Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Capstone Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with chronic respiratory failure experienced worsening symptoms, including congestion and altered mental status, but the physician was not notified. Despite the resident's health care proxy expressing concern, there was no documentation of physician notification, leading to a lack of new orders to manage symptoms. The resident was later found unresponsive and expired, highlighting a deficiency in communication and adherence to notification policies.
The facility failed to treat residents with respect and dignity, as evidenced by the use of plastic flatware without explanation and inappropriate communication by staff. Four residents received plasticware instead of silverware, which was not part of their care plan, and two residents were not spoken to in a dignified manner by staff. These actions were inconsistent with the facility's policies on dignity and resident rights.
The facility was found deficient in maintaining a clean environment, with surveyors observing streak stains beneath malfunctioning hand sanitizer dispensers and a soiled building exterior. Staff interviews revealed that the dispensers often malfunctioned, causing gel to squirt onto walls, and housekeeping did not clean the walls daily. The Director of Plant Operations acknowledged the need for repairs but no immediate corrective actions were noted.
The facility failed to provide adequate pain management for three residents, as observed during a survey. A resident with chronic pain was not consistently assessed or administered medication, with documentation issues noted. Another resident with a neck fracture experienced inconsistent pain management, with missing records and undocumented pain levels. A third resident with osteoarthritis was observed in pain but did not receive timely medication. Staff interviews revealed inconsistent pain assessment practices, contributing to the deficiency.
The facility experienced significant staffing shortages from December 2 to December 10, 2024, failing to meet its minimum staffing levels for LPNs and CNAs across all units. Residents reported delays in receiving care, and family members noted insufficient staff despite their kindness. Efforts to address the issue included hiring new nurses and offering incentives, but challenges like call-ins and scheduling gaps persisted, affecting resident care.
The facility failed to ensure proper documentation of narcotic counts by two licensed staff members, as required by policy. Observations revealed unattended narcotic record books and inconsistently signed count sheets, indicating a lack of adherence to procedures. Interviews with staff highlighted gaps in training and oversight, contributing to the deficiency.
The facility failed to ensure accurate administration and documentation of Oxycodone for several residents, leading to significant medication errors. Despite policies requiring documentation in both the electronic medical record and Control Substance Record, there were numerous instances of undocumented administrations. Interviews revealed a lack of adherence to protocols and confusion among nursing staff regarding documentation responsibilities.
The facility failed to provide time-stamped electronic medication administration records for nine residents, hindering verification of proper medication administration. Staff interviews revealed a lack of knowledge and capability to access or print these records, leading to potential issues with medication timing and compliance with state regulations.
A resident with end-stage renal disease and upper extremity impairment was not provided with an accessible call device, relying on a roommate for assistance. Despite being cognitively intact and on hospice care, the resident's call bell was often out of reach, highlighting the facility's failure to accommodate their needs.
Two residents with dementia and other conditions experienced multiple falls, but their Comprehensive Care Plans were not updated to reflect these incidents and corresponding interventions. The facility's policy required care plans to be revised after each fall, but this was not consistently done, as acknowledged by the DON.
A resident with Alzheimer's and dementia, whose primary language is Spanish, did not receive adequate interpreter services in a facility. Staff used inconsistent methods like Google Translate and gestures, failing to provide effective communication. The facility had a policy for interpreter services, but staff were not properly trained or aware of how to access these resources.
The facility failed to provide meaningful activities for two residents, both with dementia and primarily Spanish-speaking. One resident was often found in bed and refused activities, while the other was anxious and unable to participate in activities not conducted in Spanish. The lack of language-appropriate activities contributed to the deficiency.
The facility failed to follow its enteral feeding protocols for two residents, leading to deficiencies in labeling and timely disposal of multiuse feeding sets and formula bottles. One resident, who was cognitively intact, had opened bottles of Jevity not labeled with the time opened and not discarded within 48 hours. Another resident, with severe cognitive impairment, had similar issues with labeling and disposal of feeding sets. Staff interviews confirmed the inconsistency in following procedures.
A resident with chronic respiratory failure did not have their oxygen tubing changed as ordered by the physician. The facility's records showed the tubing was last changed over a week before the scheduled change, and there was no documentation of a change on the required date. The DON acknowledged the lack of oxygen tubing labels and relied on medical record documentation to track changes.
The facility failed to properly label and store medications, with issues including unlabeled open medications, incorrect refrigerator temperatures, and improper storage of non-medication items in narcotic cabinets. Observations revealed that medications lacked open and expiration dates, eye drops were not labeled with residents' names, and a narcotic box was left unlocked. Additionally, non-medication items like a wedding band and open food cups were found in medication storage areas.
A resident with type 1 diabetes experienced multiple instances of elevated blood sugar levels that exceeded the threshold for physician notification. Despite the facility's policy requiring notification for significant changes, nursing staff administered insulin but failed to inform the physician of these critical results. Interviews indicated inconsistent communication practices, contributing to the deficiency.
The facility failed to report two incidents of injuries of unknown origin to the New York State Department of Health within the required timeframe. One resident with severe cognitive impairment was found with bruising, which the facility attributed to the resident's behaviors. Another resident was observed with discoloration around the eye, which was linked to self-harming behaviors and medication effects. The facility's interdisciplinary team concluded there was no abuse and did not report the incidents, revealing a misunderstanding of reporting requirements.
A resident with dementia and a history of aggression was not allowed to return to the facility after hospitalization due to insufficient staffing to provide 1:1 care. The facility was unaware of the resident's violent history at admission, leading to safety concerns for others. The resident's aggressive behavior continued, and the facility decided not to readmit them, resulting in a deficiency in staffing and care provision.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately notify the physician of a significant change in a resident's condition, leading to a deficiency. Resident #115, who had a history of chronic respiratory failure, experienced increased congestion and cough. Despite the resident's health care proxy expressing concern to a registered nurse, and the nurse noting altered mental status, decreased oxygen saturation, and abnormal lung sounds, there was no documented evidence that the physician was notified of these changes. Consequently, there were no new orders to manage the resident's symptoms. The resident was admitted with diagnoses including chronic respiratory failure, chronic kidney disease, and anxiety. Upon readmission from the hospital, the resident was noted to be alert and oriented, with stable vital signs and no respiratory distress. However, over the following days, the resident's condition worsened, showing signs of respiratory distress and altered mental status. Despite these changes, the physician was not informed, and the resident was later found unresponsive and expired after a code blue was activated. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's deteriorating condition. The registered nurse involved recalled discussing the resident's congestion with the family but failed to notify the physician adequately. The medical doctor stated they were unaware of the resident's respiratory distress and would have taken action had they been informed. This lack of communication and failure to follow the facility's policy on notifying physicians of significant changes in a resident's condition resulted in actual harm to the resident.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the use of plastic flatware for meals and inappropriate communication by staff. Specifically, four residents were provided with plastic flatware instead of silverware, without any explanation or care plan indicating the necessity for such utensils. These residents, who were cognitively intact, expressed confusion and dissatisfaction with the use of plasticware, which was not part of their care plan. Interviews with staff revealed a lack of awareness regarding the use of plasticware for these residents, indicating a breakdown in communication and adherence to care plans. Additionally, two residents were not spoken to in a dignified manner by staff members. One resident, who was severely cognitively impaired and hard of hearing, was yelled at by a Certified Nurse Aide and a Registered Nurse during care activities. The staff members justified their actions by citing the resident's hearing impairment, but this approach was not aligned with the facility's policy on treating residents with dignity and respect. Another resident, who was also severely cognitively impaired, experienced a similar lack of respectful communication when a Certified Nurse Aide shouted at them during a care interaction. The facility's policies on dignity and resident rights were not effectively implemented, as evidenced by the observations and interviews conducted during the survey. The use of plasticware was not consistently care planned, and staff communication with residents did not always adhere to the standards of respect and dignity outlined in the facility's policies. These deficiencies highlight a need for improved staff training and adherence to care plans to ensure that all residents receive care that promotes their dignity and quality of life.
Facility Fails to Maintain Clean Environment Due to Malfunctioning Sanitizers
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of unclean walls beneath hand sanitizer dispensers and a soiled building exterior. On several occasions, surveyors noted streak stains descending from the dispensers to the baseboards outside various rooms on different resident units. Additionally, the front of the building was observed to be stained with a black build-up and a green mold-like substance around the windows and along the bottom portion of the facade. Interviews with staff revealed that the hand sanitizer dispensers were malfunctioning, often empty or clogged, causing the gel to squirt onto the walls rather than into users' hands. Housekeeping staff acknowledged that while they clean the walls periodically, it is not done daily, and there was no clear plan to address the issue. The Director of Plant Operations mentioned plans to repair the building's exterior, but no immediate corrective actions were noted in the report.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, as observed during a recertification survey. Resident #22, who had chronic pain syndrome and other medical conditions, was not consistently assessed for pain or administered pain medication as ordered. Observations showed the resident in visible discomfort, and interviews revealed the resident could not recall when they last received pain medication. Documentation issues were noted, including illegible signatures on narcotic administration records and missing records for certain dates, indicating a lack of accountability and monitoring of pain management. Resident #25, with a history of chronic pain and a neck fracture, also experienced inadequate pain management. The resident's pain levels were not consistently documented before or after administering pain medication, and there were missing narcotic administration records for several dates. Interviews with the resident and staff highlighted inconsistencies in administering pain medication, with the resident expressing concerns about not receiving medication consistently. Resident #317, who had osteoarthritis and Alzheimer's Disease, was observed in pain but did not receive timely pain medication. The facility's failure to adhere to its pain management policy, which required regular pain assessments and documentation, contributed to the deficiency. Interviews with nursing staff revealed a lack of consistent pain assessment practices and documentation, further exacerbating the issue of inadequate pain management for the residents.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by staffing shortages documented from December 2, 2024, to December 10, 2024. The facility's staffing plan outlined specific minimum staffing levels, which were not met on multiple occasions across all three units. The staffing shortages included a lack of Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs) on various shifts, leading to inadequate coverage and potential impacts on resident care. Interviews with residents and family members highlighted the consequences of these staffing shortages. One resident reported waiting 10-20 minutes for assistance, while another resident expressed dissatisfaction with the wait times, which affected their ability to get up. A family member acknowledged the kindness of the staff but noted there were not enough of them to meet the residents' needs effectively. The facility's nurse schedulers and administrators were aware of the staffing issues, with efforts being made to address the problem, such as hiring new nurses and offering incentives for extra shifts. However, challenges persisted, including call-ins and scheduling gaps, particularly on Thursdays and Fridays. Despite attempts to use agency staff and shift swaps, the facility struggled to maintain adequate staffing levels, impacting the overall care and well-being of the residents.
Narcotic Count Documentation Deficiency
Penalty
Summary
The facility was found to have insufficient nursing staff with the appropriate competencies and skills to ensure resident safety and well-being. Specifically, the nursing staff failed to document the counting of unit narcotics by two licensed staff members, as required by the facility's narcotic record sheets. Observations revealed that the narcotic record book was left unattended on top of the medication cart in the hallway, accessible to anyone passing by. Additionally, narcotic count sheets were inconsistently signed, indicating that the required shift-to-shift narcotic counts were not being conducted properly. Interviews with facility staff, including the Nurse Educator, Administrator, and Director of Nursing, highlighted a lack of adherence to established policies and procedures regarding narcotic counts. The Nurse Educator was unable to explain the discrepancies in the narcotic count sheets, while the Administrator admitted to not knowing the specific policy details. The Director of Nursing confirmed that the narcotic count should be conducted by two licensed staff members at each shift change, with both staff members signing the sheets together. However, this practice was not consistently followed, leading to unsigned or incorrectly signed narcotic count sheets. The facility's training and competency assessment processes were also scrutinized. The Nurse Educator stated that Licensed Practical Nurses and Registered Nurses received orientation training, including medication competencies, which were reviewed annually. Despite these measures, the facility's failure to ensure proper narcotic count documentation and adherence to policies suggests gaps in staff training and oversight. The use of a staffing agency with a star rating system was mentioned, but it was unclear how effectively this system ensured staff competency in practice.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration and documentation of Oxycodone, a narcotic pain medication, for four residents. The facility's policy required that all medications, including narcotics, be administered by a licensed nurse and documented in both the electronic medical record and the Control Substance Record. However, there were numerous instances where Oxycodone was administered to residents without proper documentation in the Medication Administration Record, leading to discrepancies in medication records. Resident #3, who was cognitively intact and had a history of chronic pain, was prescribed Oxycodone for pain management. Despite the physician's order for administration every six hours as needed, the Medication Administration Record frequently lacked documentation of the administered doses, while the Control Substance Record indicated multiple administrations. Similar issues were observed with Resident #12, who had diagnoses of diabetes and joint disease, and Resident #22, who had chronic pain syndrome and moderately impaired cognition. Both residents received Oxycodone without consistent documentation in the Medication Administration Record, leading to potential medication errors. Interviews with nursing staff revealed a lack of awareness and adherence to documentation protocols. Licensed Practical Nurses and Registered Nurses were not consistently documenting narcotic administrations, and there was confusion regarding the responsibility for checking and verifying medication records. The Director of Nursing acknowledged the issue but was unaware of any problems with documenting PRN medications. The facility lacked a nurse signature sheet, and there were discrepancies in signatures on the Control Substance Records, further complicating the accountability for medication administration.
Deficiency in Medication Administration Documentation
Penalty
Summary
The facility failed to administer medications in a manner that ensured the highest practicable well-being of its residents, as evidenced by the lack of documented proof of electronic medication administration with time stamps. This deficiency affected nine residents, as the facility could not provide records showing the actual time medications were administered, which is crucial for verifying that medications were given as ordered. Despite requests from surveyors, the facility was unable to produce time-stamped electronic medication administration records during the survey period. The facility's policies and procedures, as outlined in their documents, require that medications be administered by licensed nurses and documented using electronic medical records. However, the facility's system did not record the exact time medications were given, except for PRN medications. This lack of time-stamping could lead to issues with medication administration, such as medications being given too close together, which was a concern expressed by the Registered Nurse Unit Manager. The inability to audit the exact times of medication administration further compounded the issue. Interviews with facility staff, including the LPN, RN Unit Manager, Administrator, and Director of Nursing, revealed a lack of knowledge and capability to print or access the required electronic medication administration records in a format that included time stamps. The staff indicated that the system only allowed for medications to be checked off without recording the specific time of administration, which hindered the facility's ability to ensure compliance with medication administration guidelines and state regulations.
Failure to Provide Accessible Call Device for Resident
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease and upper extremity impairment had access to a call device they could use. The resident, who was cognitively intact and admitted to hospice for end-of-life care, was observed multiple times with a push button call bell that was not accessible. The resident expressed that they were unable to use the call bell due to their condition and relied on their roommate to call for help. Despite the resident's need for a more accessible call device, the facility did not provide a suitable alternative in a timely manner. Observations over several days revealed that the resident's call bell was often out of reach, even after a tap call bell was provided. The hospice nurse and a registered nurse acknowledged the issue, with the registered nurse indicating that the call bell should be placed within the resident's reach and not obstructed by blankets. The deficiency was identified as the facility's failure to reasonably accommodate the resident's needs by ensuring they had a functional and accessible call device.
Failure to Update Comprehensive Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised to meet the needs of two residents who experienced multiple falls. Resident #16, who was admitted with dementia, anxiety, and osteoporosis, had falls documented on three occasions. Although the care plan was updated after the second fall, it was not revised following a subsequent fall. The Assistant Director of Nursing acknowledged that care plans were not updated after every fall if an intervention was already in place, but stated that the Director of Nursing should have ensured updates were made. Resident #79, who was admitted with dementia, an above-knee amputation, legal blindness, and anxiety disorder, had falls documented on two occasions. The care plan for falls, which included interventions such as wearing non-skid footwear and ensuring proper lighting, was not updated after the falls. The Director of Nursing confirmed that the care plans should have been updated after each fall, noting that the previous Director of Nursing had not made the necessary updates.
Inadequate Interpreter Services for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide adequate and consistent interpreter services for a resident whose primary language is Spanish, as required by professional standards of care. The resident, diagnosed with Alzheimer's Disease, dementia, and anxiety, was observed to be distressed and speaking Spanish, yet staff did not respond appropriately. During dining observations, the resident required significant redirection and staff communicated with gestures and English, which the resident did not understand. The facility's policy outlined the use of interpreter services for residents who speak a language other than English, but these services were not effectively utilized for the resident. Interviews with staff revealed inconsistencies in the use of interpreter services. The social worker stated that a translation line was available, but staff were not adequately trained or aware of how to access it. Some staff used Google Translate or hand gestures to communicate, while others were unaware of the available resources. The administrator acknowledged the existence of a language line but confirmed there was no specific training provided. This lack of consistent and effective communication support led to the resident not receiving the necessary treatment and services to maintain or improve their language and communication abilities.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide ongoing programs that support each resident's choices of activities, which are designed to meet their interests and support their physical, mental, and psychosocial well-being. This deficiency was observed in two residents. One resident, who was diagnosed with dementia, anxiety, and was hard of hearing, was found in bed during multiple observations and did not attend meaningful activities. The resident's activity log showed refusals for various activities, and the activities aide, who did not speak Spanish, had limited interaction with the resident. Another resident, diagnosed with Alzheimer's Disease and dementia, primarily spoke Spanish and was observed pacing anxiously. The activities offered, such as BINGO and cooking club, were not conducted in Spanish, limiting the resident's ability to participate. The resident was observed to be happy and engaged when visited by a Spanish-speaking visitor who brought Latin music. The facility's failure to provide activities in the resident's preferred language contributed to the deficiency.
Failure to Adhere to Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that residents receiving enteral feeding were provided with appropriate treatment and services to prevent complications. Specifically, for two residents, the facility did not adhere to its policy and procedure regarding the labeling and timely disposal of multiuse feeding sets and bottles of formula. Resident #114, who was cognitively intact and had a gastrostomy, was observed with opened multiuse bottles of Jevity that were not labeled with the time opened and were not discarded within the required 48 hours. Additionally, multiuse feeding sets were not changed every 24 hours as per the facility's policy. Similarly, Resident #172, who had severe cognitive impairment and a gastrostomy, was found with an opened multiuse bottle of Jevity that was not labeled with the time opened and was not discarded within the required timeframe. The multiuse feeding set in the resident's room was also not dated, indicating a failure to follow the facility's policy. Interviews with nursing staff confirmed that the labeling and disposal procedures were not consistently followed, contributing to the deficiency identified during the survey.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that a resident received respiratory care consistent with professional standards of practice. Specifically, the oxygen tubing for a resident with chronic respiratory failure and hypoxia was not changed as ordered by the physician. The physician's order required the oxygen nasal cannula and tubing to be changed weekly on Sunday during the night shift. However, observations and record reviews revealed that the tubing was not changed on the specified date, and there was no documentation to indicate that the change occurred. The resident involved was cognitively intact and received continuous oxygen therapy due to chronic respiratory failure with hypoxia. During an observation, it was noted that the oxygen tubing lacked a date, and the Treatment Administration Record confirmed that the last change occurred over a week prior to the scheduled change. The Director of Nursing acknowledged the oversight and mentioned that the facility did not have oxygen tubing labels, relying instead on documentation in the medical record to track changes.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards in two medication rooms and three medication carts. Specifically, opened medications lacked open and expiration dates, and stock eye drops were not labeled with residents' names. Additionally, the medication refrigerator's temperature was outside the therapeutic range, and non-medication items were improperly stored in the narcotic cabinet. A narcotic box was not secured with a double lock, and open cups of food were found in a medication cart. During observations and interviews, it was noted that a Humalog Kwik pen was not labeled with an open or expiration date, and an albuterol inhaler lacked a clear expiration date. A narcotic box contained a wallet and a medic alert of an expired resident, and another narcotic box was left unlocked. Eye drops were not labeled with residents' names, and the medication refrigerator was at an incorrect temperature. Non-medication items, such as a wedding band and open food cups, were found in medication storage areas. The facility's policies on medication storage and administration were not adhered to, contributing to these deficiencies.
Failure to Notify Physician of Critical Blood Sugar Levels
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results that were outside of clinical reference ranges for a resident with type 1 diabetes. The resident's blood sugar levels were consistently above the threshold that required physician notification, as per the physician's orders. On multiple occasions, including specific dates in July 2024, the resident's blood sugar levels were recorded as significantly high, yet there was no documentation indicating that the physician was informed of these critical results. The resident, who was cognitively intact and able to communicate effectively, had a care plan that required maintaining blood sugar levels within a therapeutic range. Despite this, the nursing staff administered insulin according to the prescribed scale but failed to notify the physician when the blood sugar levels exceeded 400, as required. Interviews with nursing staff revealed a lack of consistent communication with the physician regarding these elevated blood sugar levels, which was a deviation from the facility's policy and procedure for notifying physicians of significant changes in a resident's condition.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, to the New York State Department of Health within the required timeframe. Specifically, two incidents involving residents with injuries of unknown origin were not reported. The facility's policy mandates that such incidents be reported immediately, but not later than two hours after the allegation is made. However, in the cases of Resident #2 and Resident #3, the facility conducted internal investigations but did not report the incidents to the state agency. Resident #2, who had severe cognitive impairment and a history of behavioral disturbances, was found with bruising on the chest and shoulder area. The facility's investigation concluded that the bruising was likely due to the resident's behaviors, such as pushing a tray table into themselves and not wearing a bra, which could cause the breasts to get caught in the gait belt. The interdisciplinary team determined that there were no signs of abuse or neglect and decided not to report the incident. Resident #3, also with severe cognitive impairment, was observed with discoloration around the left eye. The resident's son requested an X-ray, which showed no abnormal findings. The facility's investigation noted that the resident had been observed exhibiting behaviors that could have caused the injury, such as repeatedly hitting their head on a table. Additionally, the resident was on a blood-thinning medication, which could contribute to bruising. The interdisciplinary team concluded that there was no indication of abuse and chose not to report the incident. Interviews with facility staff revealed a misunderstanding of the requirement to report all injuries of unknown origin, regardless of the outcome of the internal investigation.
Deficiency in Staffing and Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of a resident, leading to a deficiency in providing care. A resident with a history of unspecified dementia with behavioral disturbance, PTSD, and Alzheimer's Disease was sent to the hospital for evaluation due to aggressive behavior. After being medically cleared, the resident was not permitted to return to the facility because the facility stated they could not provide 1:1 care upon readmission. The facility's policy required documentation of specific needs that could not be met, attempts to meet those needs, and the services available at the receiving facility, which was not adequately followed. The resident had a documented history of violent behaviors, and during their short stay at the facility, they exhibited aggressive actions towards other residents and staff. The facility attempted to medicate the resident, but they refused to take the medication. The facility's administration was unaware of the resident's violent history at the time of admission, which was noted on the last page of the admission paperwork. The resident's aggressive behavior continued, leading to their transfer to the hospital, and the facility decided not to readmit the resident due to safety concerns for others. Interviews with the Nursing Home Administrator revealed a breakdown in communication and awareness of the resident's history prior to admission. The facility's process for transferring residents involved social work assistance, but in this case, the resident was not set up for a safe discharge. The facility's inability to provide adequate care and ensure the safety of other residents resulted in the decision not to allow the resident to return, highlighting a deficiency in staffing and care provision.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Amsterdam
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Ridge Living Center | 5.3 mi | ★★★★★ | 2 | 0 |
| Wilkinson Residential Health Care Facility | 6.4 mi | ★★★★★ | 0 | 0 |
| Baptist Health Nursing And Rehabilitation Center | 9.4 mi | ★★★★★ | 0 | 0 |
| Glendale Home-schdy Cnty Dept Social Services | 10.3 mi | ★★★★★ | 7 | 0 |
| Pathways Nursing And Rehabilitation Center | 12.1 mi | ★★★★★ | 0 | 0 |
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