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 Casa Promesa during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of elopement, equipped with a wander alert device, exited the facility undetected after a security guard, untrained on the wander alert system, mistakenly allowed the resident to leave and failed to respond to the alarm. Staff monitoring and communication lapses contributed to the delayed discovery of the resident's absence.
The facility failed to update comprehensive care plans for four residents following incidents of resident-to-resident altercations. Despite documentation of the incidents, care plans were not revised to reflect changes in residents' status. Interviews with the Director of Social Services and the DON revealed a lack of clarity regarding responsibility for updating care plans.
The facility did not adhere to professional standards for storing medications and biologicals. Expired Heparin syringes were found in the 4th Floor Medication Room, and food items were improperly stored with IV bags on the 3rd Floor. Staff acknowledged these storage breaches.
The facility was found to have expired food items, including beef stew and frozen omelets, during a recertification survey. The facility's policy requires stock rotation and date marking, but the Assistant Food Manager acknowledged an oversight in checking expiration dates.
A resident's right to refuse care was not respected when a CNA forcefully provided care despite the resident's refusal, citing concerns about skin integrity. The facility's policy emphasizes self-determination, but the CNA did not report the refusal to nursing staff. Interviews with other staff indicated that the proper protocol was not followed.
A resident with COPD and other conditions received oxygen at a flow rate inconsistent with the physician's order, and there was no documentation of when the oxygen tubing was last changed. Staff were unaware of the discrepancy, and the facility's policy on oxygen therapy was not followed.
The facility's Infection Preventionist did not complete the required specialized training in infection prevention and control, as identified during a survey. Despite being in the role since early 2023, the Infection Preventionist only had a certificate in Infection Control and Barrier Precautions, which did not meet the requirement. Interviews revealed that the Infection Preventionist, Director of Nursing, and Administrator were unaware of the training requirement.
During a life safety code survey, it was observed that a Christmas tree in the third floor lounge was plugged into an unapproved power strip, violating NFPA codes. This was noted on one of the four units surveyed.
The facility did not maintain fully functional lighting in the egress path of a stairwell leading to Anthony Avenue, with two lighting tubes partially illuminated. This was observed during a life safety code survey, affecting one out of four units. The Maintenance Director was informed of the issue.
The facility did not ensure that the soiled utility room door on the fourth floor latched properly, as observed during a life safety survey. The door to room 425 failed to latch when tested, and the maintenance director acknowledged the issue.
The facility inaccurately documented antiviral medications as antibiotics for three residents due to an electronic medical record system error. Additionally, a resident was incorrectly assessed with Non-Alzheimer's Dementia despite having no such diagnosis. These inaccuracies were identified during a recertification survey.
The facility failed to provide two residents with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) upon the termination of their Medicare Part A benefits. The Minimum Data Set Coordinator, responsible for informing residents about their Medicare coverage, was unaware of this requirement, leading to a deficiency under regulation 10 NYCRR 415.3(h)(2)(i).
A resident with a mood disorder and aphasia reported verbal abuse by a CNA to a Social Worker a week after the incident. The Social Worker placed the grievance in the DON's mailbox, leading to a delayed report to the Department of Health, contrary to the facility's policy requiring immediate reporting.
Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision and Staff Training
Penalty
Summary
A resident assessed as cognitively impaired and at risk for elopement, with a history of previous elopement attempts, exited the facility undetected. The resident was admitted from the hospital with diagnoses including deafness, dementia related to a communicable disease, and altered mental status. Hospital records indicated the resident lacked capacity and had a history of attempting to leave care settings. Upon admission, the resident was identified as an elopement risk, and a wander alert device was placed on their ankle. The care plan included interventions such as ensuring proper placement and function of the wander alert device, informing staff of the elopement risk, and providing the resident's picture to security. Despite these measures, the resident was able to leave the facility without detection. On the day of the incident, the resident was last seen at 10:00 AM during hourly monitoring. Surveillance footage showed the resident leaving their room, entering the elevator, and exiting through the main lobby. The security guard at the front desk released the door for the resident, mistaking them for an employee, and did not recognize the activation of the wander alert alarm. The security guard heard a beeping sound after the resident exited but did not investigate, search the lobby, or notify other staff. The security guard later stated they had not been educated on the wander alert system or the appropriate response to an alarm. The resident's absence was not discovered until a visual check at 11:00 AM, at which point a search and Code Yellow were initiated. Interviews with staff revealed gaps in monitoring and communication. The certified nursing assistant assigned to the resident did not observe the wander alert device during vital sign checks and was unaware of the resident's whereabouts until after the elopement. The security guard was new and had not received training on elopement prevention or the wander alert system. The resident's picture had not been obtained for security purposes, and there was no documented evidence of staff education on the wander alert system. The facility's policies required the use of wander management systems and staff accountability for resident safety, but these were not effectively implemented, resulting in the resident's undetected elopement.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to ensure that comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team following incidents of resident-to-resident altercations. The care plans were not updated to reflect changes in the residents' status after these incidents, which is a requirement as per the facility's policy. The incidents involved verbal and physical altercations between residents, which were documented in the facility's records but not followed by necessary updates to the care plans. Resident #42, diagnosed with Bipolar Disorder and Anxiety Disorder, was involved in a verbal altercation with Resident #51, who has Peripheral Vascular Disease and PTSD. The altercation was triggered by transphobic text messages sent by Resident #42 to Resident #51. Despite the incident being documented and verified, there was no evidence that the care plans for either resident were reviewed or revised to include new interventions addressing the altercation. Similarly, Resident #50, with severe cognitive impairment, was involved in a physical altercation with Resident #61, who has Alcohol Dependence and other diagnoses. Resident #61 threw water at Resident #50 without apparent cause. Although the incident was documented, the care plans for both residents were not updated to reflect the altercation. Interviews with the Director of Social Services and the Director of Nursing revealed a lack of clarity and responsibility regarding the updating of care plans following such incidents.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Director of Social Services on 12/09/2024 and 12/10/2024 conducted care plan reviews and revision to assess Resident #42, Resident #50, Resident #51, and Resident #61 for physical, emotional, and behavioral changes post-altercation. DSS updated findings in the medical records and ensured appropriate interventions were implemented. The updated care plans include specific behavioral interventions, safety measures, and triggers identified during the assessment. - The Director of Social Services conducted an urgent IDT huddle on 12/10/2024 to review and revise care plans for all residents involved in the incident. The IDT team was informed of the care plan updates and instructed on implementing the new interventions. Identification of Others Potentially Affected: The facility respectfully submits all residents were reviewed and were not affected by this practice. System Changes to Prevent Recurrence: - The Compliance team on 12/12/2024 reviewed the facility’s care plan policies. No amendments were needed. The Compliance officer re-in-serviced the DSS and social workers to mandate immediate IDT care plan reviews and updates following significant resident incidents, such as altercations, falls, or changes in condition. - The Social Services team and senior nursing team received mandatory training on 12/12/2024 by the compliance officer on Identifying triggers for care plan updates, Proper documentation of incidents and interventions, Collaboration during care plan reviews, and implementing a communication system to ensure direct care staff promptly report significant resident incidents to the IDT for review. - The Compliance team on 12/13/2024 instilled protocol for monitoring and documenting behavior changes following incidents, and responsibilities for ensuring care plan alignment. IDT and all direct care staff as of 12/31/2024 were in-serviced. Quality Assurance Monitoring: - The DSS will perform weekly audits of resident incident reports to verify care plan updates were completed for all significant changes. The DSS will also review a random sample of 10% of care plans weekly for three months to ensure they reflect the resident’s current status and needs. - The audit results will be discussed at monthly Quality Assurance (QA) meetings to adjust training or policies based on findings from the ongoing audits. - The Performance Metrics is set at a compliance target of 100% for care plan updates following significant resident-to-resident incidences. - Audit Tool created. Responsible Party: Director of Social Services
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored according to professional standards of practice, as observed during the Recertification Survey. On the 4th Floor Medication Room, nineteen Heparin lock flush syringes with expired dates were found in a drawer, indicating a lapse in removing expired medications from storage. Registered Nurse #2 acknowledged that medications should be used by their expiration date to maintain effectiveness. Additionally, in the 3rd Floor Medication Room, food items such as plastic containers of coffee and coffee creamer were improperly stored next to intravenous fluid bags inside a cabinet. Both Registered Nurse #3 and the Director of Nursing confirmed that food should not be stored in the Medication Room, highlighting a breach in the facility's policy on Medication Storage and Handling.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - All expired medication (19 [MEDICATION NAME] lock flush syringes) were removed and discarded from Unit 3 (4th floor) medication room. - All food items were removed from Unit 2 (3rd floor) medication room. - RN #3 and RN #4 were re-educated on the Medication Labeling / Storage policy and procedure. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - All Unit RN Managers will do daily rounds to ensure all medications rooms, drawers and cabinets are free from expired Medication and food. - Review of the Medication Storage and Handling Policy was done on 12/13/24. The policies align with the current standards and professional practice and regulatory guidelines. No modifications made. - All Nurses will be re-educated on the policy. - The Pharmacy Consultant will audit unit medication carts when onsite monthly for expired medications. Quality Assurance Monitoring: - The Director of Nursing developed a tool to audit all medication rooms and medication carts. - Audits will be performed by the Director of Nursing/designee. - Audits will be performed on all Medication Carts and Medication Rooms, bi-weekly for 3 months, then monthly thereafter, until 95% accuracy is achieved. - The Director of Nursing will maintain a list of negative findings and any corrective actions taken including but not limited to immediate reporting to the Administrator/designee, re-education of involved staff and progressive disciplinary actions. - Audit findings will be reviewed and presented to the QAPI Committee at least quarterly for needed revisions in the action plan, and improvement of our delivery and resident outcomes. - The lesson plan for this plan of correction will be included in the facility’s orientation and annual training of all Nurses. Responsible Party: Director of Nursing
Expired Food Storage Deficiency
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. During an initial tour of the kitchen, surveyors found multiple cans of expired beef stew in the emergency food storage and expired frozen omelets in the kitchen freezer. The facility's undated food storage policy requires that all stock be rotated with each new order received, using the First in - First out method, and that food be dated as it is placed on shelves. However, the Assistant Food Manager admitted during an interview that the expired food was an oversight and that they did not check the dates during rounds.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - All expired food was immediately removed and discarded. - Assistant Food Manager and Food Manager doubled check all emergency food storage for expired food. - Assistant Food Manager and Food Manager was re-educated on the food storage safety policy. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - The Compliance Officer reviewed the food storage safety policy on [DATE] and no modifications were made. The policy and procedure align with the standardized state and regulatory requirements. - The Compliance Officer in-serviced all kitchen staff on [DATE] on the food storage safety policy. - In order to improve our current intake monitoring system, we are implementing a check and balances rotation checkup form, which will consist of cataloging our inventory with the dates in which everything was received, contrasted with the expiration date on said products. Quality Assurance Monitoring: - Food Manager and Assistant Food Manager will audit the emergency food storage biweekly for 3 months, thereafter monthly. - All findings and/or deficiencies will be highlighted during the QAPI monthly meetings. - Audit tool was created and implemented for ongoing monitoring. Responsible Party: Food Manager/ Assistant Food Manager
Failure to Respect Resident's Right to Refuse Care
Penalty
Summary
The facility failed to respect and facilitate a resident's right to self-determination, specifically regarding the refusal of care by Resident #43. The resident, who had intact cognition and was dependent on staff for personal hygiene and other activities of daily living, reported an incident where their choice to refuse care was not respected. On one occasion, Certified Nursing Assistant #2 forcefully provided care despite the resident's refusal, which included removing the resident's covers and incontinence briefs against their will. This incident was reported by the resident to the administration, highlighting a breach in respecting the resident's autonomy and choice. The facility's policy on resident rights emphasizes the importance of self-determination and respect for resident choices. However, during the survey, it was found that the staff did not adhere to this policy. Certified Nursing Assistant #2 admitted to forcing care due to concerns about the resident's skin integrity but failed to report the resident's refusal to the nursing staff. Interviews with other staff members, including a Licensed Practical Nurse and a Registered Nurse, indicated that the proper protocol would have been to report the refusal and attempt to offer care later. The Director of Nursing and the Administrator acknowledged the grievance filed by the resident and reiterated the importance of respecting residents' rights to refuse care.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Administrator held an audio conference with the Director of Nursing, Assistant Director of Nursing, and Compliance Officer on 12/06/2024 to review the current facility's policy titled Resident's Bill of Rights dated 10/2022; and strategize on maintaining fidelity during residents’ refusal of care to assure that all residents are guaranteed the right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration, and privacy in treatment and care while at the facility. The policy remains intact. - The Facility Administrator and Director of Nursing issued a memorandum on 12/06/2024 to resident #43, and all other residents and care unit representatives to reassure their bill of rights while at the facility in accordance with CFR(s): 483.10(f)(1)-(3)(8). Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - Resident #43 was interviewed on 12/09/2024 by the Director of Social Services to identify/address any additional grievances. Resident #43 did not have any additional grievances and requested to remain at the facility. - RN #2, LPN #2, CNA #2, and all other direct resident care nursing staff including the Interdisciplinary team were re-in-serviced on Resident Bill of Rights and Refusal of Care & Non-Adherence to Care Plan from 12/09/2024 to 12/12/2024 by the ADON. - From 12/09/2024 to 12/21/2024, the DON and RN Managers reviewed the nursing notes in Sigma care for all residents during the period of 08.2024 – 12.2024 to identify any refusal of care and reconciliation outline. No additional defective practice was identified. RN Managers and DON will observe ADLs (change of linens, grooming, etc.) for residents 2x per week over the next eight weeks. Quality Assurance Monitoring: - An audit tool has been created and implemented for ongoing monitoring. - The Director of Nursing Services will perform weekly audits for randomized resident(s) for the next 4 months, then quarterly thereafter to sustain 100% compliance. Defective Practices will be reported to the compliance team and findings presented to the quarterly QAPI team meetings. Responsible Party: Director of Nursing
Inconsistent Oxygen Therapy and Lack of Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for a resident diagnosed with Chronic Obstructive Pulmonary Disease, Hypertension, and Chronic Kidney Disease. The resident was observed receiving oxygen at a flow rate of 5 liters per minute, which was not consistent with the physician's order of 3 to 4 liters per minute. This discrepancy was noted over several days, and there was no documented evidence in the electronic medical record of a physician's order to increase the oxygen flow rate. Additionally, the facility did not document when the oxygen tubing was last changed for the resident, as required by their policy. Licensed Practical Nurses and the Registered Nurse were unaware of the change in oxygen flow rate and could not provide information on when the tubing was last changed. The Director of Nursing Service confirmed that oxygen should be administered as per the physician's order and that tubing should be changed weekly and dated, but this was not being documented in the medical record.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - The DON and ADON on 12/04/2024 and 12/05/2024 immediately assessed and informed resident #36 and all other applicable residents to ensure they were receiving oxygen at the correct flow rate or replace any oxygen tubing as outlined in the physician’s order. The IDT team simultaneously reviewed resident #36 care plans and checked for any adverse effects due to the incorrect flow rate. - The Physician Assistant performed a general evaluation on 12.05.2024 to identify any symptomatic or chief complaints as a result of the error. No adverse effects were identified as of 01/02/2024. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - The Facility’s Policy and Procedure titled Oxygen therapy was reviewed by the IDT team on 12/12/2024. No amendments were made. - The compliance team and DON created and enforced the respiratory care policies dated 12/12/2024 to include verification of oxygen flow rates against physician orders [REDACTED], scheduled changes of oxygen tubing with proper documentation and labeling. - As of 01/02/2024, 100% direct nursing care staff (RNs and LPNs) were in-serviced on the respiratory care policy, ensuring oxygen flow rates align with physician orders [REDACTED]. - Audit tool created. Quality Assurance Monitoring: - The ADON will perform weekly audits for the first month, then monthly thereafter. Audit results will be reviewed in monthly QAPI meetings to assess compliance and determine if further action is necessary. Responsible Party: Assistant Director of Nursing Services
Infection Preventionist Lacks Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had completed the required specialized training in infection prevention and control. This deficiency was identified during a recertification survey conducted from December 2, 2024, to December 9, 2024. The review of the Infection Control Task revealed that the Infection Preventionist, who had been in the role since early 2023, did not have documented evidence of completing the necessary specialized training. The facility's job description for the Infection Preventionist clearly stated that the candidate must have completed such training, yet the only documentation provided was a certificate in Infection Control and Barrier Precautions with four contact hours dated February 28, 2023, which did not meet the specialized training requirement. Interviews conducted during the survey further highlighted the lack of awareness regarding the training requirement among the facility's leadership. The Infection Preventionist, Director of Nursing, and Administrator all stated they were unaware of the specialized training requirement for the role. The Infection Preventionist assumed the position without the necessary training, and the Director of Nursing and Administrator were not informed of this requirement, leading to the deficiency in the facility's infection prevention and control program.
Plan Of Correction
Plan of Correction: Approved January 7, 2025 Immediate Corrective Action: - Assistant DON (Infection Preventionist) successfully completed the specialized training in infection prevention on 12/03/24. - In addition, we will continue the support of The Infection Control Preventionist from our Nurse Practitioner who provides additional onsite support. - DON and Assistant DON was re-educated on the Infection Preventionist policy and procedure. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - Compliance Officer reviewed and revised the Infection Preventionist job description and policy and procedure on 12/05/24. - DON, ADON and NP were in-serviced on the revised job description and policy and procedure on 12/10/24. - ADON and Nurse Practitioner will actively participate in IPRO QIN QIO that offers free access to AHCA/NCAL’s Infection Preventionist Specialized Training (IPCO). - Audit tool has been created and put into place for ongoing compliance monitoring. Quality Assurance Monitoring: - Infection Preventionist is a member of the facility’s QAA Committee. The Infection Preventionist routinely report to the QAA Committee on the facility’s IPCP. - Audit tool has been created and put into place for ongoing compliance monitoring. - The Director of Nursing will conduct auditing and monitoring to ensure surveillance and monitoring of active infections in the facility is being implemented, and the ADON (Infection Preventionist) is receiving specialized education and training. After 4 weeks of weekly monitoring and demonstrating that expectations are being met, monitoring will reduce to twice monthly for one month. Monthly monitoring will continue at a minimum for 2 months. Responsible Party: - Assistant DON and Nurse Practitioner
Non-compliance with Power Strip Regulations
Penalty
Summary
The facility failed to ensure the use of approved UL listed power strips, as observed during a life safety code survey. On the third floor lounge area, a Christmas tree was found plugged into an unapproved power strip. This observation was made on one out of four units, indicating non-compliance with specific NFPA codes.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and Facility Supervisor on 12.03.2024 removed the unapproved power strip on the third floor of the facility. A Christmas tree was plugged into the extension cord and as such, required a direct outlet. The Maintenance team rectified this deficiency as of 12.04.2024. The Senior Administrator and Quality Improvement team issued a memorandum on 12.03.2024 to the Maintenance Director and facility team regarding power strips in accordance to CMS K-Tag 920. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Maintenance team are now mandated to have biannual Life Safety Code checklist in-services. The maintenance and facilities supervisor will conduct daily (M-F) maintenance walk-through ensuring existing UL power strips are installed as outlined in K-Tag-920. Quality Assurance Monitoring: The Facility supervisor will audit the daily test logs, monthly test reports and complete the quarterly internal tracker -K category to ensure compliance with the required Life Safety Code lists. Any deficiency identified for K-Tag 920 will be rectified immediately and subjected to quarterly internal audit by the quality assurance unit until substantial measures are enacted. Responsible Party: Facility Supervisor
Deficient Lighting in Egress Path
Penalty
Summary
The facility failed to ensure that the lighting in the path of egress was fully functional. During a life safety code survey, it was observed that the egress path in a stairwell leading to Anthony Avenue had two lighting tubes that were only partially illuminated. This issue was noted on one out of four units. The observation was made on two consecutive days, and the Maintenance Director was informed immediately after the finding.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and Facilities Supervisor on 12.04.2024 effectively replaced the two identified lightbulbs/lighting tubes that were partially illuminated in stairwell egress to (NAME) Avenue - in accordance with NFPA 101 section 7.9. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Maintenance Director and facility team were re-in-serviced on 12.09.2024 for state requirements regarding Means of Egress and TAG K-291: Emergency Lighting specificities by the compliance officer. The Maintenance Director will continue to perform Monthly emergency Lights test - 30 seconds per month hold button; and annual checks of 90 minutes unplugged. In addition, the maintenance team are now required to observe, record and ensure the path of egress is functionally illuminated during daily environmental rounds. Quality Assurance Monitoring: The Maintenance Director will complete the updated daily compliance facilities testing tracker and immediately provide replacement or work order(s) for TAG K291 on the tracker in the event illumination is affected. The Internal Record of Inspection and Testing reports are then reviewed by the facilities Manager and the compliance team. Any deficient practice/findings will be reported for reconciliation during the QA monthly meetings. Responsible Party: Maintenance Director
Improper Latching of Soiled Utility Room Door
Penalty
Summary
The facility failed to ensure that a hazardous area door, specifically the soiled utility room door on the fourth floor, latched completely in its frame. This deficiency was observed during a life safety survey conducted on December 3rd and 4th, 2024, between 09:30 am and 02:30 pm. On December 3rd, at approximately 10:43 am, the door to room 425 was tested and found not to latch properly. During an interview, the maintenance director acknowledged the issue and indicated it would be corrected immediately.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and facility team on 12.03.2024 adjusted the hinges on the door for the Soiled Utility Room (RM-425) that failed to latch in its frame. The facility team on 12.04.2024 successfully completed and tested the requested work order from the Senior Administrator to ensure the Hazardous Area – (RM-425) designated as the Soiled Utility Room was equipped with a door that properly latched. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Compliance Officer has updated the daily compliance facilities testing tracker to identify hazardous areas that are artificially propped open or inoperable to latch in its frame. The facility supervisor will observe and test the latches within Hazardous areas during the daily (M-F) maintenance rounds. Any discrepancies will be logged and immediate work order(s) submitted for approval by the executive team. Quality Assurance Monitoring: The Maintenance Director will conduct weekly review/reconciliation on the test logs, monthly test reports and vendor reports to ensure complete compliance with the required Life Safety Code testing lists. Any maintenance/testing that is required will be documented and subjected to quarterly internal audit by the quality assurance unit. Responsible Party: Maintenance Director
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments for four residents during a recertification survey. For three residents, antiviral medications were incorrectly documented as antibiotics in the Minimum Data Set (MDS) assessments. This error was attributed to the electronic medical record system, which automatically classified antivirals as antibiotics. Interviews with the Nurse Unit Manager, MDS Coordinator, and Director of Nursing revealed a misunderstanding of the classification of antiviral medications, which was not aligned with the Resident Assessment Instrument manual or Centers for Medicare and Medicaid Services guidelines. Additionally, the assessment for another resident inaccurately documented a diagnosis of Non-Alzheimer's Dementia, despite the resident having no such diagnosis in their medical records. The resident was noted to have mild cognitive impairment but was alert and oriented. The error was made by the Nurse Unit Manager, who checked off the dementia diagnosis in the MDS assessment. Interviews with the Physician Assistant and Director of Nursing confirmed the absence of a dementia diagnosis in the resident's medical records.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: -The MDS coordinator on 12/06/2024 corrected immediately the deficiencies identified to accurately reflect the residents’ clinical diagnoses. The antibiotic checkbox was unticked for Resident #1, Resident #36, and Resident #42, and the corrected MDS was re-submitted to CMS. The MDS for the affected resident #54 was also immediately reviewed, corrected to remove the non-Alzheimer’s dementia diagnosis, and re-submitted to CMS. The error did not affect the residents’ quality of care at the facility. -The DON on 12/06/2024 held an IDT team huddle with the facility’s physician, physician assistant #1, unit RN managers, and individually informed the affected residents of the coding error and the corrective actions taken. -The IDT team from 12/06/2024 to 12/11/2024 performed due diligence in assuring that no care plan changes or interventions were affected by the incorrect coding, and no adverse impact occurred. No additional residents were inaccurately documented during the prior MDS submissions from 08/2024 to 11/2024. -The Compliance team on 12/12/2024 reviewed the facility’s Minimum Data Set Functional Coding Policy. No amendments were needed. Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice, after reviewing MDS records. System Changes to Prevent Recurrence: -The MDS coordinator was re-in-serviced on proper Section N (Medications) coding procedures, emphasizing accuracy and review processes. Training included the importance of cross-referencing the MAR indicated [REDACTED] facilitated by the compliance officer. In addition, training was also provided for proper coding for Section I (Active Diagnoses), including verifying [DIAGNOSES REDACTED] resident’s medical record before coding. -Subsequent to a root cause analysis, the Administrator contacted the MDS software vendor on 12/10/2024 to address the automated logic or interface issues causing incorrect antibiotic selection. Thus, implementing software updates or adjustments to prevent related errors. -The DON on 12/10/2024 instituted a secondary review process for all MDS submissions: A designated staff member (Senior RN Manager or ADON) will verify accuracy before all submission. Quality Assurance Monitoring: -The DON will conduct weekly audits of 10% of MDS submissions for the next 90 days to ensure accuracy in functional coding, with special focus on Section I and Section N. Findings will be reviewed during monthly QA meetings, and adjustments to processes will be made as necessary. -The Performance Metrics is set at a goal of 100% compliance with accurate MDS coding. Any errors identified during audits will be addressed immediately. -Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator
Failure to Provide Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate liability and appeal notices to Medicare beneficiaries, as required by Medicare guidelines. This deficiency was identified during a recertification survey, where it was found that two residents, who were receiving Medicare Part A Skilled Services, were not given the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN- form CMS-10055) upon the termination of their Medicare benefits. The facility's policy mandates the issuance of this notice to inform residents of potential liability for services not covered by Medicare, but there was no documented evidence that the notice was provided to the affected residents. Interviews conducted during the survey revealed that the Minimum Data Set Coordinator, who is responsible for informing residents about their Medicare coverage, was unaware of the requirement to issue the SNF ABN. The Director of Nursing Services stated that they were not involved in the beneficiary notification process, which is handled by the Minimum Data Set Coordinator. This lack of awareness and communication within the facility led to the failure to provide the necessary notices to the residents, resulting in a deficiency under the regulation 10 NYCRR 415.3(h)(2)(i).
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Facility Administrator on 12/09/2024 issued the Minimum Data Set Coordinator a memorandum regarding Medicaid/Medicare Coverage/Liability Notice and updated protocols for ensuring residents are aware of their rights. - An Adhoc meeting was held by the DON on 12/09/2024 with the MDS coordinator and Compliance Officer to review and discuss the notification process and policy. No amendments were made to the policy. Resident #24 and Resident #36 were individually notified at the conclusion of the meeting regarding the ineffective notification and the facility’s commitment to minimizing these deficiencies. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. A list of other residents that remained in the facility and were discharged from a MCR Part A stay were reviewed and will be given the SNFABN as appropriate. Systemic Changes to Prevent Recurrence: - The Compliance officer and DON formulated and reinstated the protocol and procedure for Medicaid/Medicare Coverage/Liability Notification on 12.10.2024. - The MDS coordinator and RN Managers were re-in-serviced on 12.12.2024 by DON for the protocols and procedures regarding NOTIFYING RESIDENTS OF MEDICAID/MEDICARE COVERAGE OR LIABILITY. Quality Assurance Monitoring: - The Minimum Data Set Coordinator will perform weekly audits for residents for the next 2 months, then monthly thereafter to maintain compliance. Any discrepancies identified during the audit will be reported and documented to the DON. The qualitative summary and analytics will be presented quarterly at the QAPI team meetings. - Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the New York State Department of Health within the required timeframe. The incident involved a resident with a diagnosis of persistent mood disorder and aphasia, who reported verbal abuse by a Certified Nursing Assistant. The resident, who has intact cognitive status and uses a wheelchair, reported the incident to the Social Worker a week after it allegedly occurred. The Social Worker then placed the grievance in the Director of Nursing's mailbox, which was not checked until two days later, resulting in a delayed report to the Department of Health. The facility's policy mandates immediate reporting of any alleged abuse to the administrator and relevant authorities. However, the Social Worker did not follow this protocol, leading to a late notification to the Department of Health. Interviews with the Director of Social Services, Director of Nursing, and the Administrator confirmed the delay and acknowledged that the Social Worker should have reported the incident immediately via phone or in person. Attempts to contact the Social Worker for further clarification were unsuccessful.
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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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Nursing homes near Bronx
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bronx Gardens Rehabilitation And Nursing Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Bronxcare Special Care Center | 1 mi | ★★★★★ | 22 | 0 |
| Hope Center For Hiv And Nursing Care | 1.1 mi | ★★★★★ | 0 | 0 |
| Triboro Center For Rehabilitation And Nursing | 1.1 mi | ★★★★★ | 5 | 0 |
| University Center For Rehabilitation And Nursing | 1.3 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 July 2026) and official state health department websites.