Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Bridgewater Center For Rehab & Nursing L L C during CMS and state inspections, most recent first.
The facility failed to ensure an accessible grievance process for all residents. Residents stated they did not know where to get grievance forms, how to file anonymously, or who the grievance officer was, and resident council concerns such as long call bell times, missing clothing, room cleanliness, and staff attitudes were repeatedly raised without documented investigation or responses. Observations showed only the grievance officer’s contact information posted, with no anonymous drop box or clear instructions for filing grievances.
Food storage, cooling, and sanitation practices were not maintained in the kitchen, unit pantries, and rolling coolers. Staff left prepared pork loin cooling without proper documentation, handled food after touching a garbage can without washing hands, stored expired milk and food on freezer floors, and kept multiple refrigerators and rolling coolers above safe temperatures. Several areas were also unclean, and some sinks lacked soap or paper towels.
A resident’s wheelchair was observed dirty and broken, another resident was found covering themselves with trash bags because a ceiling leaked liquid onto the bed, and a third resident reported a labeled clothing item never came back and was later seen on another resident. In a resident group meeting, most residents said clothing was mislabeled, not returned from laundry, or given to other residents, and staff described a backlog in the labeling process.
Unsafe and Unclean Resident Unit Environment: Multiple resident units had sticky floors, odors, debris, broken fixtures, peeling wallpaper, ceiling leaks, and other disrepair. Staff described housekeeping and maintenance responsibilities, but observations showed repeated environmental problems in resident rooms, hallways, the dining area, and the kitchenette, including missing handwashing supplies, a broken outlet, and water intrusion.
Food and drink were not consistently palatable or served at safe temperatures. A mobile refrigerator on the unit was found with torn gaskets and temperatures above the safe range, and test trays showed hot items served cold and cold items served warm. Residents reported cold, flavorless food, spoiled milk, brown lettuce, missing items, and shortages of food and cups, while staff confirmed ongoing complaints about meal quality and temperature.
The facility failed to maintain infection control precautions for two residents with suspected or confirmed C. difficile. A CNA entered a resident’s room without the required gown and gloves, used hand sanitizer instead of soap and water, and an HSKP used a quaternary sanitizer on C. difficile rooms despite the facility’s bleach-based cleaning procedure. Another resident with a stool order for C. difficile had no contact precaution sign posted, even though staff said the sign determined the PPE required.
Medication carts on multiple units contained unlabeled, undated, and expired drugs and biologics. An LPN found eye drops, inhalers, and insulin pens without open dates or pharmacy labels, an unlabeled pill in a med cup, an expired medication card, and an inhaler with conflicting open dates. Staff also administered a medication from an expired box and acknowledged that multidose meds such as eye drops, inhalers, and insulin must be dated when opened.
Kitchen freezer not removed from service. The main kitchen walk-in freezer was observed at 52 degrees Fahrenheit with frozen fish still inside, and no out-of-service sign was posted. The FSD stated the freezer had malfunctioned, food was not supposed to be stored in it, and staff were monitoring the high temperatures while using a refrigeration truck.
A resident with diabetes, anxiety, and intact cognition repeatedly received meal trays missing ordered items and containing foods they had requested not to receive. Trays were missing items such as toast, salad, condiments, jelly, coffee, and a sandwich, and some trays included gravy or ranch dressing despite no-gravy or specific dressing instructions. Staff reported that tray accuracy checks were performed, but items were often still missing or unavailable, and the resident frequently complained that preferences were not being honored.
A resident with dementia, schizophrenia, and obstructive lung disease had two budesonide-formoterol inhalers in the room, but there was no documented self-administration assessment or MD order allowing self-medication. The MAR showed the inhaler was administered, but staff could not identify the nurse on the record, and an LPN and RN UM stated an order and documented assessment would normally be required before bedside inhaler use.
Failure to thoroughly investigate and report an unexplained fracture: A resident with Alzheimer's disease, severe cognitive impairment, and fall risk was found unable to stand and later diagnosed with a displaced femoral neck fracture. Staff interviews did not identify a witnessed fall, and the facility concluded the injury was an unwitnessed or pathological fracture and ruled out abuse, neglect, and mistreatment, but there was no documented evidence supporting that determination or reporting to NYSDOH.
A resident with dysphagia and documented dependence with eating was care planned for supervision at each meal and feeding if needed, but staff left the resident alone with meals. Observations showed the resident with an untouched lunch tray in the room with no staff present, and later eating lunch in the hall after a staff member cut the meat and then walked away, with no further assistance or encouragement provided.
A resident reported a new buttock wound and asked for only the wound team or provider to assess it, but the concern was not communicated and the area was not assessed for several days; another resident received a leg dressing without a provider order and without documentation of the intervention; and a third resident with a PICC line had no documented order for site monitoring or evidence of required line-length measurements.
A resident with a stroke history, severe cognitive impairment, and right-sided contracture was ordered to wear a right palm guard at all times except for skin checks and hygiene, but staff did not apply it and it was not listed on the TAR. The resident was repeatedly observed without the palm guard, with the right wrist bent downward and fingers in a loose fist, while staff said the device had stopped being used and the order had been entered incorrectly.
A resident with repeated falls, fractures, and TBI was assessed as needing supervision for transfers and ambulation and had a care plan that included non-skid socks and two fall mats. Despite this, staff observations found the fall mats were not consistently in place, one mat was stored under a TV or folded by the bed, and the call bell was wrapped behind the headboard and out of reach. Staff interviews confirmed the fall interventions were expected to be followed, but the resident’s precautions were not consistently implemented.
A resident with dementia, cachexia, and severe underweight status had a care plan for supervision at meals, finger foods, and nutritional supplements, but staff repeatedly failed to provide the planned meal assistance and all ordered food items. During observed meals, the resident was thin, often ate poorly, and did not receive encouragement or assistance; meal trays were also missing items such as a Magic Cup, pudding, and a peanut butter and jelly sandwich. Staff interviews confirmed trays were supposed to be checked for accuracy and that the resident needed encouragement and handheld foods to support intake.
A resident with a tracheostomy, dysphagia, and a mouth yeast infection did not receive consistent oral care despite orders for mouth care every shift and at bedtime by RT. Staff gave conflicting accounts of who was responsible, oral care was not documented as provided at bedtime, and observations showed dried green or yellow buildup on the tongue, teeth, lips, and roof of the mouth. The family reported the mouth looked dirty and uncomfortable and said they had raised the concern to staff.
The facility failed to maintain a clean and homelike environment in three units, with issues such as strong urine odors, unclean floors, and food debris on surfaces. Observations revealed that cleaning policies were not consistently followed, and staff interviews indicated a lack of clarity in cleaning responsibilities. Residents and family members reported dissatisfaction with the facility's cleanliness, further highlighting the deficiency.
Two residents in an LTC facility did not receive scheduled showers, impacting their personal hygiene. One resident with COPD and muscle weakness missed three weeks of showers due to staffing issues, while another with cerebral palsy and muscular dystrophy missed a shower due to equipment unavailability. Staff failed to communicate these issues, leading to a deficiency in care.
Two residents in an LTC facility did not receive care according to their care plans. An LPN administered medications outside acceptable time frames and failed to document tube feedings for a resident with complex medical needs. Another resident did not receive their prescribed medicated shampoo as ordered, with CNAs administering it instead of licensed staff. The facility failed to notify providers of missed or late treatments, leading to deficiencies in care.
Grievance Process Not Accessible or Responsive
Penalty
Summary
The facility failed to ensure residents had an effective process to voice grievances and have them addressed appropriately for 349 of 349 residents. During a resident group meeting, 12 of 12 anonymous residents stated they did not know where to obtain grievance forms, did not know their right to file grievances anonymously, and did not know who the grievance officer was. They reported they had to tell a unit manager or social worker about concerns, and that concerns voiced during resident council meetings were not acted upon or responded to with a rationale. The facility policy stated residents, families, and caregivers could express concerns anonymously or individually, and grievances were to be resolved or addressed within 48 hours, with written documentation available to the complainant. Resident council meeting minutes showed repeated concerns across multiple meetings, including long call bell times, missing clothing, cleanliness of rooms, staff cell phone use, help with finances, ability to self-propel within the facility and courtyard, more art supplies, bed linen concerns, ability to go outside, and staff with poor attitudes. There was no documented evidence that these concerns were investigated or that rationales and responses were provided at subsequent meetings. Observation of the facility showed the grievance officer’s contact information posted on a bulletin board, but there were no instructions for anonymous filing, no readily available grievance forms without asking staff, and no box for anonymous submission. Staff interviews confirmed residents had to verbalize concerns to staff to complete a grievance form, that anonymous filing was not available in practice, and that resident council concerns were emailed to department heads without documented responses.
Food Storage, Cooling, and Sanitation Failures
Penalty
Summary
Food storage, preparation, distribution, and serving practices were not maintained in accordance with professional standards in the main kitchen, unit pantries, and rolling coolers. In the main kitchen, prepared pork loin was observed cooling at 87 degrees Fahrenheit after being placed in the walk-in cooler at 8:30 AM, and later measured at 79.6 degrees Fahrenheit; the staff member stated temperatures were taken every 30 minutes but were not written down and had not actually been checked until the surveyor observed it. The same staff member was observed touching a garbage can while wearing gloves and then moving the pork into the cooler, and changed gloves only when asked, without washing hands. The kitchen also contained 56 2% milk cartons past their best used by date, food stored on the freezer floor, an open box of tilapia with the inner bag unsealed, and unclean areas including sticky freezer floors, debris, spillage, broken tiles, and sinks without paper towels. The Unit 5A pantry refrigerator was not maintaining proper cold temperature. The ambient temperature felt warm, the thermometer on the shelf read 60 degrees Fahrenheit, and the surveyor’s thermometer measured 53.5 degrees Fahrenheit after the door was shut. Milk in the refrigerator measured 60.8 degrees Fahrenheit and then 63 degrees Fahrenheit after the refrigerator remained closed for 11 minutes. The Unit 5A rolling cooler also failed to maintain temperature, with outside and internal readings ranging from 45.3 to 52 degrees Fahrenheit, and milk in the cart measured 47.8 and 50 degrees Fahrenheit. The Unit 2B rolling cooler was also out of temperature, with readings of 56 degrees Fahrenheit and later 46 degrees Fahrenheit, and its door did not seal properly because the gaskets were broken and the door was clipped shut with an S hook. The unit pantry and kitchen areas were also observed to be unclean and lacking handwashing supplies. The Unit 5A pantry had sticky drawers with built-up grime, a partially eaten resident lunch tray on the counter, and an ice machine with whitish streaks and black grime. The Unit 4A kitchenette had no soap dispenser or paper towel dispenser at the sink, and staff reported there were no paper towels available. In the main kitchen, handwashing sinks lacked paper towels, the dish room paper towel dispenser did not work, the walk-in cooler racks and floors were dirty, the dry storage area had food debris and spillage, and the basement dry storage room contained canned goods and other food items stored beneath large black pipes identified by maintenance as storm drains or sewer drains.
Unclean wheelchair, leaking ceiling, and missing clothing
Penalty
Summary
The facility failed to ensure residents had a dignified existence and a homelike environment when a resident’s wheelchair was observed unclean and in disrepair. Resident #19 had Alzheimer’s disease, severely impaired cognition, and required supervision or touching assistance with chair transfers. The resident was observed in a geriatric chair with a broken arm rest and dried white debris drips on the chair base air on two separate occasions. Facility staff stated certified nurse aides were responsible for cleaning wheelchairs and maintenance was responsible for repairs, but the chair remained dirty and broken during the observations. The facility also failed to maintain a safe, clean, comfortable, and homelike environment for Resident #41 when the ceiling in the resident’s room leaked liquid onto the resident and their bed. Resident #41 had sepsis and lower leg cellulitis and required supervision for bed mobility. During observation, the resident was in bed covered with a clear trash bag and stated they were protecting themselves because the ceiling leaked at times and they did not want to get wet. The ceiling showed white tape running from the window to the wall with puckering and large brown stains along the tape line. The resident stated staff had previously brought trash bags so they could cover their body and stay dry, and later showed trash bags stored in their shoe on the windowsill for use as a tarp when the ceiling leaked. The facility further failed to ensure residents’ clothing was properly labeled, returned, and not given to other residents. Resident #72 stated a zippered top given by their church was sent to be labeled, never returned, and later seen on another resident. During a resident group meeting, 10 of 12 anonymous residents reported their clothes were taken to laundry and given to other people, labeled with another resident’s name, or not returned after laundering. The 2025 and 2026 Missing Items Logs documented multiple reports of clothing or blankets going to laundry to be labeled and not returning. Staff interviews described a labeling process involving inventory sheets, reception, laundry, and a backlog of items due to a broken labeler, with some unlabeled items going to a donation area if ownership could not be determined.
Unsafe and Unclean Resident Unit Environment
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for four of seven resident units reviewed, with Units 2A, 3A, 4A, and 5A observed to be unclean and in disrepair. The facility policy stated residents were to be provided a safe, clean, comfortable, and homelike environment and encouraged to use personal belongings to the extent possible. On Unit 2A, the floors were very sticky throughout the unit and staff shoes were heard squeaking during the observation. On Unit 3B, a resident room had peeling wallpaper and a broken toilet paper holder, and a visitor stated the condition had been present for a long time and had been reported months earlier without repair. Work orders showed wallpaper issues dating back to 08/19/2025 and another entry on 06/09/2026 noting the wallpaper was peeling. On Unit 4A, multiple observations identified spoiled and stale odors, a strong urine odor, sticky floors in several resident rooms and common areas, a broken wall outlet prong in the dining room, liquid on the floor in front of a bathroom, a white powdery substance and straw under a urinary catheter bag, water on the floor at the base of a bed, wet towels on the floor, visible ceiling leaking, and the Administrator moving a trash can to catch the leak. A Dietary Aide stated there was no soap or paper towels in the kitchenette for handwashing before or after meal preparation, and work orders documented clogged pantry sinks months earlier. On Unit 5A, observations showed sticky floors at the nursing station and in resident rooms, crumbs and debris in hallways and around beds, dried liquid spills and smears, dirty and sticky pantry drawers, a hole in the hallway flooring, black spots and stuck-on debris near the nursing station, and ceiling damage including bubbling tiles and a large water stain. A bucket was placed under a ceiling leak while the DON and Maintenance observed the area. Staff interviews stated housekeeping was responsible for cleaning and mopping, maintenance handled repairs, and sticky floors, odors, leaks, and other environmental issues were repeatedly noted on the units.
Food and drink served at improper temperatures and not palatable
Penalty
Summary
The facility failed to ensure food and drink were palatable and served at safe, appetizing temperatures for two test trays and for residents who reported ongoing meal quality concerns. During observation, the 2-door mobile refrigerator on 2B was found plugged in in the hallway outside the dining room with a thermometer reading 56 degrees Fahrenheit, torn door gaskets, and a door clipped closed with S-hooks that did not securely seal the unit. Dietary staff stated the unit had been brought to the floor around 10:00 AM, but the internal thermometer could not initially be located and later read 52 degrees Fahrenheit. The lunch tray tested for Resident #379 included creamy Maryland chicken with mushroom at 128.7 degrees Fahrenheit, mandarin oranges at 58.1 degrees Fahrenheit, milk at 55.8 degrees Fahrenheit, and water at 72 degrees Fahrenheit, and the beverages tasted warm. At the resident council meeting, 10 anonymous residents stated the hot food was cold and flavorless, milk was often spoiled, lettuce was often brown, meals were not on time, and the facility frequently ran out of food and cups. On the breakfast tray tested for Resident #9, scrambled eggs were 120.9 degrees Fahrenheit, milk was 50 degrees Fahrenheit, yogurt was 49.5 degrees Fahrenheit, and oatmeal was 172.4 degrees Fahrenheit and burned the surveyor's mouth. Staff interviews confirmed residents often complained that hot food was cold, items were missing from trays, and the food did not look or taste appealing. The Food Service Director stated the dietary aide was responsible for recording temperatures, that cold items should be held at 41 degrees Fahrenheit or lower and hot items at 135 degrees Fahrenheit or higher, and that residents had recently complained about spoiled and out-of-date milk.
Infection Control Failures With C. difficile Precautions and Cleaning
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 two residents and two staff observations related to clostridioides difficile precautions, room signage, and environmental cleaning practices. Resident #13 had diagnoses including recurring clostridioides difficile, frequent bowel incontinence, and staff supervision with toileting. The resident’s care card documented contact precautions for clostridioides difficile, and the facility’s purple contact precautions sign required staff to wear a gown and gloves before entering the room and to wash hands with soap and water when exiting. During observation, a CNA entered the resident’s room without a gown or gloves to retrieve a breakfast tray, then used hand sanitizer and entered another resident’s room. The CNA stated they believed gown and gloves were only needed for direct care and that hand sanitizer was effective after leaving the room, while RNs stated gown and gloves were required any time the room was entered and handwashing with soap and water was required on exit. Housekeeper #64 also stated they used a quaternary sanitizer on sinks and floors in all resident rooms, including rooms on contact precautions for clostridioides difficile, even though the facility procedure called for sodium hypochlorite disinfectant for those rooms and the Infection Preventionist stated quaternary sanitizer would not kill clostridioides difficile. Resident #376 had diagnoses including osteomyelitis, urinary tract infection, and diarrhea, was cognitively intact, frequently incontinent of bowel, taking an antibiotic, and receiving intravenous medications. The resident had a stool specimen order for clostridioides difficile due to diarrhea, and staff interviews showed they relied on the sign outside the room to determine PPE requirements. However, the room was observed multiple times without contact precaution signage outside the door. Staff stated the sign should have been placed when the clostridioides difficile specimen was ordered, and the Infection Preventionist stated they were responsible for initiating and maintaining isolation precautions and that clostridioides difficile precautions should begin as soon as a specimen was ordered.
Medication Labeling and Storage Deficiencies on Multiple Carts
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles on three medication carts, including Unit 4A, Unit 4B, and Unit 5A. The facility policy required medications to be stored according to manufacturer directions and kept physically separated to prevent contamination. On Unit 4A, the medication cart contained Lumigan eye drops that were not dated when opened, two albuterol inhalers that were not dated when opened, a blister pack of lisinopril that had expired, a lispro insulin pen dated 05/02/2026, and an Admelog insulin pen without a pharmacy label. The nurse stated eye drops had to be dated when opened and that medications should not be given without a pharmacy label. On Unit 4B, the cart contained a Lantus insulin pen without an open date, and the nurse stated insulin should be dated when opened. On Unit 5A, the medication cart contained an unlabeled yellow oblong pill in a medication cup, an expired ondansetron card for a resident, and a fluticasone-salmeterol inhaler with two different open dates on it. The nurse stated the medication in the cup was gabapentin for a resident who was at an activity, but it was not labeled in the cup. The report also noted mycophenolate mofetil was administered from a box with an expiration date of March 2026, and the nurse stated the expiration date was not checked before administration. The unit manager stated all nurses administering medications should ensure medications had a pharmacy label and open date, and that multidose medications such as eye drops, inhalers, nasal sprays, and insulins had to be dated when opened.
Kitchen Freezer Not Removed From Service
Penalty
Summary
The facility failed to maintain the main kitchen walk-in freezer in safe operating condition and did not post an out-of-service sign when the freezer malfunctioned. During observation and interview on 06/10/2026 at 10:10 AM, the walk-in freezer in the main kitchen was 52 degrees Fahrenheit and contained one box of frozen tilapia. Food Service Director #25 stated the freezer had gone down, no food was supposed to be inside it, and when equipment was out of order a sign was supposed to be posted. The director also stated the freezer temperatures had been high over the weekend, staff were monitoring them, and a refrigeration truck delivered on 06/09/2026 was being used in the parking lot.
Meal trays did not match resident preferences or diet instructions
Penalty
Summary
The facility failed to ensure that a resident received food that matched documented preferences and meal ticket instructions. The resident had diagnoses including anxiety and diabetes, intact cognition, required set-up assistance with eating, and was on a therapeutic diet. The care plan documented nutritional concerns related to multiple chronic conditions and included interventions to maintain weight, follow the prescribed diet, and provide food preferences, including a sandwich with lunch and dinner. During multiple meal observations, the resident’s trays were repeatedly missing items listed on the meal ticket or included items the resident had requested not to receive. The lunch tray was missing margarine, tossed salad, and a grilled cheese sandwich, and pork chop was served with gravy despite the ticket stating no gravy. The resident stated they repeatedly asked for no gravy but received it often, and that missing margarine prevented them from eating noodles. On another occasion, the dinner tray did not include the grilled cheese sandwich, and the resident sent the tray back without eating and was not brought a replacement tray or offered the sandwich. Additional observations showed the breakfast tray missing toast, with a replacement tray also missing toast, and another lunch tray missing tossed salad and the requested condiments while containing gravy despite the no-gravy instruction. Other trays were missing wheat toast, diet jelly, coffee, and Italian dressing, and one tray contained ranch dressing instead of Italian dressing. Staff interviews indicated that kitchen staff and CNAs were responsible for tray accuracy, but they also reported that items were often missing, sometimes unavailable, or not placed on trays, and that residents frequently complained about missing food items.
Failure to Assess Self-Administration of Inhalers
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined whether a resident could safely self-administer medications when clinically appropriate. Resident #361 had diagnoses including dementia, schizophrenia, and obstructive lung disease, and the 5/15/2026 MDS documented moderate cognitive impairment and the need for partial/moderate assistance with personal hygiene. During observations on 06/08/2026, 06/09/2026, and 06/10/2026, a clear zipped pouch containing two budesonide-formoterol fumarate inhalers was seen at the end of the resident’s bed. The June 2026 MAR documented budesonide-formoterol fumarate dihydrate aerosol, two puffs by mouth twice daily, and the medication was recorded as administered on 06/09/2026 and 06/10/2026, though the MAR did not identify the nurse who administered it. There was no documented evidence of a self-administration assessment, a physician order for self-medication, or a comprehensive care plan related to self-administration or storage of medication in the resident’s room. An LPN stated the resident needed an order to have an inhaler at bedside and that self-administration training would usually be documented, while an RN unit manager stated a self-administration assessment was updated every 90 days and that a physician order would follow successful demonstration; they also found the resident had two inhalers at the bedside and did not know how long they had been there.
Failure to Thoroughly Investigate and Report an Unexplained Fracture
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for Resident #298 to rule out abuse, neglect, or mistreatment, and the incident was not reported to the New York State Department of Health as required. Resident #298 had diagnoses including Alzheimer's disease and a right femur fracture, and the 03/22/2026 MDS documented severely impaired cognition, no behaviors, and prior independence with several mobility tasks. The care plan identified the resident as a potential victim of abuse due to cognitive disability and as a fall risk related to unsteady gait, confusion, and impaired judgment. According to the facility's investigative summary, on 04/18/2026 the resident was found grimacing, resistant to care, and unable to stand on the right leg, and was sent to the hospital where a displaced femoral neck fracture was diagnosed and surgically treated. Staff interviews indicated the resident had no reported fall or pain during the overnight shift, while day shift staff reported the resident was not walking like baseline. The facility concluded the injury was an unforeseen incident, believed the resident had an unwitnessed fall or a pathological fracture related to osteoporosis, and ruled out abuse, neglect, and mistreatment, but there was no documented evidence showing how that determination was made.
Failure to Follow Meal Assistance Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for Resident #16, whose diagnoses included dysphagia and whose 03/02/2026 MDS documented dependence with eating. The resident’s comprehensive care plan, initiated 12/19/2025 and revised 05/27/2026, documented that the resident was to be supervised at each meal and fed if needed, and the CNA care card documented the resident as dependent with eating. The facility policy on Activities of Daily Living stated that the care plan and CNA care cards would document the level of assistance required and that the CNA would document the completed level of care in the EMR daily. During an observation on 06/08/2026, Resident #16 was in bed with a lunch tray on a tray table to the side, unopened and untouched, with no staff present in the room or nearby. During another observation on 06/09/2026, the resident was served lunch while sitting in the hall; the meal tray was set up and the meat was cut by an unidentified staff member, who then left the resident without assisting them and returned later to retrieve the tray. The resident ate approximately 50% of the lunch, and no staff approached to offer encouragement or assistance. Staff interviews indicated they used the care plan or profile card to determine meal assistance needs, and the AD of Rehab stated the resident was care planned for one-to-one assistance at meals and should not have been given a tray and left alone.
Failure to follow wound and central line orders
Penalty
Summary
The facility failed to ensure care and treatment were provided according to orders and professional standards for three residents. One resident reported a new open area on the buttocks and stated they wanted only the wound team or provider to assess it, but that request was not communicated to the provider or wound team for several days. Nursing notes show the resident repeatedly complained of the area, refused bedside assessment by nursing staff, and was told the complaint would be passed on, yet there was no documented evidence that the wound care team or medical provider were notified until the wound was finally assessed and found to be a full-thickness gluteal cyst with slough, reddened surrounding skin, and severe pain. A second resident had a weeping left leg wound and was observed with a blue absorbent dressing and gauze wrap in place even though there was no physician order for that dressing. The resident stated the dressing had been applied by a nurse and had not been changed for several days. The record contained no nursing progress notes documenting the weeping leg or the dressing application during that period, and staff later stated the dressing was applied because the leg was weeping, but they did not know whether an order existed and did not document the intervention or notify the provider. A third resident had a PICC line for IV ceftriaxone for osteomyelitis, with orders for dressing changes, weekly extension set and cap changes, and measurement of the external catheter length on Mondays. The record did not contain an order specifically directing monitoring of the PICC site, and there was no documented evidence of initial catheter length measurements. Staff stated they monitored the site during antibiotic administration and that the Infection Preventionist changed the dressing, but the site monitoring and line measurements were not documented in the medical record.
Failure to Apply Ordered Palm Guard for Resident with Right-Sided Contracture
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received the ordered treatment and services to prevent further decrease in ROM when the resident’s right-hand palm guard was not applied as ordered. The resident had diagnoses including stroke and arthritis, severe cognitive impairment, was dependent on staff for all ADLs, and had upper and lower extremity impairment on one side. The care plan documented contractures to the right hand and arm, and later updated interventions included a right palm guard to be worn at all times except for skin checks and hygiene each shift. An OT evaluation noted the resident had a right upper extremity contracture from a stroke and could tolerate a palm guard already in place, with no skilled services needed at that time. The physician ordered the right palm guard to be worn at all times except for skin checks and hygiene each shift, but there was no documented evidence that the order was included on the treatment administration record. The resident was observed multiple times over several days with the right wrist bent downward and fingers bent into a loose fist, and was not wearing the palm guard during those observations. Staff interviews indicated the CNA believed the palm guard had stopped being used, the LPN stated the order had been entered incorrectly so it did not appear on the TAR, and the unit manager was unsure why the palm guard was not in place. The OT stated nursing was responsible for ensuring the palm guard was used as ordered.
Failure to Maintain Fall Precautions for a High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and an environment free from accident hazards for a resident with a history of repeated falls, multiple fractures, and traumatic brain injury. The resident’s assessments documented moderate cognitive impairment, need for supervision with transfers and ambulation, and a comprehensive care plan identified falls as a problem with interventions including high-visibility placement when awake, non-skid socks, and two fall mats. The facility policy stated fall interventions were to be documented on the care plan and on the CNA care card, and additional or different interventions were to be implemented after each fall based on the resident’s needs. Accident reports showed multiple falls, including an unwitnessed fall that resulted in finger fractures, and later a fall risk assessment documented the resident as high risk for falls with a history of multiple falls. During observations, the resident was seen in bed with only one fall mat present at times, with no fall mats in place at other times, and one mat folded under the television or folded next to the bed instead of being placed on the floor as planned. The call bell was wrapped behind the headboard and not within the resident’s reach. Staff interviews confirmed the resident had fall interventions in the care plan, that fall mats should be implemented if they were part of the intervention, and that the resident’s bed should be lowered if not already in low position.
Failure to Provide Planned Meal Assistance and Nutritional Items
Penalty
Summary
The facility failed to ensure that Resident #194 received the meal assistance and nutritional items that were care planned. The resident had diagnoses of dementia, cachexia, and underweight status, with a severely low body mass index of 11 and a weight of 60.6 pounds. The care plan and care card directed staff to provide supervision or touching assistance at meals, finger foods, set-up help, encouragement to eat and drink, and nutritional supplements, including 240 milliliters of Ensure Plus three times daily. The resident also had a mechanically altered diet and was documented as being on comfort care. During multiple observed meals, the resident was seated in the dining room and appeared thin with prominent cheek bones. On one occasion, the meal ticket listed a Magic Cup, but the resident did not have it and staff did not encourage or assist with the meal. On another occasion, the meal tray did not include the peanut butter and jelly sandwich or pudding listed on the meal ticket, and the resident again did not receive encouragement or assistance. On a later meal, the resident received the tray but still did not receive any encouragement or assistance while eating, and consumed only part of the meal and beverages. At breakfast, the resident’s tray was missing the peanut butter and jelly sandwich listed on the meal ticket. Although a CNA was cutting up and opening food items, the resident continued to push food around the plate, took very small bites, and received no encouragement or assistance during the meal. Staff interviews confirmed that trays were supposed to be checked for accuracy, missing items should be reported to the kitchen, and residents who were not eating well should be encouraged and assisted. Interviews also confirmed that the resident needed encouragement, liked peanut butter and jelly sandwiches, did better with handheld items, and typically ate most of the Magic Cup. The resident’s meal intakes were documented as variable and often low, with the dietitian noting average meal intake of 26-50%.
Inconsistent oral care for a resident with a tracheostomy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory-related oral care for a resident with a tracheostomy, difficulty swallowing, and a yeast infection of the mouth. The resident’s MDS documented severely impaired cognition, dependence on oral hygiene, and no refusal of care. The hospital discharge summary instructed that the resident remain strictly nothing by mouth except for occasional scant ice chips after direct assistance with stringent oral care when awake and alert, but the comprehensive care plan did not document oral care. Physician orders directed mouth care by RT at bedtime and mouth care every shift, and the treatment administration records documented mouth care every shift, but there was no documented evidence of an oral cavity assessment or of mouth care by RT at bedtime. Observations showed the resident repeatedly had visible dried buildup in the mouth while lying in bed with the mouth open. The tongue had light green dried buildup, the lips had a dry crust, and later the tongue, teeth, and roof of the mouth had green or yellow buildup that appeared hard. During one observation, an LPN hung tube feeding and did not provide oral care even though it was signed for during that time frame. The resident’s family member reported noticing the buildup, stated they had raised the concern to staff, and said the resident’s mouth looked disgusting and uncomfortable. The family member also stated they had performed mouth care with an oral swab but were concerned about dislodging material and causing choking. Staff interviews showed inconsistent understanding of who was responsible for oral care and when it should be done. CNA, RT, LPNs, and the unit manager each described oral care as shared between nursing and respiratory therapy, but their accounts differed on timing and frequency. The RT stated oral care was provided once a shift and that the buildup had not been noticed until the family brought it to attention. The unit manager stated oral care was scheduled twice a day and as needed, and that the resident had thick yellow coating and buildup on the teeth. The report stated that infrequent mouth care caused buildup and that the purpose was to keep the mouth moist to prevent infection and thrush.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in three of the eight units reviewed during the survey. Specifically, Unit 2 A was found to have a strong smell of urine, unclean bedroom floors, and bathrooms with brown splatter on the toilets. Additionally, over bed tables were covered with food debris. Unit 3 A's dining room floor was sticky and unclean, with debris on the base of food carts and brown material on a raised toilet seat in a resident room. Unit 4 A had a continuously running sink in a resident room, unclean floors in multiple resident rooms, and food splatter on the floors and walls. The facility's policy on resident room cleaning, revised in March 2020, required daily cleaning to ensure cleanliness and sanitation, prevent infection, and maintain the facility's appearance. However, observations revealed that the policy was not consistently followed, as evidenced by the presence of food debris, dried splatter, and brown stains in various rooms. Interviews with staff, including housekeepers and nursing staff, indicated that there was a lack of clarity and consistency in cleaning responsibilities, particularly regarding the handling of bodily fluids and deep cleaning procedures. Interviews with residents and their family members further highlighted the facility's failure to provide a homelike environment. A family member reported that the facility was consistently unclean during their visits, with stool on the toilet and bathroom floor. The resident expressed dissatisfaction with the cleanliness of their room, stating it was never cleaned and did not feel homelike. Staff interviews confirmed that the presence of sticky floors, debris, and unclean surfaces was not acceptable and did not align with the facility's standards for a homelike environment.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene, specifically showering, for two residents. Resident #46, who had chronic obstructive pulmonary disease and muscle weakness, required substantial assistance with showering. Despite being cognitively intact and expressing a preference for showers, the resident did not receive scheduled showers for three consecutive weeks. The certified nurse aide responsible for Resident #46's care did not provide the showers due to staffing issues and did not report the missed showers to the nursing staff, resulting in the resident going without a shower for an extended period. Resident #99, diagnosed with cerebral palsy and muscular dystrophy, also required substantial assistance with showering. The resident expressed a preference for showers twice a week but was scheduled for only one shower per week. On a scheduled shower day, the resident did not receive a shower due to the unavailability of a mechanical lift pad and the certified nurse aide's inability to return to assist them. The failure to provide the shower was not communicated to the nursing staff, and the resident went without a shower for two weeks. Interviews with facility staff, including certified nurse aides, licensed practical nurses, and the Director of Nursing, revealed a lack of communication and adherence to the shower schedule. The staff acknowledged the importance of providing showers for resident dignity and hygiene but failed to ensure that the residents received their scheduled showers. The facility's policies on activities of daily living and bathing were not followed, leading to the deficiency in care for these residents.
Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #236, Licensed Practical Nurses administered medications outside of acceptable time parameters, failed to administer and document tube feedings, and signed off on treatments and medications that were not completed. Observations revealed that the resident's tube feeding was not connected, and medications were documented as given without the nurse entering the resident's room. The nurse practitioner was not notified of missed or late medications and treatments, which were critical for the resident's nutrition and health. Resident #99, who had diagnoses including atopic and seborrheic dermatitis, did not receive their prescribed medicated shampoo as ordered. The shampoo was left at the resident's bedside, and certified nurse aides administered it instead of licensed staff. The resident reported not always receiving their weekly shower, which was necessary for the treatment of their scalp condition. The facility's staff failed to communicate effectively, and the nurse practitioner was not informed of missed doses of the medicated shampoo, which could exacerbate the resident's condition. Interviews with staff, including Licensed Practical Nurses, Registered Nurse Unit Manager, and the Director of Nursing, highlighted a lack of adherence to medication administration policies and inadequate communication regarding missed treatments. The facility's policies required that medications be administered by licensed nurses and documented accurately, with providers notified of any deviations. However, these protocols were not followed, leading to deficiencies in the care provided to the residents.
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What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Binghamton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Shepherd-fairview Home Inc | 0.5 mi | ★★★★★ | 0 | 0 |
| Elizabeth Church Manor Nursing Home | 2.2 mi | ★★★★★ | 0 | 0 |
| Susquehanna Nursing & Rehabilitation Center, L L C | 4.7 mi | ★★★★★ | 1 | 0 |
| James G Johnston Memorial Nursing Home | 5.3 mi | — | 0 | 0 |
| Willow Point Rehabilitation And Nursing Center | 5.4 mi | ★★★★★ | 0 | 0 |
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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.