completed within the required timeframe, resulting in a deficiency. The resident, with conditions including Parkinson's and Schizophrenia, had their Annual MDS assessment delayed by 31 days. The facility's policy lacked specific timeframes, and staffing changes contributed to the oversight.
The facility failed to transmit MDS assessments to CMS within the required 14-day period for several residents. The delay was due to staffing changes and the end of a consulting firm's contract, leading to tracking difficulties. The MDS Director acknowledged the issue, while the Administrator and DON were unaware until the survey. The facility's policy lacked a specified timeframe for transmissions.
Failure to Provide Ordered Care and Unordered Restraint Use
Penalty
Summary
The facility failed to ensure that a resident with severely impaired cognition, Down syndrome, bipolar disorder, and a facility-acquired pressure ulcer received care and treatment in accordance with the resident’s comprehensive assessment and plan of care. The resident was dependent on two staff members for all aspects of care except eating, was always incontinent of bowel and bladder, and had a right buttock pressure ulcer. The care plan required turning and positioning every two to four hours, and brief checks and changes every two to four hours, but the resident was observed sleeping in a tilt-in-space wheelchair in a dark room while restrained with an upper body Posey belt without a physician’s order. On multiple observations, the resident remained seated upright in the wheelchair with the Posey belt in place, including while asleep. At one observation, the resident was awake and still in the wheelchair with the restraint in place. Review of surveillance video and staff interviews showed the resident was not turned, positioned, or provided care for more than seven hours. The assigned CNA stated the resident had been put in bed at 11:00 PM and later transferred to the wheelchair around 5:39 AM, but video showed the CNA did not enter the room for an extended period overnight. The medication nurse also reported seeing the resident asleep in the wheelchair during rounds and stated she did not know whether skin checks were needed with the device. The resident’s record showed a restraint alternative/restraint assessment for leaning forward and poor trunk control, but the form did not indicate whether the device was considered a restraint alternative or a restraint, and it did not show that the resident representative was notified. The physician’s orders included out of bed to a personal tilt-in-space wheelchair, but there was no documented order for the Posey belt restraint or related monitoring and skin check instructions. The DON stated the Posey device was not considered a restraint and did not require a physician’s order, while the Medical Director stated the nurse should have asked for an order for the Posey restraint. The wound nurse stated the resident’s pressure ulcer would deteriorate if left seated in the wheelchair all night without repositioning or incontinence care, and the Administrator stated the resident should not have been left in the wheelchair all night.
Failure to Provide Ordered Pressure Ulcer Prevention and Incontinence Care
Penalty
Summary
The facility failed to ensure that Resident #180 received pressure ulcer prevention and incontinence care consistent with the resident’s care plan. The resident was admitted with no pressure ulcers, had severely impaired memory, was dependent on staff for all activities of daily living, was incontinent of bowel and bladder, and used a wheelchair. The comprehensive care plan required skin checks every shift, brief changes every 2-4 hours and as needed, turning and positioning every 2-4 hours in bed, and repositioning in the wheelchair every 2 hours. Resident #180 developed a Stage 2 pressure ulcer on the coccyx, then a new unstageable pressure injury on the right buttock, which later became a Stage 3 pressure ulcer after debridement. The record included wound care notes, physician orders for topical treatment, and care plan updates documenting the pressure injuries and interventions. The report stated there was no documented evidence that the resident’s brief was checked and changed or that the resident was turned and positioned every 2-4 hours to offload pressure areas as required by the care plan. Survey observations and interviews showed the resident was repeatedly found sitting in a wheelchair at night, restrained with a Posey belt, and sleeping in a dark room. Video review showed the assigned CNA did not enter the resident’s room for several hours overnight, while the LPN observed the resident asleep in the wheelchair during overnight medication rounds. The CNA stated the resident was placed in bed at 11:00 PM and returned to the wheelchair around 5:39 AM, but the video and other observations did not support regular repositioning or incontinence care during the night. The DON and Administrator acknowledged that staff should have provided incontinence care and turning and positioning according to the plan of care, and the Medical Director stated that leaving the resident sitting in urine and feces without turning could cause pressure ulcers to develop or worsen.
Missing Infection Control Care Plan for Resident on Precautions
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident that included measurable objectives and timeframes to meet the resident’s medical and nursing needs identified in the comprehensive assessment. The deficiency was identified for Resident #12, who was admitted with diagnoses including acute embolism and thrombosis of the right lower extremity, a non-pressure chronic ulcer of the right foot, and extended spectrum beta lactamase infection of the skin and subcutaneous tissue. The Quarterly MDS documented a BIMS score of 11, indicating moderate cognitive impairment, and also documented one stage 3 pressure ulcer and three venous and arterial ulcers. The resident had a physician’s order for contact precautions due to ESBL infection in the coccyx wound and enhanced barrier precautions for wounds on both heels. During observation, contact precautions signage was placed outside the resident’s room and a green dot was noted next to the resident’s name indicating enhanced barrier precautions. Review of the medical record showed there was no comprehensive care plan with interventions to address the resident’s enhanced barrier precaution and contact precautions status. The Wound Care Nurse stated the infection control care plan should have been initiated and continued until the precautions were resolved, and the DON stated the infection control care plan should have been initiated to address the resident’s enhanced barrier precaution and contact precaution status.
Uncovered Foley Drainage Bag Visible From Hallway
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when the resident’s Foley catheter drainage bag was left uncovered and visible from the hallway on multiple observations. Resident #104 had diagnoses including neuromuscular dysfunction of the bladder, hemiplegia and hemiparesis, and urinary retention, and the quarterly MDS documented severe cognitive impairment with the resident rarely and never understood. The resident also had an indwelling catheter and a care plan that included keeping the Foley drainage bag from touching the floor, monitoring for decreased urinary output or leakage, and emptying the drainage bag every shift. During observations, the resident was seen in bed and later eating lunch in bed with the Foley drainage bag not covered by a privacy cover and visible from the hallway; on one occasion the bag was lying on the resident’s landing mat and was half-filled with yellow urine. Staff interviews indicated that CNAs were responsible for placing the privacy covers, but one CNA stated they forgot to do so because they were busy with other residents, and another CNA stated they did not notice the bag was uncovered. An LPN stated they were not sure whether a privacy cover was in place when administering medications, and the DON stated the Foley drainage bag should have been covered with a privacy bag and that staff were expected to care for residents in a dignified manner.
Resident Record Left Visible in Hallway
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when an LPN left Resident #27's electronic record open and visible in the hallway during a medication administration observation. The resident was admitted with diagnoses including a fracture of the finger in the right hand, cerebral infarction, and COPD, and the admission MDS documented that a Brief Interview for Mental Status was not completed because the resident was rarely or never understood. During the observation, the LPN entered the resident's room to administer medications and left the computer screen open with the resident's personal and medical information visible to other staff, residents, and visitors. When interviewed, the LPN stated the information should have been protected and the computer screen should have been closed, and the DON later stated the screen needed to be minimized or closed when not in use.
Unordered Posey Belt Used Without Monitoring or Consent
Penalty
Summary
The facility failed to ensure that Resident #180 was free from the use of a physical restraint unless needed for medical treatment, and failed to document a physician’s order, medical necessity, care instructions, monitoring, or ongoing re-evaluation for the restraint. Resident #180 had diagnoses including Down syndrome with severely impaired cognition, bipolar disorder, and a facility-acquired stage 3 pressure ulcer to the right buttock. The quarterly MDS documented the resident used a wheelchair, was dependent on two staff for all aspects of care, and had no restraints in or out of bed. The care plan documented that the resident required restraint alternative use because of inability to sit up independently and maintain proper body alignment, with interventions for quarterly review, evaluation, and informing the family representative of the benefits and risks of restraint use. A restraint alternative vs. restraint determination form documented that the resident tended to lean forward and had poor trunk control, but it did not indicate whether the device was a restraint alternative or a restraint, and it did not show that the resident representative was notified. The physician’s order only documented out of bed to a personal tilt-in-space wheelchair, and the record contained no order for the Posey belt, no monitoring instructions, and no skin check instructions. Observations showed the resident strapped to the wheelchair with a Posey belt while sitting on a Roho cushion, including while asleep in a dark room. During one observation, the resident could remove their hands from under the belt but could not release the belt on request. Nursing notes also documented repeated episodes of the resident crawling out of bed and into the hallway, after which the resident was redirected and placed in the wheelchair. Staff interviews showed inconsistent awareness of the restraint use: a CNA stated the resident had been placed in bed and later transferred to the wheelchair, while an LPN stated the resident was often sleeping in the wheelchair and did not know whether skin checks were needed. The DON stated the Posey device was considered an assistive device and not a restraint, while the Medical Director stated the nurse should have asked for an order for the Posey restraint.
Unsecured Oxygen Cylinder Found at Resident Bedside
Penalty
Summary
The facility did not ensure that each resident’s environment remained free of accident hazards when an unsecured oxygen E-cylinder tank was observed on the bedside of Resident #28. The tank was free-standing and not secured in a holder, rolling safety stand, or metal rack, despite the facility policy requiring oxygen cylinders to be stored and secured to prevent tipping, damage, contamination, or fire hazards. The report identified this as a deficiency under 10 NYCRR 415.12(h)(1). Resident #28 was admitted with diagnoses including shortness of breath, aphasia, and traumatic brain injury, and the quarterly MDS documented that the resident was rarely and never understood and had severe cognitive impairment. The resident did not have a physician’s order for oxygen, although the care plan included oxygen as needed. During observation, the resident was in bed sleeping while the unsecured E-cylinder was positioned on the left side of the bed. Staff interviews indicated that the tank should have been secured, and the charge nurse stated the resident should not have had any free-standing E-cylinder in the room and was unaware the resident was on oxygen therapy.
Improper Foley Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for a resident with a chronic long-term Foley catheter to help prevent urinary tract infections. Resident #40 was admitted with benign prostatic hyperplasia without lower urinary tract symptoms, had a Brief Interview for Mental Status score of 15 indicating cognitive intactness, required substantial/maximal assistance for toilet use, was non-ambulatory, and had an indwelling catheter for urinary retention. The resident’s care plan identified increased risk for urinary tract infection related to the Foley catheter and history of UTI, and physician orders directed Foley catheter care every shift, flushing as needed, and catheter changes every four weeks. During observation, the resident’s Foley catheter drainage bag was stored above the resident’s waist level on the wheelchair arm pad. A subsequent observation confirmed the bag remained above waist level, and an LPN stated they did not realize the bag was not stored properly. RN staff, the DON, and the Medical Director each stated the drainage bag should be positioned below the bladder or waist level so urine can drain properly; they stated that placing the bag above that level can prevent effective drainage and can cause urinary retention and infections.
Failure to Document Fluid Intake for Residents on Fluid Restriction
Penalty
Summary
The facility failed to ensure that fluid intake was monitored and documented for residents with physician-ordered 1200 mL fluid restrictions. The deficiency was identified for two residents: one admitted with diagnoses including dehydration, acute kidney injury on chronic kidney disease, and acute heart failure, and another admitted with end stage renal disease, arteriovenous fistula, diabetes mellitus, and dialysis treatment. Both residents had care plans and physician orders addressing fluid restriction and monitoring, but the record did not show that the actual fluid intake was consistently documented in numerical form. For the resident with heart failure and renal disease, the physician ordered a 1200 mL fluid restriction with 60 mL of fluid per medication pass. Dietary and nursing notes documented that the resident had a good appetite and fluids were encouraged, but the records did not show the total amount of fluid consumed. Review of the medication administration record and meal intake record showed no evidence that fluid intake was recorded to determine whether the 1200 mL restriction was followed. Staff interviews confirmed that fluid amounts were provided and discussed, but the total daily fluid intake was not documented. For the resident receiving dialysis, the care plan identified risk for dehydration and excess fluid retention with a 1200 mL per day fluid restriction. The meal consumption records contained inconsistent and missing entries for fluid intake on multiple dates, and the medication administration record contained no record of fluid intake for medication passes. Nursing progress notes for the month reviewed did not include the amount of fluid consumed. Staff interviews showed that CNAs were expected to record meal fluids, nurses provided fluids during medication passes, and the fluid given by nurses was not documented in the MAR. The DON and unit manager stated that the actual amount of fluid consumed should be documented in numerical form, but the records reviewed did not show that this was done.
Unsecured Medication Cart Left Unlocked in Hallway
Penalty
Summary
The facility did not ensure medications were properly stored in medication carts. During observation, record review, and interviews, surveyors found one unlocked and unsupervised medication cart on Unit 3 Southwest in the hallway, with no nursing staff present in the vicinity. During a medication pass observation, an LPN went into a resident’s room to administer medications and left the medication cart unsecured and out of view in the hallway. Facility policies titled Storage of Medications and Medication Administration stated that the medication nurse on duty is responsible for the security of the cart’s contents, that the cart must be locked and secure at all times when not in use, and that all medications are to be kept under lock and key. The LPN stated they forgot to lock the cart and acknowledged that the cart should be locked when they go into a resident’s room and the cart is out of view. The DON stated nursing staff are expected to lock the medication cart after removing medications and that it should always be locked when not in use.
Unlabeled Tube Feeding Formula and Water Bags
Penalty
Summary
Food was not prepared, distributed, and served in accordance with professional standards for food service safety when Resident #74’s gastrostomy tube feeding formula and water bags were observed unlabeled and without the resident’s name, the date, or the time the feeding was initiated. The facility policy titled Gastronomy Feedings, last reviewed 02/02/2026, did not include documentation for labeling the feeding with the resident’s name, date, and start time, although it stated disposable equipment is to be changed every 24 hours or as necessary and the feeding is to be disposed within 24 hours of administration. Resident #74 had diagnoses including traumatic subdural hemorrhage, nondisplaced fracture of the first cervical vertebra, and anoxic brain damage, and the Quarterly MDS documented severe cognitive impairment and the need for a gastrostomy tube for nutrition. The physician’s order directed Jevity 1.5 via feeding pump at 75 cc per hour starting at 4:00 PM daily, with specified water flushes and total volumes. On 03/09/2026, the MAR showed no documented evidence that the feeding was started at 4:00 PM, and the tube feeding was observed running in bed without a label showing the resident’s name, date, or time hung. An LPN stated the feeding should have been labeled and that the nurse who hung it should have included the resident’s name, date, time, rate, and total volume; another LPN stated the feeding should have been labeled and acknowledged the omission was an oversight. The DON stated the tube feeding bottle should be labeled with the resident’s name, time hung, and date.
Infection Control Program Failure During Precautionary Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved one resident who had physician orders for contact precautions for an ESBL infection of the coccyx wound and enhanced barrier precautions for wounds on both heels. The resident’s record also documented a stage 3 pressure ulcer, three venous and arterial ulcers, bowel and bladder incontinence, and moderate cognitive impairment. During observation, a CNA was providing incontinence care to the resident while wearing two pairs of gloves, without a protective gown, and with a surgical mask worn below the mouth. The facility’s infection control policy stated that gloves are to be worn when entering a contact precautions room and removed before leaving, and that gowns are indicated when soiling is likely or contact with the resident or items in the room is expected. The enhanced barrier precaution policy stated that gowns and gloves are needed during high-contact resident care activities, including dressing, bathing, changing linens, changing briefs, and assisting with toileting. Interviews showed staff confusion about which resident in the room was on precautions and how to identify the correct resident from the signage. The CNA stated they believed the roommate was on contact precautions, did not know what the green dot on the signage meant, and used double gloves to protect themselves while wearing the mask below the mouth. An LPN stated the signage was posted on the wrong side of the door, another LPN stated staff relied on physician orders and verbal report rather than the signage to identify precautions, and the Infection Prevention Nurse stated staff should ask the nurse which resident was on transmission-based precautions. The DON stated it was not acceptable that staff were unable to identify the precaution residents in the rooms.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with contact precautions for residents with communicable diseases. Resident #214, who had a physician's order for contact precautions due to Methicillin-Resistant Staphylococcus Aureus (MRSA) in the sputum, was involved in two separate incidents. On one occasion, a physical therapist entered the resident's room without wearing the appropriate Personal Protective Equipment (PPE) and transported the resident to the Rehabilitation Room without performing hand hygiene afterward. Additionally, during a medication pass, a Licensed Practical Nurse (LPN) failed to change gloves and perform hand hygiene after unclogging the resident's Gastrostomy Tube before administering eye drops. Resident #546, admitted with heel wounds requiring contact precautions, did not have a physician's order for such precautions until six days post-admission. An LPN was observed entering the resident's room without performing hand hygiene or wearing the required PPE, despite the presence of a sign indicating the need for contact precautions. The LPN later acknowledged the oversight and the necessity of following proper infection control protocols. The facility's policies on infection control and medication administration were not adhered to, as staff failed to follow the outlined procedures for PPE use and hand hygiene. The Infection Preventionist and Director of Nursing Services confirmed the expectations for staff compliance with these protocols, highlighting the lapses in infection control practices that contributed to the deficiencies observed during the survey.
Deficiencies in Wound and Tube Care Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the comprehensive person-centered care plan for several residents. Resident #544, who was admitted with an abdominal surgical incision, did not receive the recommended wound care treatment as per hospital discharge instructions and wound care consultant recommendations. There were no physician's orders obtained for the treatment, and the medical record lacked documentation of treatment administration, leading to the resident being sent to the hospital for evaluation of the open surgical incision site. Resident #10, with a history of a vascular ulcer on the left second toe, was observed with a gauze dressing between the toes without a physician's order. The resident complained of itching and pain, but the nursing staff did not alert the unit manager or wound care nurse for further assessment. The medical record did not contain any physician's orders for the treatment of the left second toe, and the wound care nurse was not notified of the resident's condition. Resident #193, who had a gastronomy tube that was no longer in use, did not have a physician's order to flush the tube to maintain patency. The nursing staff failed to contact the physician to obtain an order, and the dietician acknowledged the oversight in placing the order. The lack of a flushing order could lead to the tube becoming clogged, requiring removal and replacement.
Inaccurate Air Mattress Setting for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The resident, who had a traumatic brain injury, respiratory failure, and depression, was documented to have severely impaired cognition and two unstageable pressure ulcers. The care plan for the resident included the use of an air mattress to aid in pressure ulcer management. However, during observations, the air mattress's weight setting was inaccurately set at 265 pounds, despite the resident's actual weight being 156.2 pounds. The facility's policy required nurses to check the air mattress for proper placement, setting, and functioning every shift. Despite this, the Treatment Administration Record indicated that the air mattress was checked and signed off as accurate, even though it was not set correctly. Interviews with the wound care nurse, wound care consultant, and Director of Nursing Services confirmed that the weight setting should match the resident's weight to assist with wound healing. The discrepancy in the air mattress setting was not identified or corrected by the staff, potentially impacting the resident's comfort and wound healing process.
Aerosol Spray Hazard in Resident Room
Penalty
Summary
During a Recertification Survey, it was found that the facility did not maintain a resident environment free from accident hazards. Specifically, an aerosol container of Lysol spray was observed on the bedside table of a resident with moderately impaired cognition and receiving continuous oxygen therapy for Chronic Obstructive Pulmonary Disease. The facility's policy prohibits the use of aerosols within the facility due to their flammable nature. Despite this, the aerosol spray was present in the resident's room, and staff were aware of its presence but did not remove it immediately. The resident stated that their family brought the Lysol spray, and it had been used in the room for a couple of months. Staff members, including a Certified Nursing Assistant and a Registered Nurse, were aware of the aerosol spray but did not take action to remove it, assuming it was allowed. The Director of Nursing Services confirmed that aerosol sprays are not permitted due to their flammability and should have been removed when first noticed by the staff.
Failure to Administer IV Fluids as Ordered
Penalty
Summary
The facility failed to administer intravenous (IV) fluids to a resident in accordance with physician orders and professional standards of practice. Resident #58, who had a physician's order to receive Dextrose 5% solution at 70 cubic centimeters (cc) per hour for hypoglycemia, was observed receiving the solution at a reduced rate of 50 cc per hour on two separate occasions. This discrepancy was noted during a recertification survey, where it was found that the nursing staff did not adhere to the prescribed infusion rate, potentially impacting the resident's treatment for hypoglycemia. The resident, who had diagnoses including Parkinson's Disease, hypoglycemia, and pneumonia, was at risk for dehydration and complications from IV therapy. Despite the physician's order and the facility's policy requiring documentation of the IV solution type and rate per shift, the nursing staff failed to adjust the flow rate to the correct setting. Interviews with the nursing staff revealed a lack of awareness and adherence to the updated physician's order, leading to the administration of the IV fluids at an incorrect rate. The attending physician expressed concern that the incorrect infusion rate could delay the resolution of the resident's hypoglycemic episode.
Improper Labeling of Insulin Pens
Penalty
Summary
During a Recertification Survey, it was observed that the facility failed to ensure proper labeling of insulin pens in accordance with professional principles. Specifically, on the Unit 3 South medication cart, an opened Basaglar insulin pen for one resident and an opened Lantus insulin pen for another resident were found without a documented date of opening. This deficiency was identified during a Medication Storage Task, which reviewed six medication carts in total. The lack of labeling was confirmed through interviews with staff, including an LPN, the nurse manager, a pharmacist, and the Director of Nursing Services. The LPN acknowledged the absence of open dates on the insulin pens and stated that all nurses are responsible for proper labeling. The nurse manager and pharmacist both emphasized the importance of discarding insulin pens 28 days after opening due to potential loss of effectiveness. The Director of Nursing Services reiterated that an open date should have been documented to ensure timely disposal of the insulin pens.
Failure to Accommodate Resident's Food Allergies
Penalty
Summary
The facility failed to ensure that a resident received food that accommodated their allergies, specifically to artificial sweeteners. This deficiency was identified during a recertification survey for a resident with intact cognition and a physician's order prohibiting artificial sweeteners. Despite this order, the resident was served sugar-free snack puddings and reduced-calorie syrup containing artificial sweeteners, which were found on their overbed table. The resident confirmed that these items were included with their meal tray. The facility's policy required communication of resident allergies to the dietary department, but this was not effectively implemented. The Food Service Director acknowledged that the items came from the kitchen and were mistakenly placed on the resident's tray. A dietary aide admitted to not recognizing artificial sweeteners in certain products, indicating a lack of knowledge and oversight. The Director of Nursing Services and a Registered Dietitian both emphasized the responsibility of kitchen and unit staff to check meal trays for accuracy, especially for residents with food allergies.
Delayed Completion of Resident Assessment
Penalty
Summary
The facility failed to ensure that comprehensive assessments of residents were conducted within the required timeframe, specifically within 14 calendar days after admission and not less than once every 12 months. This deficiency was identified during a recertification survey for a resident who had been admitted with diagnoses including Parkinson's Disease, Schizophrenia, and Traumatic Subdural Hemorrhage. The resident's Annual Minimum Data Set (MDS) assessment was not completed until 31 days after the Assessment Reference Date, which was a significant delay beyond the required 14 days. The facility's policy required a Registered Nurse to conduct and coordinate each resident's assessment, but it did not specify the timeframe for completion. The MDS Director, who was responsible for ensuring timely completion of assessments, acknowledged the delay and stated that the assessment should have been completed earlier. The facility had hired a consulting firm to assist with MDS assessments due to staffing changes, but the Administrator and Director of Nursing were unaware of the delay until the survey. This oversight led to the deficiency being cited during the survey.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required 14-day period following the completion of the resident assessments. This deficiency was identified during a recertification survey for seven residents whose MDS assessments were transmitted late. The facility's policy, last revised in August 2023, did not specify the timeframe for transmitting these assessments. The MDS Director, who was responsible for timely transmissions, acknowledged the delay and attributed it to difficulties in tracking and transmitting the assessments due to recent changes in staffing and the termination of a consulting firm's contract. Interviews with facility staff revealed a lack of awareness and communication regarding the issue. The MDS Assessor maintained an Excel spreadsheet to track due dates manually, as they could not generate reports from the electronic medical record system. The Assessor had informed the Administrator about the lateness but could not recall the details of the conversation. The Administrator and the Director of Nursing Service were unaware of the transmittal issues until informed during the survey. The Director of Nursing Service stated that all MDS assessments should be transmitted within the 14-day timeframe, highlighting a gap in communication and oversight within the facility.
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 148 citations issued within 25 miles in the last 12 months — including the 8 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 Oakdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Nursing And Rehabilitation Care Ctr | 2.1 mi | ★★★★★ | 5 | 0 |
| Sayville Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Momentum At South Bay For Rehabilation And Nursing | 3.3 mi | ★★★★★ | 6 | 0 |
| Swan Lake Nursing & Rehabilitation | 6.4 mi | ★★★★★ | 5 | 1 |
| Sunrise Manor Ctr For Nursing And Rehabilitation | 6.7 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.