Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Epic Rehabilitation And Nursing At White Plains during CMS and state inspections, most recent first.
Food items were found improperly stored and labeled in multiple kitchen areas, including a nutritional refrigerator, walk-in refrigerator, walk-in freezer, cook's freezer, and dry storage room. Observations showed cheese, milk, potatoes, waffles, pork loin, tilapia, pasta, and vinegar that were open to air, missing opening dates, or lacking expiration dates. The FSD stated the items were not properly labeled or protected from exposure to air and that all items must be labeled upon opening with both the dates opened and expiration date.
Two residents did not receive ordered care as documented. One resident’s 9 AM meds, including BP, CHF, and asthma treatments, were omitted until mid-afternoon, and staff acknowledged the LPN did not give the meds on time or seek help. Another resident with urinary symptoms had a UA/C&S order that was not collected for several days, and there was no documented physician notification when staff could not obtain the specimen. The record showed the resident was incontinent and symptomatic, with delayed specimen collection and incomplete communication.
Dignity violations occurred during dining when an LPN stood while assisting two residents with eating at opposite ends of a table and provided water and set-up help to others between assisting them. In a separate incident, a CNA referred to a resident as a "feeder" in front of other residents. Staff acknowledged the actions and stated residents should be addressed respectfully and not labeled.
The facility failed to complete and submit MDS assessments on time for multiple residents. Record review showed delayed admission, quarterly, annual, significant change, and 5-day assessments, and the MDS Coordinator and MDS Director acknowledged that sections were not always completed or signed off timely and that submissions to CMS were sometimes late.
Heel offloading and heel booties were not consistently implemented for three residents with pressure ulcer risk or existing heel wounds. One resident with bilateral heel ulcers was observed multiple times with heels resting on the mattress or pillow surface despite orders to keep heels off bed and use heel booties. Another resident at risk for pressure ulcers had a heel-offloading order but no CNA task or care plan direction, and staff were unaware of the order. A third resident with multiple diagnoses and bilateral heel redness had an order and care plan for heel booties every shift, but was repeatedly observed with bare heels resting on the bed or geri chair.
Enhanced barrier precautions were not followed for a resident with a stage 4 pressure ulcer and an order for EBP. A CNA provided feeding, repositioning, and gown change without an isolation gown, then assisted the roommate with the same gloves and left without hand hygiene. An LPN later provided wound care and repositioning with gloves only, with staff stating they forgot the resident was on EBP and that gown and glove use was required for high-contact care.
Failure to consistently implement fall supervision interventions: A cognitively impaired resident with multiple falls, asthma, HF, and non-Alzheimer’s dementia had orders and care plan directions for hourly in-bed checks, supervised time when awake, and being out of bed to the wheelchair on the overnight shift. The record showed unwitnessed falls when the resident was last seen earlier than documented monitoring suggested, was left unsupervised while staff were giving meds, and was later found in bed without documentation explaining why the overnight supervision intervention was not carried out.
A resident with cognitive impairment and extensive ADL assistance needs was repeatedly observed unkempt, unshaven, and wearing the same clothing, despite care plan and CNA task instructions for regular hygiene support. Staff interviews showed confusion about who was responsible for shaving and showering the resident, lack of documentation of a reported refusal, and acknowledgment that the resident should have had clothing changed and a shave over the prior days.
A resident with Alzheimer’s disease, limited mobility, and a contracted left hand did not receive the ordered left-hand palm guard splint as documented in the physician order and care plan. Staff observed the resident without the device on multiple occasions, the resident’s representative did not recall seeing it in use, and an LPN and CNA stated the device was not available or in place; the rehab dept was not aware a replacement was needed.
Failure to provide ordered oxygen therapy: A resident with COPD, dementia, and anxiety had an order for O2 at 2 to 3 L/min PRN via nasal cannula, but was observed receiving O2 at 4 L/min and at 2 L/min on multiple occasions. The MAR/TAR had no documentation showing oxygen administration, and an RN educator stated the order was not specific enough to determine whether the resident should receive 2 or 3 L/min.
A resident with chronic constipation did not receive a recommended medication after a GI consult due to a breakdown in communication and documentation. The LPN who received the resident after the appointment did not identify or act on the new order, and the consult documentation was not properly reviewed or filed. As a result, the recommended treatment was never initiated.
A resident with chronic constipation did not receive a recommended medication after a GI consult, as the consult documentation was missing from the chart and the medication was never ordered. Interviews with the DON, LPN, and NP revealed inconsistent processes for reviewing and filing consults, leading to incomplete documentation and failure to implement the consultant's recommendation.
Two residents experienced significant medication errors due to lapses in following medication administration protocols. One resident was given Lasix and Losartan without a physician's order, leading to hypotension and requiring medical intervention. Another resident was nearly given an incorrect dose of Tizanidine, but the error was caught before administration. The LPN involved admitted to not verifying the orders properly.
The facility failed to store medications securely, with two residents found with unauthorized medications at their bedside and medication carts left unlocked. One resident had no care plan for self-administration, while another was distressed by the removal of their inhaler. Staff acknowledged the carts should be locked, highlighting a deficiency in safety protocols.
A facility failed to ensure nursing staff had the necessary competencies to provide adequate care, as evidenced by missing competency assessments in personnel files for CNAs and licensed nurses. Communication issues between HR and Nursing departments, along with the removal of the Inservice Educator position, contributed to inconsistent training and evaluations. The DON and ADON acknowledged the inadequacy of the current system for evaluating staff competencies, with evaluations only conducted in response to specific incidents.
The facility failed to conduct annual performance reviews and provide required in-service training for CNAs, as evidenced by missing documentation in personnel files. The facility's assessment required staff competencies in areas like abuse and dementia care, but these were not included in orientation or annual training. Communication issues between HR and Nursing, along with the absence of an Inservice Educator, contributed to the deficiency. Interviews revealed inconsistencies in competency evaluations and training, with the Administrator unsure of compliance with required evaluations.
During a survey, three nurses at a facility were observed failing to follow infection control practices during medication administration. An RN did not sanitize hands or equipment between residents and touched a resident's eyelid with an eye dropper. An LPN failed to sanitize hands or clean a blood pressure cuff, while another LPN's long hair came into contact with medication cups and a nebulizer box. The facility's Assistant DON confirmed that nurses were trained on infection control, but these practices were not consistently followed.
The facility did not ensure staff wore identification badges, leading to confusion among residents with cognitive impairments and concern among visitors. Despite policies and efforts by the DON and Administrator, compliance was inconsistent, partly due to a non-functional badge machine and inconsistent staff education.
The facility did not ensure residents were informed of their rights during their stay, as resident rights were not reviewed during monthly Resident Council meetings. The Director of Social Services acknowledged that while rights information was provided upon admission and posted in day rooms, it was only available upon request thereafter, with no routine or annual discussions documented.
A facility failed to develop a comprehensive care plan for a resident self-administering an albuterol inhaler. The resident, with chronic conditions, was observed using the inhaler without a documented care plan. The facility's policy requires care plans to be developed by the Interdisciplinary Team, but the Director of Nursing confirmed that registered nurses did not initiate the necessary care plan in a timely manner.
A resident with cerebral infarction, anxiety disorder, and dementia exhibited distressing behaviors without receiving necessary non-pharmacological interventions or staff interaction. Despite having a comprehensive care plan, the facility failed to review or revise it to address the resident's behaviors. Observations showed the resident was often left alone and distressed in the dayroom, with staff failing to intervene or assist. Interviews revealed a lack of staff training in behavioral health management, contributing to the deficiency.
A resident with dementia was not engaged in meaningful activities as per their care plan, with observations showing scheduled activities were not conducted. Staff interviews revealed a lack of training in dementia care, and the Director of Recreation cited scheduling conflicts as a reason for activity cancellations, which were not reported to the Administrator.
A resident with a fractured front tooth experienced a delay in receiving emergency dental services due to the facility's failure to schedule an oral surgeon appointment in a timely manner. Despite the resident's ongoing pain and the dentist's referral for extraction, the appointment was not scheduled until months later, highlighting a lack of documentation and follow-up by the staff.
The facility failed to adhere to food safety and hand hygiene standards, as observed during a survey. Food items in refrigerators were not labeled or dated, and raw meats were improperly stored. Staff members were seen touching unsanitary surfaces with gloved hands and preparing food without changing gloves. Additionally, the food thermometer was not properly sanitized, and sandwiches and juices were not labeled. The Director of Food Services was responsible for overseeing these operations, but deficiencies were noted.
The facility failed to maintain sanitary conditions for waste disposal, as observed during a survey. A mouse was seen in the kitchen, and the dumpster was uncovered with a missing lid. Staff interviews revealed lapses in oversight and adherence to the waste management policy, which was undated and unsigned.
Food Storage and Labeling Deficiency
Penalty
Summary
Food items were not stored in accordance with professional standards for safe food handling and storage practice. During the initial kitchen tour, the Nutritional Refrigerator contained a package of pasteurized processed American cheese that was not labeled with an expiration date. In the walk-in refrigerator, an opened gallon of whole milk did not have a date indicating when it was opened. In the walk-in freezer, an opened bag of [NAME] Farms Seasoned Diced Potatoes was exposed to air, a package of frozen waffles wrapped in plastic was without the original packaging and without an expiration date, and a five-pound bag of mild cheddar cheese was not within its original packaging and was without an expiration date. Additional observations showed similar storage problems in other kitchen areas. The cook's freezer contained a box of boneless pork loin partially wrapped in plastic with a large open area exposed to the air, and a ten-pound box of tilapia fillets was open to air. In the dry storage room, a bag of penne pasta did not have a date indicating when it was opened, and two one-gallon bottles of white vinegar were open and did not have dates to indicate when they had been opened. The Food Service Director stated the items were not properly labeled and/or protected from exposure to air, discarded the products without opening dates, expiration dates, and foods that were open to air, and stated that all items must be labeled upon opening with both the dates opened and expiration date.
Failure to Provide Ordered Medications and Timely Urine Collection
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two residents reviewed for change in condition. One resident with asthma, congestive heart failure, and hypertension had daily 9 AM medications, including valsartan, isosorbide mononitrate, torsemide, Trelegy Ellipta, and albuterol nebulizer treatment, omitted at the scheduled time on 04/13/2026. The medication administration record showed the medications were not given at 9 AM, and the medication incident form documented the omissions. The resident’s blood pressure was documented as 188/84 later that day, and the missed medications were ultimately given around 2:15 PM after the omission was identified. Interviews confirmed that the assigned LPN knew the medications should have been administered but did not give them as ordered and did not notify the nurse manager or ask for help. The LPN Unit Manager stated that 9 AM medications should be administered between 8 AM and 10 AM and that the assigned nurse was responsible for ensuring medications were given as ordered. The ADON stated the resident’s family reported the missed medications between 1:00 PM and 1:30 PM, after which the NP was notified and one-time orders were given. The ADON also stated the assigned nurse should have notified the unit manager or called for assistance if needed. A second resident with hypertension, chronic atrial fibrillation, hyperlipidemia, and a recent history of urinary tract infection had complaints of burning in the vaginal area and was ordered to have a urinalysis and culture/sensitivity collected, with straight catheterization permitted as needed. The record showed the urine specimen was not collected until 12/01/2024, despite the order being written on 11/29/2024, and there was no documented evidence that the physician was notified when staff were unable to collect the urine on 11/29/2024 and 11/30/2024. Nursing notes documented that the resident was incontinent and that staff were unable to obtain the specimen, but the chart did not show timely collection or physician notification during the period when the specimen remained outstanding.
Dignity Violations During Meal Assistance
Penalty
Summary
The facility failed to ensure a dignified experience for three residents during dining. During a lunch observation, an LPN was standing while assisting two residents with eating at opposite ends of the dining table, walking around the table to help both residents. The LPN also provided water and set-up assistance to other residents in between assisting these two residents. In interviews, the LPN acknowledged being aware they were standing while assisting the residents, stated the unit was short one nurse and had only two CNAs available in the dining room, and said they should have asked management for help. The LPN also stated they should not have assisted two residents seated at opposite ends of the dining room table while standing and that doing so caused delays and could have resulted in cold food being served. During another dining room observation, a CNA referred to a resident as a "feeder" while responding to another CNA in the presence of approximately fifteen residents, with five residents in the immediate area. The CNA stated they were removing the resident's tray because the resident was a feeder and no longer needed the completed tray in front of them. The CNA later acknowledged they should not have used that term and should have said the resident needed assistance with eating instead. The unit manager and DON both stated residents should not be referred to as feeders and should be addressed by name or as needing assistance with eating, and the DON stated staff are expected to be seated at eye level with residents during dining.
Late MDS Assessments and Submissions
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed and/or submitted timely for 8 of 8 residents reviewed for MDS resident assessments. The facility policy dated 4/24/2026 stated that residents are to be assessed initially on admission, with quarterly assessments completed no later than 92 days after the Assessment Reference Date and comprehensive assessments scheduled within 366 days after the Assessment Reference Date. The MDS Coordinator was responsible for assigning staff to complete sections of the MDS, maintaining the assessments electronically, and certifying that the assessment was complete, while the MDS Assessor/Coordinator was responsible for submitting completed assessments to the Quality Improvement and Evaluation System. During record review on 05/26/2026, the electronic MDS summaries showed multiple assessments for residents #38, #53, #69, #77, #85, #112, #126, and #13 were submitted after their assessment reference dates. Examples included admission, quarterly, annual, significant change, and 5-day scheduled assessments that were completed and/or submitted later than expected. The MDS Coordinator stated that all departments were responsible for completing and signing off on their sections, and acknowledged that for resident #85 dietary did not complete Section K timely and for resident #126's annual assessment Sections A and O were not signed off timely by the MDS Coordinator. The MDS Director stated they were responsible for submitting assessments to CMS when they populated to the MDS dashboard, but sometimes did not submit them timely.
Heel Offloading and Booties Not Consistently Implemented
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments and preventive measures were consistently carried out for three residents who had physician orders for heel offloading or heel booties. Resident #81 had diagnoses including a stage 3 sacral pressure ulcer and was documented as at risk for pressure ulcers with multiple heel wounds. The physician ordered heels off bed every shift, and the care plan directed frequent position changes, offloading of pressure points, and heel booties during bedtime, with a later order for strict offloading of the left heel and heel boot while in the chair. However, during multiple observations, both heels were found resting directly on the mattress or on a pillow surface rather than being fully offloaded. Resident #33 had diagnoses including cerebral infarction and was assessed as at risk for pressure ulcers. A physician order directed heels off bed, but there was no documented care plan addressing heel offloading. During repeated observations, both heels were resting on the mattress and were not offloaded. A CNA stated they were not aware of the heel offloading order, and the LPN unit manager stated there was no CNA task directing heel offloading and that such a task should have been added when the order was placed. Resident #55 had diagnoses including toxic megacolon, Ogilvie syndrome, and Alzheimer’s disease, and was documented as at risk for pressure ulcers with bilateral lower extremity impairment and dependence for ADLs, bed mobility, and transfers. The physician ordered heel booties every shift, and the care plan also directed heel booties to relieve pressure every shift. Despite this, observations showed the resident in bed and in a geri chair with bare heels resting on the mattress or chair and no heel booties in place. Redness was observed to both heels, and staff stated the resident was not wearing heel booties even though the order and task were present in the record.
Enhanced Barrier Precautions Not Followed During Resident Care
Penalty
Summary
Enhanced barrier precautions were not implemented for a resident with Parkinson's disease, a stage 4 right hip pressure ulcer, diabetes mellitus, intact cognition, substantial assistance needs for eating and personal hygiene, and dependence for bed mobility. The resident had a physician order for enhanced barrier precautions to be maintained every shift, and the care plan directed gown and glove use during high-contact care activities for residents with wounds, with signage posted on the door. During an observation, a CNA entered the resident's room with the lunch tray, applied gloves, assisted the resident to sit on the side of the bed, fed the resident, and changed a soiled gown after food spilled on it. The CNA's uniform contacted the resident's bed linen and gown during care. The CNA did not wear an isolation gown during these high-contact activities and then assisted the resident's roommate without changing gloves, touching the roommate's belongings, forearm, wheelchair parts, and privacy curtain before leaving the room without performing hand hygiene. During another observation, an LPN applied gloves and entered the room to provide wound care. The LPN set up supplies, turned the resident, provided pressure ulcer care, repositioned the resident, and adjusted the underpad, with the LPN's uniform contacting the resident's leg and underpad. The LPN also touched the privacy curtain while moving through the room and stated after exiting that they forgot the resident was on enhanced barrier precautions and that gown and glove use was required for high-contact care such as wound care.
Failure to Consistently Implement Fall Supervision Interventions
Penalty
Summary
The facility failed to ensure that interventions for fall prevention were implemented consistently for one resident with asthma, heart failure, and non-Alzheimer’s dementia who was cognitively impaired and had a history of multiple falls. The resident had a physician order to be monitored every hour when in bed, and the care plan directed that the resident be kept in a supervised area when awake and later be out of bed to the wheelchair on the 11 PM to 7 AM shift. The record showed the resident was assessed as high risk for falls on multiple occasions. On one occasion, the resident had an unwitnessed fall and was found lying on the floor mat next to the bed. The LPN’s statement said the resident was last seen at 8:15 PM, while the MAR documented hourly monitoring during the shift. The DON stated the LPN signed the MAR documenting hourly monitoring, but the LPN’s written statement showed the resident was last seen 1 hour and 45 minutes before the fall. The DON also stated the facility had not investigated whether the hourly monitoring intervention had actually been implemented. On another occasion, the resident had an unwitnessed fall and was found on the floor by the wheelchair in the resident’s room after being brought to the nurse’s station area for supervision. The RN stated the resident wheeled themself back to the room and fell while staff were administering medications. The DON stated staff should not have left the resident unsupervised and later stated there were no documented instructions describing how staff should monitor the resident for supervision and safety. On a later fall, the resident was found on the floor by the bed in the morning, and there was no documented evidence explaining why the resident was not out of bed to the wheelchair on the overnight shift or in a supervised area. The DON stated they did not know why the resident was still in bed after 7 AM and did not investigate the reason the resident was in bed at that time.
Failure to Provide Needed ADL Hygiene Assistance
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene. Resident #33 had diagnoses including unspecified folate deficiency anemia, benign prostatic hyperplasia with lower urinary tract symptoms, and cerebral infarction. The resident’s care plan documented extensive assistance and the Minimum Data Set showed moderate cognitive impairment, substantial/maximal assistance needed for showering and hygiene, and risk for pressure ulcers. The facility’s policy stated residents unable to perform ADLs independently would receive services necessary to maintain good nutrition, grooming, personal and oral hygiene. On multiple observations, Resident #33 was found in bed wearing the same grey pajama shirt and black hoodie sweater, unshaven with substantial stubble, and stated they had not been showered and had not received cares. The Certified Nurse Aide Accountability Record showed showers on some dates, including 04/23/2026, 04/27/2026, 04/30/2026, 05/17/2026, and 05/18/2026, but also noted 05/18/2026 as not shaved. During interviews, a CNA stated they knew the resident needed to be shaved but waited for the evening shift to complete the task and were unaware the resident had remained in the same clothing for three days. An LPN Unit Manager stated the resident should have had clothing changed and a shave over the last three days, and another CNA stated they had not showered the resident, had not documented the refusal, and last showered and shaved the resident on 04/17/2026.
Failure to Provide Ordered Palm Guard Splint
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion and mobility received the ordered left-hand palm guard splint as documented in the physician order and care plan. Resident #55 had diagnoses including toxic megacolon, Ogilvie syndrome, and Alzheimer's disease, and the quarterly MDS documented moderate cognitive impairment, dependence for activities of daily living, bed mobility, and transfers, and bilateral lower extremity impairment. The physician ordered a left palmer guard splint for up to six hours or as tolerated to decrease the risk of contractures, and the resident's care plans included the same intervention. During observations on multiple occasions, Resident #55 was seated in a geri chair in the day room without the left-hand palm guard in place, and the resident's left hand was contracted. The resident's representative stated they did not recall seeing the device in place during visits. CNA #14 stated the resident did not have a left-hand palm guard to be placed, and LPN Unit Manager #10 also observed that the device was not in place and could not locate it in the room. The LPN Unit Manager reviewed the record and noted the task for the left-hand palm guard was not present on the accountability task sheet even though the physician order had been entered. The Director of Rehabilitation stated they were not aware whether the resident was wearing the device daily as prescribed and that rehabilitation had not been notified that a replacement device was needed.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with diagnoses including COPD, dementia, and an anxiety disorder. The resident had a physician order dated 4/21/2026 for oxygen at 2 to 3 liters per minute as needed via nasal cannula, and the care plan documented oxygen per physician's order. However, the resident was observed on multiple occasions receiving oxygen via nasal cannula at 4 liters per minute and at 2 liters per minute, including while seated in a wheelchair and in the resident's room. The resident's cognitive assessments documented severe impairment, and the assessments stated the resident was not administered oxygen. There was no documented evidence in the April 2026 and May 2026 Medication Administration Records or Treatment Administration Records showing that oxygen was being administered. During interview, the Nurse Educator/Infection Control Preventionist stated unit nurses were responsible for checking residents on oxygen to ensure they received the correct oxygen per physician's order, and stated the order for this resident was not acceptable because it should have been specific to either 2 liters or 3 liters, not 2 to 3 liters. The Nurse Educator/Infection Control Preventionist was unable to explain how nurses would determine whether the resident needed 2 liters or 3 liters of oxygen.
Failure to Implement Gastroenterology Consultation Recommendations for Chronic Constipation
Penalty
Summary
A deficiency occurred when a resident with a history of chronic constipation and multiple comorbidities, including dementia and schizoaffective disorder, did not receive care in accordance with professional standards following a gastroenterology consultation. The resident was recommended to start Linzess, a medication for chronic constipation, after a consult, but there was no documented evidence that this medication was ever ordered or administered. The facility's policy required that consultation recommendations be reviewed by the nurse manager or supervisor within 24 to 72 hours and that the attending physician or nurse practitioner be notified within 24 hours for review and potential orders. Upon the resident's return from the gastroenterology appointment, the LPN who received the resident documented that there were no recommendations from the consult. The LPN stated during interviews that they did not recall seeing any new orders on the consultation document and would have acted if there were any. The LPN also indicated that if there were no new orders, the consultation sheet would be filed in the resident's chart. However, the consult documentation recommending Linzess was not found in the resident's chart, and the medication was never ordered. Interviews with the DON, nurse practitioner, and assistant director of nursing revealed that the consultation documentation was either not received, misfiled, or not reviewed as required. The nurse practitioner stated that if they had seen the consult documentation, the order for Linzess would have been entered. The DON confirmed that the process involves reviewing the consult and informing medical staff of recommendations, but in this case, the consult form could not be located, and the recommended medication was not initiated.
Physician Review and Documentation Lapse for Medication Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician reviewed a resident's total program of care, including medications and treatments, at each required visit. Specifically, a resident with a history of chronic constipation was seen by a gastroenterologist, who recommended starting the medication Linzess. However, there was no documented evidence that this medication was ever ordered for the resident, nor was the consultation documentation available in the resident's record for review. The resident in question had multiple diagnoses, including dementia, schizoaffective disorder, and chronic constipation, and was dependent on staff for most activities of daily living. The care plan for constipation included several medications and interventions, and the gastrointestinal consult recommended adding Linzess to the regimen. Despite this, the medication was not ordered, and the consult documentation was missing from the resident's chart. Interviews with facility staff revealed that the process for reviewing and filing consultation documentation was not consistently followed. The DON confirmed the consult was not in the chart and had to be obtained by phone. The LPN described the usual process for handling consults, and the nurse practitioner stated they did not recall seeing the consult or the recommendation for Linzess, despite documenting that the consultation services were reviewed. This lapse resulted in the resident not receiving the recommended medication and incomplete documentation in the medical record.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #202 was administered Lasix and Losartan without a physician's order, which led to the need for frequent blood pressure monitoring and intravenous fluids. The error occurred because the nurse administered the medication intended for the resident's roommate. The nurse admitted to being distracted and failing to verify the resident's identity before administering the medication. This resulted in Resident #202 experiencing hypotension, requiring medical intervention. Resident #96 was nearly given an incorrect dose of Tizanidine, a muscle relaxant, during a medication administration observation. The LPN involved took a 4 mg tablet instead of the prescribed 2 mg dose. The error was caught by a surveyor before the medication was administered. The LPN acknowledged overlooking the physician's order and admitted to making a mistake by not checking the order prior to administration. This incident highlights a lapse in following the facility's medication administration policy, which requires verification of the correct medication and dosage.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standards of practice. Specifically, two residents were found with medications at their bedside without proper authorization or care plans to self-administer these medications. Resident #12 had an ipratropium nasal spray and an albuterol sulfate inhaler on their bedside table, and they were not following the physician's instructions to rinse their mouth after using the inhaler. There was no documented care plan for Resident #12 to self-administer their medications. Similarly, Resident #96 was found with multiple medications, including Trelegy inhalers, a Flonase nasal spray, an ipratropium nasal spray, an albuterol sulfate inhaler, and a triamcinolone acetonide ointment at their bedside. Although there was a physician's order for Resident #96 to self-administer the albuterol inhaler, there was no assessment or care plan in place for self-administration of any medications. Resident #96 expressed confusion and distress when their inhaler was removed by staff, indicating a lack of communication and proper procedure. Additionally, the facility failed to secure medication and treatment carts properly. The 5th Floor Medication Cart and Treatment Cart were observed unlocked and unattended, making them accessible to residents, visitors, and unlicensed staff. This oversight was acknowledged by the staff, including a Registered Nurse and an LPN, who admitted that the carts should always be kept locked. These lapses in medication storage and security represent a significant deficiency in the facility's adherence to safety protocols.
Inadequate Staff Competency and Training in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide adequate care and maintain resident safety and well-being. This deficiency was observed on two resident units, where personnel files for six Certified Nursing Assistants (CNAs) lacked evidence of competency in basic nursing skills and activities of daily living. Additionally, four licensed nursing personnel files did not contain competency assessments for medication management. The facility's assessment indicated that staff should have competencies in various areas, including abuse prevention, resident rights, and dementia care, but these were not documented in the personnel records. The Human Resources Director acknowledged communication issues between the HR and Nursing departments, particularly regarding disciplinary actions and performance concerns. The facility had removed the Inservice Educator position, which was responsible for staff training, and the duties were absorbed by the Director of Nursing (DON). The Assistant Director of Nursing (ADON) stated that competency evaluations were only conducted in response to specific incidents or complaints, rather than consistently. The facility lacked computer terminals for staff to complete online training, and behavior management and dementia care were not included in the annual inservice training. Interviews with the DON and ADON revealed that the system for evaluating nursing staff competencies was inadequate, with evaluations not being consistently performed. The DON, who assumed the role in June 2024, was now responsible for inservice training and competency evaluations, but acknowledged that these were not consistently conducted. The facility's Administrator was unsure if competencies and performance evaluations were being performed as required, indicating a lack of oversight and accountability in ensuring staff competency.
Deficiency in Nurse Aide Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to ensure that each nurse aide received a performance review at least once every 12 months and regular in-service education based on the outcomes of these reviews. This deficiency was observed on the 5th Floor of the facility, where 6 out of 6 Certified Nursing Assistant (CNA) personnel files lacked evidence of performance evaluations and in-service training based on evaluation results. The facility's assessment documented that staff were expected to have competencies in various areas, including abuse, resident rights, and dementia care, but there was no documented evidence that these competencies were part of the orientation or annual in-service package. The facility's survey report indicated that each nurse aide was required to receive 6 hours of paid in-service training every 6 months, but the review of personnel records showed no evidence of the required 12-hour annual in-service training. Additionally, the facility did not include behavioral health care and management in the list of in-service topics provided to staff. The Human Resources Director acknowledged communication issues between Human Resources and the Nursing Department, which affected the handling of disciplinary actions and performance evaluations. The facility also lacked an Inservice Educator, as the position was absorbed into the Director of Nursing's responsibilities. Interviews with the Director of Nursing and the Assistant Director of Nursing revealed inconsistencies in conducting competency evaluations and in-service training for nursing staff. The Director of Nursing admitted that the system for ensuring competency evaluations was inadequate, and the Assistant Director of Nursing stated that they only conducted evaluations related to specific incidents or complaints. The Administrator was unsure if competencies and performance evaluations were being performed as required, indicating a lack of oversight and accountability in the facility's processes for maintaining staff competencies.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
During a recertification survey, the facility was found to have deficiencies in infection control practices by three nurses during medication administration. Registered Nurse #3 failed to practice hand hygiene or sanitize vital signs equipment between residents. This nurse also touched a resident's eyelid with an eye dropper during administration, which is against infection control protocols. Additionally, the nurse placed a thermometer on a resident's breakfast tray without sanitizing it and did not clean the blood pressure cuff between uses. The nurse acknowledged the importance of hand hygiene and equipment sanitization but did not adhere to these practices. Licensed Practical Nurse #2 also neglected to sanitize their hands or wipe down the blood pressure cuff before and after taking a resident's blood pressure. Licensed Practical Nurse #1 was observed with long hair that came into contact with medication cups and a nebulizer treatment box, which they admitted was a poor infection control practice. The Assistant Director of Nursing confirmed that nurses were trained on the importance of hand hygiene and equipment sanitization, but these practices were not consistently followed during the survey observations.
Failure to Ensure Staff Identification and Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by several nursing staff on the Dementia unit not wearing identification badges. This was observed during the recertification survey, where Certified Nursing Assistants (CNAs) were seen without identification badges, which is against the facility's policy. The absence of identification badges was noted to cause confusion among residents, particularly those with cognitive impairments, and concern among visitors and families regarding staff accountability and the dignity and respect afforded to residents. The issue was compounded by the facility's inconsistent staff education and a non-functional identification badge machine during a period when the Human Resources Director was on leave. Despite efforts by the Director of Nursing and the Administrator to ensure compliance through regular rounds, the problem persisted. The lack of identification badges was identified as a persistent concern, and new employees were reportedly provided with badges before working on resident units, yet compliance remained an issue.
Failure to Review Resident Rights During Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and the rules and regulations governing resident conduct and responsibilities during their stay. Specifically, the facility did not provide or review resident rights during monthly Resident Council meetings. The policy and procedure for Resident Council did not include documentation of a review of residents' rights, and meeting minutes from April 2024 to August 2024 lacked evidence of such reviews. During a Resident Council meeting on October 4, 2024, residents confirmed that their rights were not discussed in these meetings, although they received information about their rights upon admission. The Director of Social Services/Grievance Official acknowledged awareness of the Resident Council meetings and reviewed the minutes post-meeting with the Director of Activities. They stated that resident rights information was included in admission packets and posted in day rooms, but after admission, this information was only available upon request. There was no routine or annual discussion of resident rights, and the facility could not provide documentation that these rights were reviewed annually or during the last five Resident Council meetings or care plan meetings.
Failure to Develop Comprehensive Care Plan for Self-Administering Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was self-administering medication. The resident, who had chronic obstructive pulmonary disease, chronic atrial fibrillation, chronic rhinitis, and shortness of breath, was observed with an albuterol sulfate inhaler in their room. The resident stated they could use the inhaler whenever needed for chest tightness, and it was always at their bedside. However, there was no documented evidence in the electronic medical record that a Self-Administration of Medication Care Plan was initiated prior to a specific date. The facility's policy requires the Interdisciplinary Team, in conjunction with the resident and their family or legal representative, to develop and implement a comprehensive, person-centered care plan for each resident. This care plan should describe the services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Director of Nursing acknowledged that registered nurses are responsible for initiating care plans and that all residents should have care plans reflecting their plan of care. The deficiency was identified during a recertification survey, highlighting the lack of a timely care plan for the resident's self-administration of medication.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses of cerebral infarction, anxiety disorder, and unspecified dementia, exhibited behaviors such as screaming, yelling, and flailing arms without any non-pharmacological interventions or staff interaction to address these behaviors. Despite having a comprehensive care plan that included interventions for cognition, mood, and behavior, there was no documented evidence that these plans were reviewed or revised to include non-pharmacological interventions. Observations during the survey revealed that the resident was often left alone in the dayroom without staff interaction or assistance, even when they were visibly distressed or in need of help. The resident was observed in a wheelchair with their head in their hands, hair unkempt, and clothing stained, without any staff acknowledging or interacting with them. On multiple occasions, the resident was heard screaming and expressing hunger and confusion, yet staff did not intervene or provide the requested assistance. The lack of staff response and interaction was consistent, even when the resident was tearful and expressed feelings of loneliness. Interviews with staff indicated a lack of training and awareness regarding behavioral health management. Certified Nursing Assistants reported that some resident behaviors were ignored, and there was no evidence of behavioral health and management training being part of the facility's annual inservice requirements. The Director of Recreation acknowledged scheduling conflicts that led to the cancellation of activities, which further limited the resident's engagement and social interaction. The facility's failure to implement and document appropriate behavioral interventions and staff training contributed to the deficiency in providing necessary care and services to the resident.
Deficiency in Dementia Care and Activity Engagement
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, as evidenced by the lack of engagement in meaningful activities. Resident #24, who was moderately cognitively impaired and diagnosed with dementia and anxiety disorder, was observed multiple times sitting alone in the dayroom without participating in any activities. The resident's care plan included interventions such as encouraging socialization and engagement, but there was no documented evidence that the care plan was reviewed or revised following the Minimum Data Set 3.0 assessment. Observations revealed that scheduled activities were not conducted as planned. On several occasions, the activity calendar listed specific activities, but these were not observed to be taking place. For instance, on one occasion, the Recreation Leader was seen watching two residents color, while other residents, including Resident #24, were left unengaged. Interviews with staff indicated a lack of awareness and training related to dementia care, with some staff unaware of the unit's designation as a Dementia Unit. The Director of Recreation acknowledged issues with the activity schedule, citing conflicts with kitchen timing as a reason for delays and cancellations. Despite these challenges, the Director did not escalate the issue to the Administrator or include it in a Quality Assurance Performance Improvement Project. The Administrator was unaware of the activity cancellations and could not specify how the facility measured its performance in providing dementia care. Additionally, the Human Resources Director confirmed that dementia care was not part of the facility's annual inservice requirements for staff.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide or obtain emergency dental services for Resident #56, who was evaluated by a dentist for a fractured front tooth on July 25, 2024, and was given a referral for extraction. Despite the resident experiencing discomfort while eating and requesting the extraction, the facility delayed scheduling the appointment with an oral surgeon until October 10, 2024. This delay occurred despite the resident's ongoing complaints of pain and the dentist's follow-up to ensure the referral was processed. The deficiency was further compounded by a lack of documentation and follow-up by the facility staff. Staff #22, responsible for scheduling the appointment, failed to document attempts to make the appointment before going on vacation, and no other staff followed up on the matter. The Director of Nursing confirmed that there was no note indicating attempts to schedule the appointment, and the resident continued to experience discomfort due to the delay in receiving necessary dental care.
Food Safety and Hand Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure food was stored and handled in accordance with professional standards for food safety practice during a recertification survey. Observations revealed that food items in the nutrition and storage refrigerators were not labeled and dated, including apple sauce, sliced meats, yellow cheese, frozen meat, and coleslaw. Additionally, raw meats were improperly stored with other items, such as Jello and ice cream, on the same shelf. These practices were contrary to the facility's undated policy and procedure titled Food Inventory, Receiving and Storage, which required each food item to be labeled and dated, and raw meats to be stored below all other items in the refrigerator. Further observations during a second tour of the kitchen revealed that staff members were not adhering to proper hand hygiene practices. Food Service Workers were seen touching unsanitary surfaces and equipment with gloved hands and then preparing food without changing their gloves. Additionally, the food thermometer was not sanitized with alcohol wipes after each use, and sandwiches and juices on the tray line were not labeled and dated. Interviews with the Director of Food Services and the Dietitian confirmed that the Director was responsible for overseeing kitchen operations and staff training on hand hygiene, but these practices were not being followed, leading to the deficiencies noted.
Improper Waste Disposal and Pest Attraction
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, leading to unsanitary conditions that could attract pests. During the recertification survey, it was observed that the dumpsters and compactors on the exterior of the building were not maintained in a sanitary condition. Specifically, a mouse was seen in the kitchen, and the dumpster was found uncovered with a missing lid. Additionally, a garbage bag was found on the ground between the dumpsters. These observations indicate a failure to adhere to the facility's Waste Management Policy and Procedure, which requires waste to be in leak-proof and secured containers. Interviews with facility staff revealed lapses in responsibility and oversight. The Food Service Director acknowledged the dumpster should have been covered but was unsure how long it had been uncovered. The Director of Housekeeping/Laundry admitted to not checking the dumpsters on the scheduled day, which was part of their responsibility to ensure cleanliness. The Administrator, who was responsible for approving the waste management policy, was unaware of the dumpster's condition and had not conducted environmental checks that would have identified the issue. The policy itself was undated and unsigned, indicating a lack of formal documentation and accountability.
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.
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What surveyors actually found near you
We read the 1,097 citations issued within 25 miles in the last 12 months — including the 13 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near White Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Martine Center For Rehabilitation And Nursing | 0.9 mi | ★★★★★ | 15 | 0 |
| White Plains Center For Nursing Care, L L C | 1.3 mi | ★★★★★ | 0 | 0 |
| The Knolls | 2.7 mi | ★★★★★ | 0 | 0 |
| The Grove At Valhalla Rehab And Nursing Center | 2.7 mi | ★★★★★ | 20 | 0 |
| Greenwich Woods Rehabilitation | 4.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.