Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Elizabeth Church Manor Nursing Home during CMS and state inspections, most recent first.
Insufficient dietary staffing led to late meal service and concerns with food and nutrition operations for two resident units. Staff reported frequent call-offs, recent turnover in the cook position, and reliance on CNA and nursing staff to help with tray line duties. Meals were sometimes delayed, with weekend meals often about 30 minutes late and some meals delayed up to 1 hour, while the kitchen also prepared food for Assisted Living and Independent Living.
Meals were repeatedly served late on the First and Third Floors, and residents at the same table were not always served together. Observations showed lunch and dinner arriving well after scheduled times, with one resident still waiting for lunch while no carts were on the unit and many residents not yet served. Family, residents, and dietary staff reported frequent delays tied to short staffing, and staff stated trays were sometimes loaded by seat rather than by complete table, creating an undignified dining experience.
Unclean kitchen and improper food storage and sanitation practices. Surveyors observed black greasy buildup, food debris, spills, and residue under cookline equipment, in coolers and freezers, and on dry storage floors. The walk-in freezer door would not close properly, food was stored on the floor, an ice scoop was stored in the ice, and some food in the walk-in cooler was uncovered. During tray line service, an FSM wiped a cart with a dry cloth and used the same cloth on a second cart without sanitizing it first, and staff reported they had not been taught how to test sanitizer levels in the three-bay sink.
Improper disposal of kitchen garbage and refuse was identified in the main kitchen waste area. Trash and debris were observed scattered on the ground around the dumpsters, despite facility policy requiring waste to be collected and stored to prevent pest infestation. The Food Service Manager stated garbage was taken out at the end of the night, and the Regional Director of Food Service stated the dumpsters should be closed with no debris on the ground and waste should be emptied more often, generally after each meal.
PRN Ativan for a resident with dementia and severe cognitive impairment was left active without an end date and was not reassessed or limited to 14 days as required for psychotropics. The MAR showed the order remained in place across multiple months, the resident did not receive PRN doses, and there were no provider progress notes or documented renewals showing review of the PRN use. Pharmacy reviews flagged the issue, and staff interviews confirmed the order should have been reviewed and reordered every 14 days.
The facility did not conduct and document an accurate facility-wide assessment for day-to-day and emergency staffing needs. The 2024-2025 assessment listed the wrong DON name and included Food and Nutrition leadership and staffing roles that did not match actual operations, including a part-time RD hired for clinical duties only, no Dietary Director, and a Food Service Manager and Regional Director of Food Service who were not serving in the roles listed on the assessment.
Hand hygiene was not performed during a wound dressing change for a resident with a Stage 4 heel pressure ulcer and foot infection. An LPN removed soiled gloves after taking off the old dressing, then put on clean gloves and applied the new dressing without cleaning hands first, despite the facility wound care procedure requiring hand hygiene before, during, and after the dressing change.
Unqualified staff were assigned to the infection prevention role when the facility used the DON as the Infection Preventionist while training an ADON who had not yet passed the NYS RN test and was not certified for the position. Facility documents identified the Infection Preventionist as the leader of surveillance activities and stated the role should be held by a NYS Licensed RN, but interviews showed the DON was covering the role after the prior DON and prior Infection Preventionist left.
The facility failed to ensure resident safety concerning bed rail use and supervision. A resident with impaired cognition was found deceased due to improper bed rail assessment and lack of informed consent. Other residents were also at risk due to inadequate bed rail evaluations. Additionally, two residents with wandering behaviors eloped from the facility undetected, highlighting failures in supervision and door alarm maintenance. These deficiencies placed residents at significant risk of harm.
A facility failed to ensure the correct installation and maintenance of bed rails, resulting in a resident's death due to entrapment between the bed rail and mattress. The resident, diagnosed with Alzheimer's, was found with their head wedged between the bed rail and mattress, leading to probable positional asphyxiation. Facility staff lacked familiarity with bed entrapment guidelines, and there was no documented evidence of measuring beds for entrapment risk, affecting 55 residents.
The facility's governing body failed to implement necessary safety policies, resulting in a resident elopement and a fatal bedrail incident. A resident with wandering behaviors was not monitored, leading to an elopement, while another resident was found deceased due to improper bedrail assessment and maintenance. These deficiencies placed residents at risk for serious harm.
The facility failed to provide food and drink at palatable and appropriate temperatures, as observed during surveys. Residents reported dissatisfaction with cold and unappetizing meals, and staff confirmed that food temperatures did not meet facility standards. Observations showed that meals were served below the required temperature, affecting the quality and enjoyment of the food.
The facility failed to promptly resolve resident grievances, as evidenced by unresolved issues such as missing personal items, unaddressed dietary requests, and an overgrown garden. Residents expressed dissatisfaction with the facility's inaction and lack of communication regarding their grievances. The facility's grievance policy required prompt resolution and documentation, but several grievances lacked follow-up and resolution, highlighting inconsistencies in the grievance process.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. A resident on hospice care lacked a coordinated plan for pain management, another receiving antipsychotics had no care plan for medication monitoring, and a third with diabetes had no care plan for diabetes management or self-medication. These oversights left staff without necessary guidance for proper care.
The facility failed to store and prepare food according to professional standards, with improper cooling of potentially hazardous foods like brown gravy and unclean kitchen and storage areas. Observations revealed incomplete cooling logs, unclean equipment, mold, and unprotected food products, posing a risk to resident safety.
Two residents with severe cognitive impairments and incontinence issues were not provided timely toileting care, as required by their care plans. One resident was left in a wet brief for over 4 hours, while another was not toileted for a similar duration, with no call bell in reach. Staff interviews revealed a lack of adherence to care protocols and communication failures regarding care refusals.
A resident with acute pancreatitis, myasthenia gravis, and diabetes was found with medications in an unlocked drawer, without documented assessment of their ability to self-administer. The facility's policy required an interdisciplinary team assessment and secure storage of medications, which was not followed. Nursing staff were unsure if an assessment had been completed, and the medications were not counted or stored securely.
A resident's call bell was repeatedly found out of reach, contrary to their care plan, during a survey. Despite the resident's cognitive impairments, staff interviews confirmed the importance of having the call bell accessible to communicate needs. Uncertainty existed among staff about the resident's ability to use the call bell, and no alternative communication method was documented.
A resident with lymphedema and localized edema did not have their ACE wraps applied as ordered, despite documentation indicating otherwise. Observations showed the resident without the wraps on multiple occasions, and staff interviews revealed inconsistencies in their application. The care plan did not include the use of ACE wraps, and there was no documentation of resident refusal.
Two residents with pressure ulcers did not receive necessary care as per their care plans. One resident with a Stage 4 ulcer on the elbow lacked proper arm support, while another with heel ulcers did not have pressure relieving devices applied. Staff interviews revealed a lack of adherence to care plans, leading to inadequate ulcer management.
A facility failed to maintain an effective infection control program, as evidenced by improper wound care for a resident with a Stage 4 pressure ulcer. An LPN did not perform hand hygiene between glove changes and used unclean scissors for wound packing, compromising sterility. Additionally, the facility's infection control policies were not reviewed annually, indicating systemic issues.
The facility failed to provide adequate supervision and care plan management for a resident with frontal temporal neurocognitive disorder and dementia, resulting in multiple incidents of aggression towards other residents and staff. Despite known risks and repeated altercations, the care plan was not consistently updated, and interventions were not effectively implemented.
The facility failed to thoroughly investigate and report incidents of resident altercations involving mistreatment, neglect, or abuse. Incidents were not fully documented, and required care plan interventions were not verified. Staff interviews revealed inconsistencies in the reporting process, and the Director of Nursing acknowledged incomplete investigations and unreported incidents.
Insufficient Dietary Staffing Led to Late Meal Service
Penalty
Summary
The facility did not ensure sufficient support personnel were available to safely and effectively carry out food and nutrition services for 2 of 3 resident units, Units 1 and 3. Surveyors found that meal trays for these units were consistently delivered after the posted scheduled mealtimes, and concerns were identified with the effectiveness of meal preparation and other food and nutrition services. The cited deficiencies also included F 809 Frequency of Meals/Snacks at Bedtime, F 812 Food Procurement, Store/Prepare/Serve, and F 814 Dispose of Garbage and Refuse Properly. The resident census was documented as 117, and the facility policy stated dietary staffing should be adequate and qualified to ensure meals and snacks were safely prepared, handled, and served in a timely and person-centered manner. The projected staffing schedule showed varying numbers of cooks, supervisors, and kitchen staff across the survey dates, with some shifts affected by call-offs and no-shows. Staff interviews described ongoing shortages in the dietary department, active hiring for diet aides and a Food Service Manager, and frequent reliance on CNA assistance to put trays together and serve meals. Multiple staff members stated that meals were sometimes late because of short staffing, with weekend meals usually about one-half hour late and some meals delayed up to one hour. Dietary staff reported that one cook was covering breakfast and lunch, that the kitchen also prepared meals for Assisted Living and Independent Living, and that staffing shortages made it difficult to complete tray service adequately. Leadership interviews confirmed staffing issues, recent turnover in the cook position, and that nursing staff were trained to assist with tray line duties when needed.
Delayed meal service and uneven tray delivery
Penalty
Summary
The facility did not ensure residents had a dignified dining experience on the First and Third Floors because meals were served late and residents at the same table were not always served together. The facility’s Dining Experience Policy stated meals would be served at consistent, scheduled times, and the Dignity policy stated meals would be served in a manner that maintained dignity and that residents would be encouraged and supported to make choices about their daily schedule, meals, activities, and care. The facility’s posted cart delivery times showed scheduled breakfast, lunch, and dinner cart times for both floors, but observations and interviews showed meals were frequently delayed beyond those times. During observations, the First Floor lunch meal was not served until 1:10 PM, and the First Floor dinner meal was served at 6:20 PM. On the Third Floor, staff began bringing residents to the dining room for lunch at 11:42 AM, but by 12:39 PM a resident was still waiting with an empty tray table, and no meal carts were on the unit at 12:44 PM. The first cart did not arrive until 1:00 PM, and staff served one table in stages rather than together; one staff member stated the cart was not stocked per table, and another stated they would have to wait for the second cart to serve tables together. At 1:11 PM, 33 residents had not yet been served while only 3 were eating, and the second cart did not arrive until 1:13 PM. Interviews with residents, family members, and staff described repeated delays in meal service. A family member reported dinner had not been served until 8:00 PM and lunch had sometimes not been served until 3:00 PM. Residents in a group meeting stated meals were served late, including dinner at 7:20 PM and 6:30 PM, and that the kitchen did not have enough staff for the meals being prepared. Dietary staff stated meals were usually 30 minutes late on weekends due to staffing problems and sometimes an hour late because of short staffing. The Food Service Manager stated meals were occasionally late, and the DON stated there were complaints from residents, family, and staff, with the biggest complaint being that meals were not delivered to the floors timely.
Unclean kitchen and improper food storage and sanitation practices
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. During survey observations, the kitchen was found unclean, with water on the floor under the steamer, a heavy black greasy substance on the floor under cookline equipment, food products and residue on the floor and under shelving in the walk-in cooler, and black grimy substance on the dry storage floor. The walk-in freezer door was not closing properly, several cases of food were stored on the floor, and an ice scoop was lying on top of the ice in the ice machine. The middle reach-in refrigerator was soiled with dried food debris and liquid, and the walk-in freezer floor had built-up black greasy substance and food debris with icing in the frame preventing the door from closing properly. During tray line lunch service, the first cart was not clean and had a white liquid inside on the bottom while staff were loading trays. The Food Service Manager wiped the substance with a dry cloth, set the cloth on the counter, and used the same cloth to wipe out a second cart without placing it in sanitizer or a cleaning agent first. In the walk-in cooler, some food products were uncovered, including a large hotel pan of mixed diced fruit with a serving utensil in the product. The Food Service Manager stated potentially hazardous foods should be dated, labeled, and stored in the walk-in cooler, that the ice scoop should not have been stored in the ice, that food product could not be stored on the floor, and that sanitizer levels in the three-bay sink should be tested; a Dietary Aide stated they had not been taught how to test sanitizer levels.
Improper Disposal of Kitchen Garbage and Refuse
Penalty
Summary
The facility did not ensure garbage and refuse were disposed of properly in the main kitchen, and the exterior waste storage area was not maintained to prevent attraction and harborage of pests. During observation, piles of trash and debris were seen scattered on the ground around the dumpsters outside the main kitchen. The facility policy stated that garbage, refuse, and waste were to be collected, stored, and disposed of in a manner that minimized health risk and prevented pest infestation, that kitchen waste was to be emptied multiple times a day, and that exterior waste storage should be covered, secured, and kept free of overflowing waste. In interviews, the Food Service Manager stated kitchen garbage was taken down the hall and put out the side door into the dumpsters at the end of the night and acknowledged that garbage should not be on the ground near the dumpsters. The Regional Director of Food Service stated the dumpsters should be closed with no debris on the ground around them and that garbage should be emptied more often, generally after each meal.
PRN Ativan Order Not Limited to 14 Days
Penalty
Summary
The facility did not ensure that an as needed psychotropic medication order for Resident #14 was limited to 14 days or reassessed for continuation. Resident #14 had diagnoses including vascular dementia, paranoid personality disorder, and bipolar disorder, and the 7/23/2025 MDS documented severe cognitive impairment with use of antipsychotic, antianxiety, and antidepressant medications. The comprehensive care plan documented impaired cognitive function/dementia or impaired thought processes related to dementia and included medication administration with monitoring for side effects and effectiveness. The physician order for Ativan 0.5 mg, created by the DON and signed by the NP, included routine and as needed directions for agitation and anxiety disorder and did not include an end date. The order remained active on the MAR in June and July 2025, and the resident did not receive any as needed doses during either month. The record contained no provider progress notes showing the resident was evaluated for the as needed Ativan, and there were no documented revisions or renewals to limit the order to 14 days or justify continuation. The pharmacy consultant noted on 6/17/2025 and again on 7/15/2025 that as needed psychotropics had a 14-day limitation and requested attention to the Ativan use. The first review included a handwritten physician response stating to stop after 14 days for the PRN order, but the order was not stopped and there was no documented response to the later review. During interviews, facility staff and the physician stated that as needed Ativan should be reviewed and reordered every 14 days, and the DON acknowledged the order was still active and should have been reviewed.
Facility Assessment Did Not Reflect Actual DON and Nutrition Leadership Roles
Penalty
Summary
The facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies, and it did not review and update the assessment as necessary. During the recertification survey, the 2024-2025 Facility Assessment was found to document the incorrect name of the DON and to list staffing and department roles that did not match actual facility operations. The assessment identified one DON with a NYS license and listed a Food and Nutrition department that included a Food Service Director, diet technician/RD, Certified Dietary Manager, three cooks, and six food service aides. However, the RD was part-time and hired for clinical duties only, the facility did not have a Dietary Director, and the Food Service Manager stated they were full-time, worked as a cook, and were not the department head. The Regional Director of Food Service stated they worked two days a week and were not aware they were listed as the Food Service Director, while the DON stated they were also serving as Infection Preventionist and acting as DON while the ADON was training for the role. The ADON stated their official title was Assistant Director of Nurse Trainee, and the Administrator stated the DON was also the Infection Preventionist and training the ADON.
Hand Hygiene Not Performed During Wound Dressing Change
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident. During a wound dressing treatment for a resident with severe cognitive impairment, an unhealed pressure ulcer, and a left heel Stage 4 pressure ulcer with foot infection, an LPN removed the soiled dressing and soiled gloves, did not perform hand hygiene, put on clean gloves, and applied the clean dressing. The resident’s wound culture showed mixed flora and pseudomonas species, and the resident was receiving treatment for the foot infection, including antibiotics and daily wound care. The facility’s undated wound care dressing change procedure required hand hygiene before starting the dressing change, after removing soiled dressings, and at the end of the procedure. During interview, the LPN stated hand hygiene should have been performed before and after the dressing change and acknowledged that hand sanitizer should have been available in the room between glove changes. The Infection Preventionist stated that hand hygiene was required after removing old dressings and soiled gloves and before putting on clean gloves, and that it was critical before starting, after removing soiled gloves, and at the end of the dressing change because hands could be contaminated with organisms from the wound and could cross contaminate the clean dressing.
Unqualified staff assigned to infection prevention role
Penalty
Summary
The facility did not ensure that one qualified individual, who was not the Director of Nursing, was responsible for the Infection Prevention and Control Program. The facility policy on Infection Surveillance identified the Infection Preventionist as the leader of surveillance activities, responsible for maintaining documentation of incidents, findings, and corrective actions related to infection control, and for reporting findings to the Quality Assurance Committee and public health authorities. However, the facility’s Emergency Phone Numbers form listed the DON as the Infection Preventionist, and the 2024-2025 Facility Assessment stated the Infection Preventionist should be a New York State Licensed Registered Nurse. During the survey, the DON stated they had been in the Infection Preventionist position for about three weeks and that the ADON was being trained for the role. The ADON stated they were training for the DON role, assisted the DON with tasks within their scope of practice, and had not yet passed the New York State RN test, stating the position required a registered nurse in New York State. The Administrator stated the DON was acting as the facility’s Infection Preventionist while training the ADON, who was uncertified for the role, and acknowledged that the DON should not have any other responsibilities. The previous DON and previous Infection Preventionist had both recently terminated employment.
Deficiencies in Bed Rail Safety and Resident Supervision
Penalty
Summary
The facility failed to ensure residents remained as free of accident hazards as possible, particularly concerning the use of bed rails. Resident #1, who had severely impaired cognition, was found deceased with their head wedged between the bed rail and mattress. The facility did not assess the resident for appropriate alternatives to the bed rail, did not evaluate the risk of entrapment, and did not obtain informed consent from the resident's representative before the installation of the bed rail. Additionally, other residents with bed rails were not properly assessed for risks and benefits, nor was informed consent obtained, placing them at risk for serious harm. The facility also failed to provide adequate supervision to prevent accidents, as evidenced by the elopement of Resident #17, who had severely impaired cognition and known wandering behaviors. The resident exited the building undetected by staff and was found at a nearby gas station after being away from the facility for over 40 minutes. Similarly, Resident #16, who also had severely impaired cognition and a history of wandering, was observed exiting the facility's front lobby door in their wheelchair without staff intervention. These incidents resulted in Immediate Jeopardy for the residents involved and highlighted the facility's failure to ensure the safety of residents with exit-seeking behaviors. The deficiencies were further compounded by inadequate staff training and assessment procedures. The Registered Nurse responsible for bed rail assessments lacked specific training and a clear understanding of the risks associated with bed rail use. The facility's maintenance and security protocols were also insufficient, as evidenced by the failure to properly check and maintain door alarms, which contributed to the elopement incidents. These systemic issues in assessment, supervision, and environmental safety placed residents at significant risk of harm.
Removal Plan
- All residents with bed rails received updated bed rail assessments and physical restraint/safety assessments if their beds were placed against the wall, care plans were updated and orders for bed rails were obtained.
- A revised bed rail assessment tool was created to address interventions attempted prior to bed rail installation taking into consideration medical conditions; an area on the assessment form addressed risks and benefits of bed rail use with an area for documentation; and informed consent, whether verbal or in person, by the resident or resident representative, with their name.
- Education of staff was done for the new bed rail assessment tool, bed rail policy and procedure and safety of the residents' environment.
- Plan to educate any staff that has not received training will be completed before going on the floor to work.
Failure to Ensure Bed Rail Safety Leads to Resident Death
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails, leading to a significant safety risk for 55 residents. Specifically, the facility did not inspect and regularly check the mattress and bed rail for areas of possible entrapment. This oversight was evident in the case of a resident with a contour mattress and a right side bed rail, where the facility did not evaluate alternatives to bed rails, review the risks and benefits with the resident or their representative, or obtain informed consent prior to the installation of bed rails. The deficiency was highlighted by a tragic incident involving a resident diagnosed with Alzheimer's disease, who was found with their head wedged between the bed rail and the mattress, resulting in their death. The resident was last observed at approximately 4:30 AM for incontinence care, and at 5:45 AM, they were found in a kneeling position beside the bed, with no pulse or respirations. The cause of death was listed as probable positional asphyxiation. Interviews with facility staff revealed a lack of familiarity with guidelines for the prevention of bed entrapment and an absence of specific measurements regarding entrapment risk zones. Maintenance staff were responsible for installing bed rails and performing bed safety checks, but they did not have a process for measuring entrapment risk zones. The facility's policy did not include entrapment guidelines, and there was no documented evidence that beds were measured for entrapment risk, putting residents at risk for serious injury or death.
Removal Plan
- Maintenance was trained on entrapment zones and how to measure per FDA guidelines.
- An audit tool that contained all aspects of bed safety, compatibility of bed, mattress, and bed rails; mattress inspection, and entrapment zones was completed for all beds in the facility.
- The updated bed rail policy and procedure was provided which included Maintenance will check the bed model and install a compatible bed rail. Once installed the bed will be checked prior to use for entrapment zones, and if any are determined to be non-compliant the device will be un-installed immediately and nursing will be informed. Maintenance will close out the work order ticket once completed and update nursing of completion. Staff education was completed.
- A bed rail process and procedure audit tool was developed to monitor alternatives tried, bed rail assessment completed, Interdisciplinary Team review, care plan update, consent after provision of information, order in place, maintenance measured, monitoring resident safety, and physical restraint assessment.
- Continued education provided to all direct care workers, housekeeping, maintenance, social work, therapy, and activities are reminded of bed safety, entrapment zones, bed placement and potential for creating entrapment zones. Mattresses should not move on the bed frame. Mattress stops located on the 4 corners of the bed frame. Staff are responsible for reporting any entrapment zone issues or concerns. All staff who are actively employed by the facility have been trained.
- Education of staff that has not received training (due to illness, vacation, or leave of absence) will be completed before reporting to their workstations on their next schedule day.
Deficient Safety Policies Lead to Resident Elopement and Fatal Bedrail Incident
Penalty
Summary
The facility's governing body failed to establish and implement necessary policies for managing and operating the facility, leading to significant deficiencies in resident care. Specifically, the facility did not maintain updated policies and equipment to ensure resident safety, resulting in two critical incidents. In one case, a resident with wandering behaviors was not consistently monitored, leading to an elopement incident where the resident exited the building, crossed a busy road, and was later returned to the facility. The facility's outdated door testing procedures contributed to this incident, as exterior doors were not consistently monitored or documented. In another incident, a resident with a contour mattress and bedrails was not properly assessed for bedrail alternatives, nor were the risks and benefits discussed with the resident's representative. This oversight resulted in the resident being found deceased, with their head wedged between the bedrail and mattress. The facility also failed to regularly inspect mattresses and bedrails for potential entrapment risks, as per FDA guidelines. These deficiencies placed residents at risk for serious injury or death, highlighting the facility's failure to maintain accountability and responsibility for resident safety.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and at appropriate temperatures during the recertification and abbreviated surveys conducted. Specifically, the lunch meals served on two consecutive days were not at appetizing temperatures and lacked flavor. Residents expressed dissatisfaction with the food, describing it as cold and unappetizing. Observations confirmed that food items such as meatloaf, mashed potatoes, and spinach were served at temperatures below the facility's policy standards, and some items were difficult to consume due to their texture. Interviews with residents and staff revealed consistent concerns about the food quality and temperature. Residents reported that hot food was not served hot enough, and cold beverages were not sufficiently chilled. Staff members acknowledged the importance of serving food at proper temperatures to prevent illness and ensure resident satisfaction. The Dining Service Director admitted to receiving complaints about food service and confirmed that the temperatures of certain food items were not within the acceptable range as per the facility's policy.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly resolve resident grievances, as evidenced by the experiences of three anonymous residents and five specific grievances that lacked documented resolutions. During a Resident Council meeting, residents expressed that their grievances were not always addressed or resolved, and they were not informed of the reasons for inaction. Specific grievances included requests for gluten-free pasta and concerns about an overgrown garden in the courtyard, which remained unaddressed. Additionally, a resident's request to remove garbage cans from under the American flag in the dining room was not fulfilled, as observed during a survey. The facility's grievance policy, last reviewed in 2017, required prompt resolution of grievances and written documentation of the resolution process. However, grievances from August 2023 to August 2024 revealed several unresolved issues. These included a missing wheelchair for a resident, a missing hearing aid, lost dentures and a remote control, a curdled glass of milk, and a broken hearing aid. In each case, there was no documented follow-up or resolution, and the facility's grievance forms lacked the necessary information to confirm whether the issues were addressed. Interviews with the Social Services Director and the Administrator highlighted a lack of clarity and consistency in the grievance resolution process. The Social Services Director was unaware of the exact timeframe for resolving grievances and acknowledged that the forms did not indicate whether grievances were resolved. The Administrator confirmed that the grievance process required documentation of resolutions, but this was not consistently done. The facility's failure to maintain the courtyard garden and address resident concerns contributed to the perception that grievances were not being resolved.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical and nursing needs. Resident #93, who had diagnoses including palliative care and severe pain, did not have a care plan that included pain management or coordination with hospice services. Despite being on hospice care and frequently using morphine for pain, there was no documented evidence of collaboration with hospice providers, and the care plan lacked necessary details for staff to provide appropriate care. Resident #47, diagnosed with severe dementia and receiving antipsychotic medication, did not have a care plan addressing the use of antipsychotics. The absence of a care plan for the medication meant there was no monitoring for potential adverse reactions or considerations for gradual dose reduction. This oversight was acknowledged by the Registered Nurse Unit Manager, who confirmed that antipsychotic medications should be included in the care plan to ensure proper monitoring and management. Resident #74, with diagnoses including diabetes and myasthenia gravis, did not have a care plan for diabetes management or self-medication administration. The resident was self-administering medications and receiving insulin daily, yet the care plan did not reflect these aspects of care. The lack of a comprehensive care plan for diabetes and self-medication administration meant that staff were not adequately informed about the resident's needs and the necessary interventions to ensure safe and effective care.
Improper Food Storage and Preparation in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety. During the recertification survey, it was observed that potentially hazardous foods, such as brown gravy, were not cooled properly in the main kitchen. The gravy was found at temperatures between 124 and 128 degrees Fahrenheit, which did not meet the required cooling standards of reducing the temperature to 70 degrees Fahrenheit within 2 hours and then to 40 degrees Fahrenheit within the next 2 hours. The Dining Service Director acknowledged that the cooling logs were incomplete and did not provide sufficient information to confirm proper cooling procedures. Additionally, the facility's kitchen and food storage areas were found to be unclean and contained unprotected food products. Observations revealed food debris, grease, and grime under and behind cookline equipment, as well as mold and condensation in the walk-in cooler. Uncovered desserts were left in the cooler, and flies were seen landing on uncovered cakes. The old kitchen walk-in cooler and freezer, used as backup storage, were also found to be unclean, with moldy shelving and excessive ice buildup. The Dining Service Director admitted that the old kitchen coolers were not cleaned regularly, and the cleaning documentation was incomplete. The facility's cleaning list indicated that certain cleaning tasks were not completed, such as sweeping under cook equipment and cleaning the walk-in cooler. The lack of cleanliness in food preparation and storage areas posed a risk to the health and safety of the residents.
Failure to Provide Timely Toileting Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically toileting, for two residents, leading to deficiencies in maintaining grooming and personal hygiene. Resident #6, who had severe cognitive impairment and was dependent on staff for toileting, was not checked or provided incontinence care for approximately 4.5 hours, despite the care plan requiring checks every 2 hours. Observations revealed that the resident was left in a wet brief, which was uncomfortable and posed a risk for skin issues. Resident #71, with diagnoses of Alzheimer's disease and Crohn's disease, was also not provided timely toileting care. The resident was observed in bed with a noticeable urine odor and no call bell within reach, indicating a lack of interaction and care from staff. The care plan required checks every 2 hours, but the resident was not toileted for over 4 hours. Staff interviews revealed that the resident was resistive to care, but refusals were not reported to the nurse, and no alternative approaches were attempted. Interviews with staff, including CNAs and nursing management, highlighted a lack of adherence to the care plans and communication failures regarding care refusals. Staff acknowledged the importance of regular checks to prevent skin breakdown and infections but did not follow through with the required care protocols. The failure to provide timely and adequate care compromised the residents' dignity and increased their risk for health complications.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident's ability to self-administer medications was clinically appropriate. Resident #74, who had diagnoses of acute pancreatitis, myasthenia gravis, and diabetes, was observed with medications stored in an unlocked drawer of their dresser. There was no documented evidence that the interdisciplinary team had assessed the resident's ability to safely self-administer medication, as required by the facility's policy. The resident's comprehensive care plan did not include self-administration of medications and interventions, and there was no documented assessment for medication self-administration. Observations revealed that the resident self-administered Creon and pyridostigmine bromide without supervision, and the medications were not stored in a locked drawer as required. Interviews with nursing staff indicated uncertainty about whether an assessment had been completed and confirmed that the medications were not counted by nursing staff. The Assistant Director of Nursing acknowledged that residents should have an assessment for safe self-medication administration and a care plan documenting a resident-specific plan, with medications kept locked to ensure compliance.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident #71's call bell was within reach, as care planned, during the recertification survey conducted from August 19 to August 22, 2024. The resident, who had diagnoses including Alzheimer's disease and dysphagia, was usually able to make themselves understood and understood others, despite having severely impaired cognition. The resident was independent with bed mobility, transfers, and ambulation but required moderate to maximal assistance with personal hygiene and dressing. The Comprehensive Care Plan initiated on August 1, 2023, documented that the resident was at high risk for falls and required the call light to be within reach to request assistance as needed. Observations made during the survey revealed that on multiple occasions, the resident's call bell was not within reach. On August 19, 2024, the call bell was hooked to itself at the wall, out of the resident's reach. On August 20, 2024, the call bell was found under a chair and on the floor, both times out of reach. Interviews with staff, including a CNA, RN Unit Manager, LPN, and the Assistant Director of Nursing, confirmed that call bells should be within reach to allow residents to communicate their needs. However, there was uncertainty among staff about whether Resident #71 could use the call bell, and it was noted that if a resident could not use a call bell, an alternative should be provided and documented in the care plan.
Failure to Apply ACE Wraps as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's care plan. Specifically, the resident, who had diagnoses of lymphedema and localized edema, did not have their elastic compression bandage (ACE wrap) applied as ordered. The physician's order required the ACE wraps to be applied every day in the morning and removed at bedtime, but observations on multiple occasions revealed that the resident was not wearing the ACE wraps, despite documentation indicating they had been applied. The resident was observed with swollen ankles and bilateral lower extremity edema without the ACE wraps on several occasions. The resident stated that staff did not always apply the wraps. Interviews with nursing staff revealed inconsistencies in the application of the ACE wraps, with one LPN unable to confirm if they had applied the wraps on specific dates, despite having signed the Treatment Administration Record. The care plan did not include the use of ACE wraps, and the failure to apply them as ordered was not documented as a resident refusal.
Failure to Implement Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident #31, who had a Stage 4 pressure ulcer on the left elbow, did not receive the required pressure relief as outlined in their care plan. Observations revealed that the resident's left arm was not supported by a pillow or towel as mandated, which was crucial to prevent further deterioration of the ulcer. Interviews with staff indicated a lack of awareness and adherence to the care plan, resulting in improper positioning of the resident's arm. Similarly, Resident #58, who had a Stage 2 pressure ulcer on the right heel and deep tissue damage on the left heel, did not receive the prescribed pressure relief measures. The resident was observed without heel elevator cushions or pressure relieving boots while in a recliner chair, contrary to the care plan and physician's orders. Staff interviews revealed that the necessary pressure relieving devices were not implemented, and there was a lack of communication and understanding regarding the resident's care plan. The facility's policies on pressure ulcer prevention and resident-centered care planning were not effectively executed, as evidenced by the failure to apply pressure relieving devices for both residents. The interdisciplinary team did not ensure that the care plans were followed, leading to inadequate pressure ulcer management and potential risk of worsening conditions for the residents involved.
Inadequate Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper wound care practices for a resident with a Stage 4 pressure ulcer. During a wound care observation, a Licensed Practical Nurse (LPN) did not perform appropriate hand hygiene between glove changes and used unclean scissors to cut iodoform packing strips, which were then placed into the resident's wound. The LPN also placed unpackaged gauze squares on an unclean nightstand before moving them to a barrier sheet, further compromising the sterility of the wound care process. The resident involved had a severely impaired decision-making ability and was dependent on staff for all activities of daily living. The resident's care plan included specific interventions for managing the Stage 4 pressure ulcer, such as using a pressure-reducing device and providing wound care per treatment orders. However, the LPN did not adhere to these protocols, as they failed to perform hand hygiene at critical points during the wound care procedure, increasing the risk of infection. Additionally, the facility's infection control policies were not reviewed annually as required. The policies, including those for antibiotic stewardship and skin and wound infection prevention, lacked documented review dates, indicating a lapse in maintaining up-to-date infection control standards. The Assistant Director of Nursing/Infection Control Nurse acknowledged that the policies were supposed to be reviewed annually but were not documented as such, highlighting a systemic issue in the facility's infection control program.
Inadequate Supervision and Care Plan Management for Resident with Aggressive Behaviors
Penalty
Summary
The facility did not ensure adequate supervision to prevent accidents for Resident #5, who exhibited increased anxiety and aggressive behaviors towards other residents. Resident #5, diagnosed with frontal temporal neurocognitive disorder, pseudobulbar disorder, and dementia, had a history of wandering and aggressive behaviors. Despite these known risks, the facility failed to provide consistent and adequate supervision, resulting in multiple incidents where Resident #5 physically assaulted other residents and staff members. The comprehensive care plan for Resident #5 was not consistently updated to address these behaviors, and interventions such as 15-minute checks were not effectively implemented or documented. On several occasions, Resident #5 was involved in altercations with other residents, including hitting, slapping, and taking belongings from them. For instance, on 12/1/2023, Resident #5 hit Resident #6, and on 12/29/2023, Resident #7 hit Resident #5 in retaliation for entering their room. Despite these incidents, the care plan was not revised to include adequate supervision or additional non-pharmacological interventions. The facility's failure to provide meaningful activities and consistent monitoring allowed Resident #5 to continue wandering and exhibiting aggressive behaviors. Interviews with staff revealed a lack of specific direction on how to handle Resident #5's behaviors and inadequate training on non-pharmacological interventions. The Director of Nursing and other responsible staff members acknowledged that the care plan was not consistently reviewed or updated following incidents. The facility's approach to managing Resident #5's behaviors was insufficient, leading to repeated incidents of aggression and inadequate supervision to prevent harm to other residents and staff.
Failure to Investigate and Report Resident Altercations
Penalty
Summary
The facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated or reported to the New York State Department of Health timely when required for three residents. Specifically, incidents involving physical altercations between residents were not thoroughly investigated, and some were not reported to the state health department as required. For instance, an incident on 12/1/2023 where one resident hit another was not fully investigated to determine if a stop sign was in place as per the care plan. Another incident on 12/25/2023 involving aggressive behavior and physical altercations was not investigated or reported to the state health department. The facility's policies on abuse and incident/accident investigation were not followed. The policies required thorough investigation, documentation, and reporting of incidents involving resident mistreatment or abuse. However, the facility failed to document whether care plan interventions, such as the placement of a stop sign on a resident's door, were in place at the time of the incidents. Additionally, there was no evidence that the incidents were reported to the New York State Department of Health as required. Interviews with staff revealed inconsistencies in the reporting and investigation process. Some staff members were unaware of the proper procedures, and there was a lack of documentation and follow-up on reported incidents. The Director of Nursing acknowledged that some incidents were not reported to the state health department and that the investigations were incomplete. This lack of thorough investigation and timely reporting led to deficiencies in ensuring resident safety and compliance with state regulations.
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 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Binghamton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Shepherd-fairview Home Inc | 1.7 mi | ★★★★★ | 0 | 0 |
| Bridgewater Center For Rehab & Nursing L L C | 2.2 mi | ★★★★★ | 0 | 0 |
| Susquehanna Nursing & Rehabilitation Center, L L C | 2.6 mi | ★★★★★ | 1 | 0 |
| Willow Point Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 0 | 0 |
| James G Johnston Memorial Nursing Home | 3.3 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.