Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concord Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that residents’ right to a safe, clean, and homelike environment was not maintained on several units. On multiple floors, strong urine odors were present, resident rooms and bathrooms had brown and black staining on toilets, tiles, walls, and sinks, and equipment such as oxygen concentrators and GT poles were dusty or coated with residue while in use. Common areas, including nurses’ stations, hallways, dining rooms, and shower rooms, showed dark greasy stains, cracked or blackened tiles, rusted fixtures, peeling wallpaper, and visible dirt and debris, with some shower stalls lacking adequately hot water. Housekeeping and maintenance staff reported unclear or inconsistent cleaning responsibilities, reduced staffing, lack of scheduled cleaning for specific items, and acknowledged that floors, tiles, and walls were dirty and in need of replacement, while leadership acknowledged the poor overall condition of the environment.
The facility did not maintain two of three elevators in safe working condition for several months, resulting in restricted resident movement and delays in services. Despite "Not Working" signs on two elevators, one was still used and skipped a floor. Multiple residents reported repeated complaints at council meetings about broken elevators, difficulty leaving their units, and food arriving cold because the service elevator used for meal transport was out of service, requiring use of an alternate elevator. The Director of Recreation acknowledged delays in moving residents and needing to wait or page for an elevator, while the Director of Maintenance and the Administrator confirmed that two elevators were out of service for an extended period and that complaints had been received.
Insufficient weekend nursing staffing was identified when PBJ data and staffing schedules showed repeated CNA and LPN shortages across multiple units and shifts. Staff described heavy assignments, frequent 2-staff assists, Hoyer lift care, and difficulty taking breaks, while residents reported delayed call bell response and poor overnight and weekend coverage. The DON, Staffing Coordinator, and Administrator acknowledged that weekend coverage was difficult and that the facility often relied on overtime, per diem staff, or asking other staff to stay or come in early.
Expired and contaminated food was found in the kitchen and a resident refrigerator, with spoiled onions, stained sauces, and multiple outdated dairy and dressing items observed. The FSD stated some items should have been discarded, while staff gave conflicting accounts about who was responsible for inspecting food, cleaning resident refrigerators, and completing temperature logs. The refrigerator temperature log also lacked entries for several days, and the FSD acknowledged inconsistent monitoring on the ventilator unit.
Unordered hand mitten restraint used without required documentation. A resident with cerebral infarction, seizure disorder, and respiratory failure was observed wearing a left-hand mitten restraint on multiple occasions, but the chart did not show a physician order, consent, care plan, or ongoing restraint re-evaluation. Staff stated the mitten was used because the resident had tried to remove a trach and G-tube, yet the RN UM, DON, ADON, physician, and Medical Director all confirmed the required restraint documentation was missing or could not be verified.
Missing Care Plan for Wander/Elopement Device: A resident with Alzheimer's Disease, DM, and HF was observed wearing a wander/elopement alarm, and the chart showed an order and risk evaluation for wandering and exit-seeking behavior. However, the EMR did not contain a comprehensive, person-centered care plan with measurable objectives and timeframes for the device use, and the RN UM acknowledged the care plan had been overlooked.
A resident with dementia, Parkinson's disease, and other chronic conditions had severe cognitive impairment and was dependent for all ADLs. After a fall from bed with a lip injury, the fall-risk care plan remained unchanged, with no documented review or revision after quarterly MDS assessments or the incident, despite the resident's ongoing fall risk and injury.
A resident with CHF, sepsis, cardiogenic shock, and severe cognitive impairment was ordered supplemental O2 via NC at 2 L/min, but surveyors observed the bedside concentrator delivering 3-4 L/min and then 4 L/min. The resident’s tubing was undated, and interviews with the NP, RN, and DON confirmed staff were responsible for verifying the ordered flow rate, dating/labelling tubing, and monitoring pulse ox, but the resident’s oxygen was not being provided as ordered.
Unlocked medication storage was observed at a nurses’ station when a bag of discontinued blister packs was left on a desk and stock meds were kept in an open cabinet. Staff stated there was no med room, the cabinet had no key and had been broken for months, and the DON confirmed that meds and return meds were supposed to be locked.
Improper Garbage and Refuse Disposal: Waste, debris, and trash were observed outside the facility not properly contained in closed dumpsters, including an open receptacle lid, an uncovered and overflowing dumpster, and scattered items such as chairs, bottles, cans, pallets, walkers, televisions, equipment parts, and a washing machine. The D/H/M stated the area was cleaned weekly, recycling was supposed to be picked up twice weekly, and the debris had been present for about a month.
Late Completion of Required MDS Assessments: Record review showed that most residents reviewed had admission and/or annual MDS assessments completed after the required timeframe. The Administrator, DON, and Regional MDS Coordinator acknowledged a backlog and completion/submission issues, with staffing and budgeted hours limiting timely completion of assessments.
Late Quarterly MDS Assessments: Quarterly MDS assessments for all 16 residents reviewed were completed after the 14-day deadline from the ARD. The Administrator acknowledged a backlog of late MDSs, the DON was unaware of the late submissions, and the Regional MDS Coordinator stated the facility had staffing and hour limitations affecting timely completion and submission.
Late MDS Assessment Transmission: MDS assessments for all residents reviewed were not transmitted to CMS within the required timeframe. The Administrator acknowledged a backlog of late MDS work, while the DON was unaware of the late submissions. The Regional MDS Coordinator reported staffing and hour limitations, with multiple coordinators and remote reviewers assigned, yet assessments were still being completed and submitted late.
A resident with severe cognitive impairment and high elopement risk exited the facility undetected despite wearing a wander alert device and being on enhanced monitoring. Staff failed to respond appropriately to an activated door alarm, did not conduct a full head count, and relied on incomplete checks and miscommunication, resulting in the resident being found and returned by police after leaving through a staircase and a gap in the fence.
The facility failed to maintain infection control practices, as a resident's urinary drainage bag was repeatedly observed on the floor, contrary to policy. Additionally, an RN did not perform hand hygiene between glove changes during a gastrostomy dressing change for a resident dependent on enteral feeding. The facility's Legionella Water Management Program also lacked a component specifying acceptable pathogen levels.
A resident with severe cognitive impairment was observed with a mitten on their right hand, used as a restraint without proper assessment, care planning, or documentation. Facility staff, including a CNA and RN, were unaware of the necessary procedures and documentation for restraint use, leading to the inappropriate application of the mitten.
A survey found that a resident's medications were left unattended on a medication cart in an LTC facility. The medications, belonging to a resident with severe cognitive impairment, were unsecured for over 15 minutes. Interviews with staff, including an LPN and the DON, confirmed that the medications should have been locked, as per facility policy.
The facility did not post notices about the availability of survey results in accessible areas, as required by policy. Observations showed the notice was hidden in the lobby, and no notices were in resident units. Residents were unaware of where to find the survey results, confirmed during a Resident Council Meeting. The DON and Administrator were unaware of the issue.
A resident with severe cognitive impairment and multiple diagnoses, including Dementia and Heart Disease, was observed with toe discolorations. Despite a doctor's order for an Arterial Doppler Study, the care plan for Impaired Skin Integrity was not updated to reflect this condition. The facility's policy requires ongoing assessment and revision of care plans, but the responsible nurse was unaware of the condition, leading to a deficiency citation.
A facility failed to document a medical assessment in a resident's record, despite the resident having discoloration on their toes and a history of dementia, heart disease, and atrial fibrillation. The Primary Medical Doctor assessed the condition and instructed an LPN to monitor the foot and order an Arterial Doppler Study, but the assessment was not recorded. This oversight violated the facility's documentation policy and regulatory requirements.
Widespread Environmental Uncleanliness and Disrepair Across Multiple Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on multiple resident units, contrary to its own maintenance and environmental cleaning policies. Surveyors repeatedly observed strong urine odors, stained and soiled surfaces, and disrepair across Units 2, 3, and 4. On the 2nd floor, there was a noticeable urine odor upon exiting the elevator, and a resident room had a tarnished door frame with brown staining, brown substance on the wall, brown stains on the toilet, dirty brown tiles behind the toilet, foul‑smelling hand towels, and a dripping sink faucet. The 2nd floor shower room and dirty linen cart room contained brown substances on walls and floors, a dirty linen bag on the floor, a hairbrush and comb on the shower floor, and underwear left on a wheelchair. Additional 2nd floor observations included dusty oxygen equipment with white residue, undated tubing in use on a resident’s tracheostomy, a GT pole with brown residue and buildup at the base, blackened flooring at room entrances and around furniture, white splash marks on walls, dirty baseboards, and blackened tiles. The 2nd floor nurses’ station had black floor tiles, dirty and rusted oxygen tank holders, and a buildup of dirt and dust under the desk around wires. On the 3rd floor, surveyors observed environmental uncleanliness and disrepair in common areas and resident spaces. The nurses’ station had a black chair covered with paper as a barrier from dirt or residue, another black chair missing an armrest, old food and dark‑stained floor tiles under the desk, a stained wall behind the station, a cabinet door missing handles and appearing broken, and a resident refrigerator with brown rusted stains on the exterior. The 3rd floor resident shower room had a musty, stale odor, black‑stained floor tiles at the entrance, brown stains on ceiling tiles and flooring, and white and brown substances on the floor of one shower stall. In a resident room, the sink edges had brown substance and the floor was sticky with areas of dirt; another room contained a ripped chair and dirty bedside table tray, and peeling wallpaper was noted near a room. Both radiators in the 3rd floor shower room were rusted, and floor tiles leading to the shower stall had brown‑colored substance around the edges. Hallways and the dining room on this unit had dark brown stains, dark greasy stains in corners and on baseboards, and multiple cracked tiles. During a tour of two shower stalls with maintenance staff, the hot water in both stalls remained cool to the touch despite running for several minutes, with thermometer readings in the high 70s to low 80s °F, and one shower head was leaking. On the 4th floor, surveyors noted brown stains on floors, yellow stains in dining room and hallway floors, and dark, greasy, dirt‑filled stains in the corners of hallways and the day room, as well as brown stains at the entrance to the garbage holding station. Across the 2nd floor vent unit, there were tiles with visible brown stains, brown and white discoloration and white splatter on hallway wallpaper between guardrails, peeling wallpaper, and a fire extinguisher case with brown discoloration and a peeling directional sign. Interviews with housekeeping and maintenance staff revealed inconsistent cleaning responsibilities, lack of clear schedules for cleaning specific items such as oxygen concentrators and GT poles, and acknowledgment that floors, tiles, and walls were dirty and in need of replacement. Staff reported decreased housekeeping staffing, uncertainty about who was responsible for certain areas (such as hallways and dining areas), and that some areas were only cleaned when specifically instructed. The Director of Housekeeping/Maintenance stated they rely on staff to report needed repairs and that they try to address items as they are identified, while the Administrator acknowledged the poor condition of the facility without providing an explanation, confirming that the environment did not meet regulatory requirements for cleanliness and maintenance. The facility’s written policies required that maintenance services keep the building in good repair and free from hazards, and that environmental surfaces be cleaned and disinfected regularly and when visibly soiled, in accordance with CDC and OSHA standards. However, the observations documented by surveyors showed widespread failure to follow these policies, including persistent urine odors, visible dirt and staining on floors, walls, and equipment, cracked and peeling surfaces, rusted fixtures, and inadequate hot water in resident shower areas. Staff interviews further demonstrated gaps in implementation of these policies, with staff describing ad hoc cleaning based on supervisory direction rather than a structured schedule, and multiple staff acknowledging that the building and flooring needed repairs. These combined observations and statements formed the basis of the deficiency under 10 NYCRR 415.5(h)(2) and 10 NYCRR 415.5(h)(4) for not honoring residents’ rights to a safe, clean, comfortable, and homelike environment.
Failure to Maintain Elevators in Safe Working Condition
Penalty
Summary
The facility failed to maintain essential elevator equipment in safe working condition, affecting two of three elevators (Elevator #2 and #3). Observations over several days showed "Not Working" signage posted on both elevators, yet Elevator #2 was still being used and was noted to skip the third floor. Resident council meeting notes revealed that residents reported these two elevators had been broken for several months and that they had raised this issue repeatedly at prior resident council meetings without resolution. Residents reported that the malfunctioning elevators restricted their movement within the building and interfered with normal access to other areas. Residents also reported that food was arriving cold to their units because Elevator #3, which is mainly used to transport food to all units, was broken, requiring use of an alternate elevator. One resident stated they often could not leave their unit due to the broken elevators. The Director of Recreation acknowledged awareness of the broken elevator and described delays in moving residents around the facility, including having to wait or page for an elevator when needed. The Director of Maintenance confirmed that the facility has three elevators, with two for passengers and one for moving items, and that Elevators #2 and #3 were out of service and undergoing refurbishment. The Administrator confirmed that Elevators #2 and #3 had been broken and out of service for a few months and acknowledged receiving complaints from residents and families about the elevator problems.
Insufficient Weekend Nursing Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and to help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Review of the Payroll Based Journal staffing data for the quarter dated July 1, 2025 through September 30, 2025 showed excessively low weekend staffing. The facility assessment listed unit capacities of 45 residents on the fourth floor, 45 on the third floor, 33 on the second floor, and 17 on the ventilator unit, and the facility’s PAR levels identified the expected CNA and LPN staffing for each unit and shift. Review of the actual weekend staffing schedule from July 5, 2025 through September 28, 2025 documented repeated missing staff across multiple shifts and units. The shortages included missing CNAs and LPNs on the ventilator unit, second floor, third floor, and fourth floor on numerous Saturdays and Sundays, including day, evening, and night shifts. The staffing records showed that the facility frequently operated below its stated PAR levels, with multiple instances of one or more CNAs or LPNs absent from assigned units during weekend shifts. Interviews with staff and residents described the impact of the staffing pattern. CNAs stated the assignment was very heavy, residents required two-staff assists and Hoyer lifts, and care and breaks were difficult to manage with the number of staff present. An LPN stated the unit only had three CNAs and staff worked together to complete resident care. Residents reported poor staffing at night and on weekends, delayed response to call bells, and that some residents were not getting help on time. The DON, Staffing Coordinator, and Administrator acknowledged that weekend coverage was difficult and that the facility relied on calling part-time staff, asking current staff to stay, or asking the next shift to come in early when callouts occurred.
Expired and Contaminated Food Found in Kitchen and Resident Refrigerator
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards, as evidenced by spoiled and expired food items found in multiple storage areas. During the kitchen tour, the Food Service Director identified a gallon bottle of Worcestershire sauce dated 11/23/2023 and a gallon bottle of soy sauce received on 06/14/2025; both bottles were stained with dark brown debris, and the Food Service Director stated they should have been discarded and were only supposed to be kept for 6 months. In the freezer/refrigerator, more than 30 onions were found in a clear container without being covered or dated, and 9 of the onions had white fuzzy, grey, green, and black colored contents on the outside. The floor under the meat thawing rack also had dried red-colored stains. In the resident refrigerator on the second floor ventilator unit, surveyors observed multiple expired items, including open salad dressing bottles with use-by dates of 07/04/2025, 10/28/2025, and 12/26/2025, half pint cartons of reduced fat milk and chocolate fat free milk with best-by dates of 03/01/2026 and 03/06/2026, and two facility-prepared applesauce cups labeled 03/08. A sign on the refrigerator stated that food products should be discarded 48 hours after the date labeled on the item. The Refrigerator/Freezer Temperature Log for March 2026 did not document temperature checks from 03/04/2026 through 03/11/2026. Staff interviews showed inconsistent oversight of food storage and refrigerator monitoring. The Food Service Director stated they were responsible for checking food, cleaning out resident refrigerators, and completing daily temperature checks, but also stated they did not do so consistently on the ventilator unit because only a few residents received trays there. Dietary staff reported that onions were used despite some being soft and discolored, and that daily inspection of food was not done. Nursing staff and the DON stated the kitchen department was responsible for removing expired items and logging temperatures, while the Food Service Director stated they were the only person who checked food and that food deliveries were inspected and rotated only when received each Thursday.
Unordered hand mitten restraint used without required documentation
Penalty
Summary
The facility failed to ensure that a resident was free from the use of a physical restraint unless it was needed for medical treatment, and failed to document the evaluation of the least restrictive alternative, the least amount of time, and ongoing re-evaluation of the need for the restraint. This deficiency involved one resident out of three residents reviewed for restraints. Resident #117 was admitted with diagnoses including cerebral infarction, seizure disorder, and respiratory failure, and the admission MDS documented that the resident received respiratory treatments including oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator treatment. The admission MDS also documented that the resident did not use physical restraints. However, the resident was observed on multiple occasions wearing a teal hand mitten restraint on the left hand. The record review failed to show a physician's order for the hand mitten restraint, resident or representative consent, a baseline or comprehensive care plan referencing the restraint, or documentation of the implementation date and ongoing evaluation. A speech therapy note documented that the resident was observed with a left-hand mitten secondary to tracheostomy removal. Staff interviews indicated that the mitten was being used because the resident had a history of trying to pull out tracheostomy and gastrostomy devices, but the RN Unit Manager, DON, ADON, physician, Medical Director, and Administrator all acknowledged that the required restraint documentation was missing or could not be confirmed in the record.
Missing Care Plan for Wander/Elopement Device
Penalty
Summary
The facility did not ensure that a comprehensive, person-centered care plan with measurable objectives and timeframes was completed and implemented for Resident #102. Resident #102 had diagnoses including Alzheimer's Disease, Diabetes Mellitus, and Heart Failure, and the Quarterly MDS documented daily use of a wander/elopement alarm. The physician's order dated 07/22/2025 and renewed on 10/01/2025 ordered the resident to wear a wander/elopement alarm for wandering and exit-seeking behavior, and the Elopement Risk Evaluation dated 11/27/2025 documented that the resident utilized a Wander Management Device. During observations on 03/08/2026, 03/11/2026, and 03/12/2026, Resident #102 was seen wearing a wander/elopement device on the right hand. Review of the electronic medical record did not show a Comprehensive Care Plan addressing the wander/elopement alarm use. The CNA stated the resident used the alarm due to a history of exit-seeking behavior, and the RN Unit Manager stated the resident used it due to wandering risk and that she was responsible for creating and updating the care plan, but acknowledged that no wander/elopement alarm care plan was in place and that it had been overlooked. The DON stated the RN Unit Manager was responsible for creating the care plan and did not know why it had not been completed.
Care Plan Not Updated After Fall and Quarterly Assessments
Penalty
Summary
The facility did not ensure that the Comprehensive Care Plan was reviewed and revised for one resident with a fall history and a fall with injury. Resident #6 had diagnoses including a progressive neurological condition, anemia, hypertension, perivascular disease, renal insufficiency, Parkinson's disease, and depression. Quarterly MDS assessments dated 12/8/2025 and 03/09/2026 documented short-term and long-term memory problems, no memory recall, severe cognitive impairment, and dependence for all activities of daily living. After a fall on 2/18/2026, nursing notes documented that the resident slipped off the bed while a CNA was providing care and sustained a small skin break to the right side of the mouth/lower lip. A medical progress note later described abrasion, mild swelling, and ecchymosis to the right lower lip, with no active bleeding, no pain, and no change in mental status from baseline. The resident's fall-risk care plan, last revised and effective 11/30/2025, documented interventions such as anticipating needs, keeping the call light within reach, clutter-free environment, and enhanced monitoring, but there was no documented evidence that the fall care plan was reviewed or revised after the quarterly MDS assessments or after the fall.
Incorrect Oxygen Flow Rate and Incomplete Respiratory Monitoring
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #23. The resident had diagnoses including Congestive Heart Failure, Sepsis, and Cardiogenic Shock, and the Annual MDS documented severe cognitive impairment and use of oxygen therapy in the facility. The care plan identified the resident as at risk for an alteration in the respiratory system related to cardiac disease and stated the resident would receive adequate oxygenation as evidenced by acceptable pulse oximetry levels. A physician's order dated 02/09/2026 directed supplemental oxygen via nasal cannula at 2 liters per minute, and a nurse practitioner progress note dated 03/03/2026 documented to continue oxygen 2 liters via nasal cannula as needed. During observations on 03/08/2026 and 03/09/2026, Resident #23 was seen wearing an undated nasal cannula attached to the bedside oxygen concentrator, and the oxygen was noted to be running at 3-4 liters per minute and then 4 liters per minute, rather than the ordered 2 liters per minute. The resident was unable to recall the ordered oxygen amount. Interviews with the nurse practitioner, RN #3, and the DON confirmed that the resident should have been receiving 2 liters per minute, that staff were responsible for checking the concentrator and documenting oxygen administration, and that the tubing should be dated and labeled. The nurse practitioner stated there should be parameters for the as-needed oxygen order and was unsure of the proper dating and labeling of the tubing, while the DON stated there needed to be a documented reason for oxygen, an assessment validating its need, an order, and a care plan.
Unlocked Medication Storage at Nurses’ Station
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments consistent with state and federal requirements and professional standards of practice. On the 4th floor, a large clear plastic bag containing discontinued resident medications in multiple blister packs was observed on top of a desk at the nurses’ station, with no nursing staff present. In addition, stock medications were observed inside the open medication cabinet at the 4th floor nurses’ station, including Calcium/Vitamin D Plus, Melatonin, Aspirin, Acetaminophen, Vitamin C, and Ferrous Sulfate, and the cabinet was not locked. During interviews, nursing staff stated that the unit did not have a medication room and that all medications were kept at the nursing station. Staff also stated that the medication cabinet had no key, had always been that way, and that the bag of blister packs was return medication waiting to be picked up by pharmacy. The unit manager confirmed that the medication cabinet had been broken for a few months and had been reported to maintenance but not fixed. The DON stated that medications were supposed to always be locked and confirmed that returning medications were also to be locked up.
Improper Garbage and Refuse Disposal
Penalty
Summary
The facility did not ensure garbage and refuse were disposed of properly. During an observation of the kitchen facility task, waste, debris, and trash were found not properly contained in closed dumpsters, and the garbage dumpster area was not maintained to prevent potential feeding and harborage for pests. The facility policy titled, Garbage-Food and Refuse Disposal, stated that food-related garbage and refuse are to be disposed of in accordance with current state laws, containers must have tight-fitting lids or covers and be kept covered when not in use, storage areas must be kept clean, and outside dumpsters must be kept closed and free of surrounding litter. On observation, debris was scattered outside along the fence line and a receptacle lid was left open, exposing brown colored boxes. The debris included dusty chairs with brown rust, ripped chairs, multiple bags of recyclable water bottles, juice bottles, cans, an old wheelchair, wood pallets, walkers, televisions, equipment parts, a washing machine, and open bags of cement. One large blue dumpster was uncovered and overflowing with cardboard boxes, and multiple clear trash bags containing brown colored boxes were lying on the ground next to the dumpsters. The surrounding area of a large green compactor contained black colored debris, plastic containers, and water bottles. The Director of Housekeeping/Maintenance stated the garbage area was cleaned once a week, recycled garbage was supposed to be picked up on Mondays and Thursdays, and the debris had been there for about a month.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility did not ensure that comprehensive resident assessments were completed within the required timeframes. Record review showed that 15 of 16 residents reviewed during the Resident Assessment Facility Task had admission and/or annual MDS assessments that were not completed within 14 days of the Assessment Reference Date. The report specifically identified late MDS assessments for residents including #94, #17, and #37, with CMS MDS 3.0 Nursing Home Final Validation Reports showing those assessments were completed after the required timeframe. The facility policy titled, Minimum Data Set 3.0, stated that the facility follows the guidelines of the current State-specific Resident Assessment Instrument manual and CMS requirements. During interviews, the Administrator stated that MDS assessments should be submitted on time but did not have an explanation for why they were late and acknowledged a backlog of MDS assessments. The DON stated they were not aware the assessments were submitted or completed late, and the Regional MDS Coordinator stated the facility had a completion and submission issue, with staffing and budgeted hours limiting the ability to complete assessments on time.
Late Quarterly MDS Assessments
Penalty
Summary
Each resident's quarterly assessment was not completed within 14 days of the Assessment Reference Date, affecting 16 of 16 residents reviewed in the Resident Assessment Facility Task. The residents identified included Residents 140, 143, 64, 13, 17, 26, 37, 46, 94, 41, 92, 122, 11, 103, 93, and 75. The facility policy titled Minimum Data Set Assessment 3.0 stated the facility follows the State-specific Resident Assessment Instrument manual and CMS guidelines, but the CMS Minimum Data Set 3.0 Nursing Home Final Validation Report showed that the quarterly MDS assessments for residents such as Resident 140, Resident 143, and Resident 41 were completed more than 14 days after their Assessment Reference Dates. During interviews, the Administrator stated the facility was aware the assessments should be submitted on time and acknowledged there was a backlog of MDS assessments that were being completed and submitted late. The Administrator said the MDS Coordinator completed the submissions and assessments, with oversight from the Regional MDS Coordinator. The DON stated the MDS Coordinator was on vacation and was not aware the assessments had been completed and submitted late. The Regional MDS Coordinator stated the facility had an on-time completion and submission issue, that two coordinators were assigned to the facility along with an additional remote assessor, and that staffing and available hours were not enough to complete the assessments on time.
Late MDS Assessment Transmission
Penalty
Summary
Minimum Data Set (MDS) assessments were not electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after completion for 16 of 16 residents reviewed for the Resident Assessment Facility Task. The report identified multiple residents, including Residents #92 and #37, whose quarterly MDS assessments were completed and then submitted after the required timeframe. The facility policy stated that MDS 3.0 assessments were to be completed and transmitted according to the current State-specific Resident Assessment Instrument manual and CMS requirements. During interviews, the Administrator stated that MDS assessments should be submitted on time but could not explain why they were late and acknowledged a backlog of assessments that were being submitted and completed late. The DON stated they were not aware that any MDS assessments were submitted or completed late and explained that the facility had a full-time MDS Coordinator plus two remote staff who reviewed charts but did not submit assessments. The Regional MDS Coordinator stated they were aware of completion and submission issues, described staffing limitations and insufficient hours for the work, and said the facility had two coordinators assigned plus an additional remote assessor, but assessments were still being completed and submitted late.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and a high risk for elopement exited the facility undetected by staff. The resident, who had diagnoses including Non-Traumatic Brain Dysfunction and Alzheimer's Disease, was wearing a wander alert device and was supposed to be monitored every thirty minutes. Despite these interventions, the resident was last documented as seen at 11:00 PM, but managed to leave the building at 12:24 AM. The resident was later found and returned to the facility by police officers at 12:40 AM, having exited through a staircase and a gap in the fence behind the building. Staff failed to respond appropriately to the activated door alarm. Multiple staff interviews revealed that alarms were either not heard, were faint, or were silenced without a thorough investigation. One LPN heard the alarm but only checked the area for a resident known to wander, rather than conducting a full head count or searching all possible exit routes. Security staff also failed to physically check the exit doors after the alarm was triggered, relying instead on surveillance cameras and resetting the alarm remotely. Additionally, a CNA mistook pillows in the resident's bed for the resident being present, further delaying the realization that the resident was missing. The facility's policies required enhanced monitoring, functioning wander alert devices, and prompt response to alarms, but these were not effectively implemented. Staff did not conduct a head count or search all areas after the alarm was triggered, and communication lapses occurred between staff members regarding the alarm and the resident's whereabouts. These failures allowed the resident to leave the facility without detection, resulting in an elopement event.
Infection Control Deficiencies in Urinary Catheter Care, Hand Hygiene, and Water Management
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observations of a resident's urinary drainage bag being placed on the floor. Resident #27, who had a suprapubic catheter due to neurogenic bladder and other urinary issues, was observed on several occasions with their urinary drainage bag touching the floor. Despite the facility's policy and staff education on catheter care, the bag was repeatedly found on the floor, indicating a lapse in adherence to infection control protocols by the staff, including a Certified Nursing Assistant and a Registered Nurse Supervisor. Another deficiency was noted when Registered Nurse #2 did not perform hand hygiene between glove changes during a gastrostomy dressing change for Resident #80. This resident, who had a gastrostomy and was dependent on enteral feeding, was at risk due to the nurse's failure to wash hands between removing and donning gloves. The facility's hand hygiene policy, which aligns with CDC recommendations, was not followed, as confirmed by interviews with the nurse and the Director of Nursing. Additionally, the facility's Legionella Water Management Program was found lacking a critical component specifying acceptable pathogen levels. This omission was identified during a review of the water management plan, and the Administrator acknowledged the need to include all required components. These deficiencies highlight significant gaps in the facility's infection control practices, potentially compromising resident safety.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a mitten on the resident's right hand without proper assessment, care planning, or documentation. The resident, who had diagnoses including Other Specified Disorders of Brain, Vascular Dementia, and Non-traumatic Intracerebral Hemorrhage, was observed with a mitten on their right hand during multiple observations. Despite the facility's policy promoting a restraint-free environment, there was no documented evidence of an appropriate assessment or care plan prior to the application of the mitten, nor was there any documented monitoring while the mitten was in use. Interviews with facility staff revealed a lack of awareness and communication regarding the use of the mitten as a restraint. A Certified Nursing Assistant stated they applied the mitten based on instructions from a charge nurse, but there were no instructions in the task list to do so. The unit supervisor assumed there was a restraint assessment and physician's order, while the Director of Nursing was unaware of the mitten's use. The Nurse Practitioner confirmed they did not order the mitten, and the Director of Rehabilitation noted the resident could not remove the mitten independently. This lack of documentation and communication led to the inappropriate use of a physical restraint on the resident.
Medication Storage Deficiency
Penalty
Summary
During a recertification survey, it was observed that the facility failed to store medications in accordance with accepted professional principles. On the 4th floor, medications belonging to a resident with diagnoses including Essential Hypertension, Epilepsy, Gastroesophageal Reflux Disease, and Cardiomyopathy were left unattended on top of a medication cart. The resident had severely impaired cognition, as documented in their Minimum Data Set assessment. The medications, which included Losartan, Spironolactone, Famotidine, and Levetiracetam, were left unsecured for over 15 minutes until a state surveyor intervened. Interviews with facility staff, including an LPN, a Registered Nurse Supervisor, and the Director of Nursing Services, confirmed that the medications were not stored properly. The LPN admitted that the medications were older blister packs intended for return to the pharmacy and acknowledged that they should have been secured under lock and key. Both the Registered Nurse Supervisor and the Director of Nursing Services stated that medications should not be left unsecured on top of the cart, emphasizing that all medications should be locked to ensure safety.
Failure to Post Survey Results Notices in Accessible Areas
Penalty
Summary
The facility failed to ensure that notices regarding the availability of survey results were posted in prominent and accessible areas, as required by their policy. During the recertification survey, it was observed that the notice was placed in the lobby entrance next to the security desk, behind a standing sign, making it not visible to residents or visitors. Additionally, there were no notices posted in resident units to inform residents, family members, or legal representatives about where to find the survey results. Interviews conducted during the survey revealed that residents were unaware of where to find the survey results, as confirmed by multiple residents during a Resident Council Meeting. The Director of Nursing acknowledged the absence of notices in resident units and stated that the notice was only posted in the lobby. The Administrator was also unaware of the lack of notices in resident units and mentioned that the availability of survey results is discussed in Resident Council meetings.
Failure to Update Care Plan for Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team, as required by their policy. This deficiency was identified during an abbreviated survey, where it was found that a resident's care plan was not updated to reflect a new condition. The resident, who has diagnoses including Dementia, Atherosclerotic Heart Disease, and Chronic Atrial Fibrillation, was observed with discolorations on the toes of their left lower extremity. Despite the medical doctor being notified and ordering an Arterial Doppler Study, the care plan for risk of Impaired Skin Integrity was not updated to include this new information. The facility's policy requires that care plans be comprehensive, person-centered, and revised as residents' conditions change. However, the care plan for the resident's Alteration in Comfort due to Peripheral Vascular Disease was last revised before the discoloration was noted, and the care plan for Impaired Skin Integrity had not been updated since March. The Regional Registered Nurse, responsible for updating care plans, was unaware of the discolorations and thus did not update the care plan until after the surveyor's presence in the facility. This oversight led to the deficiency being cited.
Failure to Document Medical Assessment in Resident's Record
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected their current condition, as required by professional standards. This deficiency was identified during an abbreviated survey, where it was found that a medical assessment conducted by the Primary Medical Doctor was not documented in the resident's medical record. The resident in question had a history of dementia, atherosclerotic heart disease, and chronic atrial fibrillation, and was reported to have discoloration on the toes of their left foot. Despite the Primary Medical Doctor assessing the resident's condition and instructing a Licensed Practical Nurse to monitor the foot and order an Arterial Doppler Study, the assessment was not recorded in the medical record. The facility's policy on charting and documentation, which mandates that all services and changes in a resident's condition be documented, was not followed. The Director of Nursing acknowledged that the staff member who informed the Primary Medical Doctor and received the order for the Arterial Doppler Study should have documented the event in the resident's medical record. This oversight resulted in a failure to maintain accurate and complete medical records, as required by 10 NYCRR 415.22(a)(1-4).
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,461 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Downtown Brooklyn Nursing & Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Crown Heights Center For Nursing And Rehabilitatio | 1.1 mi | ★★★★★ | 5 | 0 |
| Brooklyn Gardens Nursing & Rehabilitation Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Bedford Center For Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| New Carlton Rehab And Nursing Center, Llc | 1.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Concord Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.