Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friedwald Center For Rehab And Nursing, L L C during CMS and state inspections, most recent first.
The facility failed to ensure accurate trauma informed care assessments for several residents with severe cognitive impairment. A Social Worker completed multiple assessments using a resident interview-based tool, despite the residents' inability to participate due to their cognitive status. As a result, all assessments indicated no evidence of trauma, relying on staff and family input rather than direct resident responses.
Two residents did not have appropriate care plans implemented or updated to address significant care needs. One resident with repeated refusals of care did not have a care plan reflecting these behaviors, despite staff awareness. Another resident was readmitted with a reopened Stage 4 pressure ulcer, but the care plan for pressure ulcer management was not reactivated as required.
A resident with multiple medical conditions and a history of refusing care did not have a care plan addressing their refusal and non-compliance behaviors, despite documented instances and staff awareness. Facility staff confirmed that these behaviors should have been included in the care plan, but this was not done in accordance with facility policy.
Surveyors found that three residents dependent on staff for toileting and personal hygiene did not consistently receive necessary assistance, as evidenced by multiple undocumented care instances over two months. Staff interviews confirmed that blank documentation meant care was not provided, with reasons including short staffing, time constraints, and issues with electronic records. Facility policy required ADL documentation each shift, but this was not consistently followed.
An LPN at an LTC facility was observed on video throwing a water pitcher and bottle at a resident after the resident threw water at the LPN. The resident, with a history of aggressive behavior and diagnosed with bipolar disorder and chronic pain syndrome, was involved in a confrontation over medication timing. The LPN, an agency employee, was terminated following the incident.
The facility did not update care plans for two residents after incidents of abuse. One resident, with a history of bipolar disorder, was involved in a verbal altercation with an LPN, but their care plans were not revised. Another resident reported verbal abuse by an RN, yet their risk for abuse care plan remained unchanged. The RN Unit Manager admitted to not updating the care plans due to being absent during the incidents.
A facility failed to provide adequate behavioral health training to an LPN, resulting in an altercation with a resident known for aggressive behavior. The LPN, assigned to a dementia unit without prior training, engaged in a verbal exchange and threw water at the resident. The facility's inconsistent training process left many staff unprepared to handle such situations, as confirmed by interviews with the DON and Staff Development Coordinator.
A resident was transferred within the facility without being given the opportunity to refuse, following a CNA's discomfort due to alleged inappropriate behavior. The resident, who was cognitively intact, denied the allegations and expressed dissatisfaction with the move. The facility failed to document consent, investigate the incident, or revise care plans to address adjustment issues.
The facility failed to maintain a clean and homelike environment on the 3rd Floor, with issues such as peeling wallpaper, stained and damaged walls, and misshapen window blinds observed. A housekeeper admitted to missing cleaning spots due to obstructions, and the Director of Maintenance noted that renovations were planned but had not yet addressed the existing damage.
The facility failed to conduct grievance investigations for two residents with care concerns, despite the facility's policy requiring such actions. One resident's representative reported issues like unchanged clothing and staff refusal to assist, while another's representative raised concerns about care and supervision. Facility staff, including social workers and the administrator, did not initiate formal investigations, leaving grievances unresolved.
A resident with severe cognitive impairment was found with ecchymosis on their ear, suspected to be trauma by a dermatologist who reported it to Adult Protective Services. The facility failed to report the alleged abuse to the New York State Department of Health within the required timeframe, as the administrator decided not to report after an internal investigation found no evidence of abuse.
A resident with severe cognitive impairment was found with ecchymosis on their ear, initially attributed to anticoagulant therapy by nursing staff. A Dermatologist later suspected trauma and reported it to Adult Protective Services. The facility's investigation did not include interviews with the Dermatologist, and the Administrator was unsure if such contact was made, concluding no evidence of abuse despite the Dermatologist's findings.
A facility failed to develop a comprehensive care plan for a resident with a history of UTIs, despite the resident's severe cognitive impairment and dependency on staff for care. The lack of a care plan addressing UTI prevention was identified during a survey, with a nurse acknowledging the oversight.
A resident with severe cognitive impairment and hemiplegia was observed in a wheelchair without documented transfer assistance instructions. CNAs relied on verbal instructions due to inaccessible records, and no transfer orders were documented. The lack of documentation and communication led to a deficiency in care.
The facility failed to ensure that two residents with limited range of motion received appropriate treatment to prevent further contracture. One resident with Multiple Sclerosis was observed without the prescribed bilateral hand splints, and another resident with severe cognitive impairment was not wearing the right-hand splint as ordered. Staff interviews revealed a lack of adherence to physician orders and care plans, with issues in documentation and oversight contributing to the deficiency.
The facility did not ensure annual performance reviews for certified nurse aides, with five out of seven aides lacking documented evaluations within the required timeframe. Interviews revealed that the evaluations were not conducted, and the facility was working to reinstate them with a new administrator.
Two residents were found with medications improperly stored at their bedsides, including a cream without a current prescription and inhalers labeled from another facility. Staff interviews revealed a lack of adherence to the facility's policy requiring the reporting of medications found at the bedside.
The facility failed to ensure proper infection control measures, specifically in the use of PPE and enhanced barrier precautions. A resident with Clostridium Difficile was not protected as an aide entered their room without required PPE, and two CNAs transferred another resident without gowns, despite signage indicating the need for such precautions. Misunderstandings about PPE requirements contributed to these deficiencies.
Inaccurate Trauma Informed Care Assessments for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that all participants in the assessment process had the requisite knowledge to complete accurate trauma informed care assessments for four residents with severe cognitive impairment. The Social Worker conducted multiple trauma informed care assessments for these residents, all of whom were unable to be interviewed due to their cognitive status. Despite the residents' inability to participate, the assessments were completed and consistently scored as indicating no evidence of trauma, based solely on the absence of resident-reported trauma. The facility's policy required a multi-pronged approach to identifying a resident's trauma history, including direct questioning, screening tools, and review of medical and social histories. However, for the residents in question, the Social Worker relied on interviews with staff and family members, as well as personal knowledge of the residents, rather than direct resident input. The assessments were still completed using a resident question-based tool, which was not appropriate for individuals with severe cognitive impairment who could not respond to the questions. The residents involved had significant medical histories, including Alzheimer's disease, multiple sclerosis, cerebral palsy, dementia, and other conditions resulting in severe cognitive and physical impairments. All required extensive assistance with activities of daily living and were unable to communicate effectively for the purposes of the trauma informed care assessment. The repeated use of an interview-based assessment tool for these residents resulted in inaccurate documentation of their trauma histories.
Failure to Implement and Update Comprehensive Care Plans for Resident Refusals and Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by policy. One resident, who was cognitively intact and had a history of refusing care, had multiple documented instances of care refusal. Despite these occurrences, there was no care plan initiated to address or reflect the resident's refusal behaviors. Interviews with nursing staff and the Director of Nursing confirmed that a behavior or refusal of care plan should have been implemented but was not, and that the resident's non-compliance was known but not documented in the care plan. Another resident, who had multiple diagnoses including diabetes, end stage renal disease, and chronic obstructive pulmonary disease, was at risk for pressure ulcers and had a history of a Stage 4 sacral pressure ulcer. After the ulcer was resolved and the resident was subsequently readmitted to the facility with the ulcer reopened, there was no documented evidence that the pressure ulcer care plan was reactivated upon readmission. The facility's policy required care plans to be updated with new or recurring conditions, but this was not done for the resident's reopened pressure ulcer.
Failure to Develop Care Plan for Resident Refusing Care
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident known to refuse care and exhibit non-compliant behaviors. The resident, who had diagnoses including Hepatic Encephalopathy, Essential Hypertension, and Osteoarthritis, was cognitively intact and required significant assistance with daily activities. Nursing progress notes documented three separate occasions where the resident refused care, yet a care plan addressing these refusal behaviors and non-compliance was not initiated or documented. Interviews with facility staff, including an LPN, the DON, and an RN, confirmed that the resident's refusal and non-compliance behaviors were known but not reflected in the care plan. Staff acknowledged that such behaviors should have been captured in a behavior or refusal of care care plan, but this was not done. The facility's policy requires that care plans include measurable objectives and timeframes to address identified needs, but this was not followed for the resident in question.
Failure to Provide and Document Required Toileting and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to ensure residents who were unable to perform activities of daily living (ADLs) received necessary assistance with toileting and personal hygiene. Documentation and interviews revealed that three residents, all dependent on staff for toileting due to various medical and cognitive conditions, did not consistently receive the required care. Certified nurse aide accountability records showed multiple occasions over a two-month period where toileting was not documented as performed for these residents. One resident, who was cognitively intact but physically dependent, was found by their representative covered in urine and feces on several occasions. Review of care plans indicated the resident required assistance with all ADLs, including toileting, and was frequently incontinent. Certified nurse aide records lacked signatures for toileting on 37 occasions, and staff interviews confirmed that a blank in the documentation meant the task was not completed. Staff cited reasons such as short staffing, lack of time, and sometimes forgetting to document, but also acknowledged that if the box was blank, the care was not provided. Two other residents, both with significant cognitive and physical impairments, also had numerous instances where toileting was not documented as performed. Staff interviews revealed issues with access to electronic documentation systems and occasional computer malfunctions, but staff and nursing leadership confirmed that lack of documentation indicated the task was not completed. The facility's policy required ADL documentation on each shift, and the DON and LPN confirmed that blank documentation boxes meant the care was not provided. These findings were based on record review, staff interviews, and review of facility policies.
Resident Abuse Incident Involving LPN
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Licensed Practical Nurse (LPN) and a resident. On the date of the incident, the LPN was observed on surveillance video throwing a water pitcher and a small water bottle at the resident. This occurred after the resident had thrown water at the LPN. The facility's policy on abuse, neglect, and exploitation, which was last reviewed in October 2023, clearly prohibits such actions, defining abuse as the willful infliction of injury or intimidation causing physical harm or mental anguish. The resident involved in the incident had a history of aggressive behavior, as documented in their care plans. The resident was diagnosed with bipolar disorder, depression, and chronic pain syndrome, and required assistance with daily activities. The care plans included interventions to manage the resident's aggressive behavior, such as psychological consultations and medication management. Despite these measures, the resident exhibited aggressive behavior during the incident, which escalated into a confrontation with the LPN. The incident was reported and documented in an Accident/Incident Report, and the facility conducted an investigation, including reviewing surveillance footage and obtaining statements from witnesses. The LPN involved was an agency employee who had only worked a few shifts at the facility. The LPN was terminated following the incident, and a professional discipline complaint was filed with the New York State office of the professions. The resident reported feeling anxious and nervous after the incident, although no physical injuries were noted.
Failure to Update Care Plans After Abuse Incidents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in a timely manner for two residents following incidents of abuse. Resident #1, who has a history of bipolar disorder, depression, and chronic pain syndrome, was involved in a verbal altercation with an LPN on 7/30/2024. Despite the incident, the resident's care plans related to risk for abuse, behavior, and behavior symptoms were not updated to reflect the event. The resident's behavior care plan, which was last revised on 8/5/2024, documented aggressive behaviors and verbal abuse towards staff, but did not include any revisions or interventions following the incident. Resident #4, who has diagnoses including chronic obstructive pulmonary disease and end-stage renal disease, reported verbal abuse by an RN to the Director of Social Services on 7/16/2024. Although an abuse investigation was initiated and corrective actions were taken, the resident's risk for abuse care plan was not updated to reflect the allegation. The resident's care plan, dated 1/20/2024, indicated a risk for potential abuse due to dependence on staff for activities of daily living, but no updates were made following the reported incident. The Registered Nurse Unit Manager of the 3rd floor acknowledged responsibility for updating care plans but admitted that they did not update the care plans for Residents #1 and #4 because they were not in the building when the incidents occurred. The manager recognized that the abuse care plans should have been updated to reflect any negative psychological indications resulting from the incidents.
Inadequate Staff Training Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained to meet the behavioral health needs of residents, as evidenced by an incident involving a Licensed Practical Nurse (LPN) and a resident with known aggressive behavior. The LPN, who had not received documented training in behavioral health care, engaged in a verbal altercation with the resident and subsequently threw a pitcher of water at them. This incident occurred on a dementia unit where the LPN was assigned without prior behavioral health training, highlighting a gap in the facility's training protocol. The facility's Behavioral Health Policy mandates that all staff receive education to ensure appropriate competencies for meeting residents' behavioral health needs. However, a review of training records revealed that only a small fraction of the staff had completed both cognitive and behavioral training. The LPN involved in the incident had not received the necessary training before their assignment, despite being informed of the resident's aggressive tendencies. Interviews with staff, including the Director of Nursing and the Staff Development Coordinator, confirmed that the facility's orientation process was inconsistent, with some new staff missing essential training sessions. The resident involved in the incident had a history of bipolar disorder, depression, and chronic pain syndrome, with care plans indicating aggressive behavior and a risk for abuse. Despite these documented needs, the facility's failure to provide adequate training to the LPN contributed to the altercation. The incident exposed a systematic failure in the facility's training and onboarding processes, as acknowledged by the facility's Administrator, who noted that the LPN was scheduled for training only after the incident occurred.
Resident's Right to Refuse Room Transfer Not Honored
Penalty
Summary
The facility failed to ensure a resident's right to refuse a room transfer that was conducted solely for the convenience of staff. This deficiency was identified during a recertification survey, where it was found that a resident, who was cognitively intact and had diagnoses of a right femur fracture and end-stage renal disease, was moved from the 2nd Floor to the 3rd Floor. The transfer occurred after a Certified Nursing Assistant (CNA) reported feeling uncomfortable providing care to the resident due to alleged inappropriate behavior, which the resident denied. The resident was not given the opportunity to refuse the transfer, and there was no documented evidence of consent or a detailed assessment justifying the move. The resident expressed dissatisfaction with the room change, stating they felt more compatible with the resident population on the 2nd Floor and spent most of their time there to engage in more stimulating activities. The facility's Comprehensive Care Plans, which included interventions to honor the resident's preferences and routines, were not reviewed or revised to address the resident's adjustment difficulties following the room change. Additionally, there was no documentation of follow-up by the facility staff to ensure the resident had adjusted to the new environment. Interviews with facility staff revealed that the decision to move the resident was made collectively by the interdisciplinary team, including the social worker, Director of Social Work, and Director of Nursing, without proper documentation or investigation of the alleged incident. The social workers did not develop care plans with interventions to address potential adjustment issues, and there was no documentation of the resident's consent to the room change. The incident was not recorded in the resident's medical record, and the facility did not conduct an investigation into the allegations made by the CNA.
Deficiency in Maintaining a Homelike Environment on 3rd Floor
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents on the 3rd Floor, as observed during a recertification survey. The surveyors noted several deficiencies, including peeling wallpaper in the hallway, a dayroom with stained and damaged walls, missing and mismatched wallpaper, and misshapen and bent window blinds. These observations were made during a visit to the 3rd Floor dayroom, where issues such as a quarter-sized hole in the wall, remnants of thick white tape, missing wallpaper, dried food splatters, and black scuff marks along the walls were documented. Additionally, wallpaper near the ceiling in the hallway was found to be peeling and hanging off the wall. Interviews with facility staff revealed that routine cleaning was not adequately addressing these issues. A housekeeper responsible for daily cleaning admitted to missing spots along the walls due to obstructions like tables, chairs, and residents, and noted that wheelchair-induced scuff marks were difficult to remove. The Director of Maintenance acknowledged ongoing renovations, with the 1st and 2nd Floors already completed, and plans to start renovating the 3rd Floor in the coming months. However, the existing damage and cleanliness issues were not addressed because the staff relied on verbal reports for repair needs, and the impending renovation was expected to resolve these problems.
Failure to Conduct Grievance Investigations for Resident Concerns
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve resident grievances for two residents, as observed during a recertification and abbreviated survey. The facility's grievance policy mandates that when a grievance is reported, the grievance officer and assigned social worker must be notified, and an investigation should be conducted with findings communicated to the complainant within five business days. However, for Resident #321, who had diagnoses of Parkinson's disease and adult failure to thrive, the facility did not conduct a grievance investigation despite the Designated Representative expressing concerns about care issues, such as clothing not being changed daily and staff refusing to take the resident out of bed. These concerns were communicated via email and letter to the former Administrator and Director of Nursing, but no documented evidence of an investigation was found. Similarly, for Resident #136, who had diagnoses of dementia and metabolic encephalopathy, the facility did not conduct a grievance investigation despite the Designated Representative expressing concerns about care and supervision. These concerns were communicated to nursing staff, the Director of Social Work, and Social Worker #3 on multiple occasions. Documentation showed that emotional support was provided, but no formal grievance investigation was conducted. The Designated Representative also raised issues about the resident's condition, care team changes, and specific incidents like wet clothing and bruising, but these were not formally investigated as grievances. Interviews with facility staff, including Social Worker #3, the Director of Social Work, and the Administrator, revealed a lack of awareness and action regarding the grievance process. Social Worker #3 attempted to address concerns verbally with nursing staff but did not initiate formal investigations. The Administrator acknowledged the receipt of email correspondence from Resident #321's Designated Representative but was unaware of any grievance investigations being conducted. The facility's failure to adhere to its grievance policy resulted in unresolved care concerns for both residents.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment, diagnosed with dementia and metabolic encephalopathy, to the New York State Department of Health within the required timeframe. The incident involved ecchymosis found on the resident's ear, which was initially explained by the nursing staff as a result of anticoagulant therapy. However, a dermatologist later suspected trauma and reported the case to Adult Protective Services, supporting the suspicion of abuse. Despite this, the facility's administrator decided not to report the incident to the state agency, citing that the investigation conducted by the former Director of Nursing found no evidence of abuse. The facility's policy mandates that any allegations of abuse must be reported immediately, but not later than two hours after the allegation is made. In this case, the facility did not adhere to this policy. The resident's designated representative was not satisfied with the facility's explanation and sought further evaluation, which led to the dermatologist's involvement. The administrator acknowledged the delay in reporting but chose not to report the incident, as it was beyond the two-hour window, and the internal investigation concluded no abuse had occurred.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving a resident with severe cognitive impairment and diagnoses of dementia and metabolic encephalopathy. The incident involved ecchymosis found on the resident's ear, which was initially attributed to anticoagulant therapy by the nursing staff. However, a Dermatologist later assessed the resident and suspected physical trauma, subsequently reporting the case to Adult Protective Services. Despite this, the facility's investigation did not include interviews with the Dermatologist to explore the trauma assessment and the report to Adult Protective Services. The facility's policy mandates immediate reporting of abuse allegations to the Administrator and state agency, but the investigation into the resident's ear ecchymosis lacked thoroughness. The Administrator, during an interview, was unsure if the Dermatologist was contacted as part of the investigation and believed a thorough investigation was completed. The investigation documentation did not provide evidence of interviews with the Dermatologist, and the facility concluded there was no evidence to support abuse, despite the Dermatologist's findings and actions.
Failure to Develop Comprehensive Care Plan for UTI Prevention
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed for a resident with a history of urinary tract infections (UTIs). The resident, who was admitted with diagnoses including dementia, diabetes mellitus, and a history of UTIs, was found to have severe cognitive impairment and was dependent on staff for all activities of daily living. Despite these conditions, there was no documented evidence in the electronic medical record of a care plan addressing the prevention of reoccurring UTIs. Observations and interviews during the survey revealed that the resident was at risk for UTIs due to immobility, incontinence, dementia, and dependency on staff for care. A registered nurse acknowledged the responsibility to initiate a care plan to address these concerns, including antibiotic use and monitoring, but admitted that it had not been done. This oversight was noted during a recertification and abbreviated survey, highlighting a deficiency in the facility's compliance with care planning requirements.
Deficiency in Documenting Transfer Assistance for a Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and services in accordance with professional standards of practice and their comprehensive person-centered care plan. This deficiency was identified during a recertification survey, where it was observed that a resident with severe cognitive impairment and diagnoses of cerebral infarction and left side hemiplegia was out of bed in a reclining back wheelchair with a hoyer lift canvas underneath. There was no documented evidence in the care plan or occupational therapy discharge note to address the level of assistance and devices required for safe bed-to-chair transfer, despite the resident being dependent on staff assistance for transfers. Further investigation revealed inconsistencies in the documentation and communication of the resident's transfer needs. Certified Nursing Assistants (CNAs) were unable to access the resident's instructions on the computer console and relied on verbal instructions from coworkers. A Registered Nurse confirmed that there were no transfer orders documented for the resident, and the Director of Rehabilitation stated that recommendations for transfer devices were communicated to the nursing department but were not documented in the resident's chart. The lack of documented transfer orders and instructions led to the deficiency in providing appropriate care for the resident.
Failure to Ensure Proper Use of Splints for Residents with Limited ROM
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Specifically, two residents were affected by this deficiency. Resident #21, who was diagnosed with Multiple Sclerosis, Functional Quadriplegia, and Type 2 Diabetes, was observed multiple times without the prescribed bilateral hand splints that were supposed to be worn throughout the day to prevent further contracture. Despite the physician's order and care plan, there was no documented evidence in the electronic medical record indicating that the hand splints were applied prior to the survey observations. Resident #98, who had severe cognitive impairment and functional limitation in the range of motion of the upper extremity following a cerebral infarction, was also not wearing the prescribed right-hand splint as per the physician's order. Observations revealed that the resident's right hand was clenched closed, and the splint was not applied correctly. Although the resident reportedly refused to wear the splint, there was no documentation in the care plan regarding the refusal or any alternative plan to address the issue. Interviews with staff, including CNAs and nurses, revealed a lack of adherence to the physician's orders and care plans. The Director of Nursing acknowledged that the physician's order for Resident #21 did not carry over to the treatment administration record, preventing nurses from signing off on the application of the splints. Similarly, for Resident #98, there was no directive in the administration record for the use of the right-hand splint, and the care plan did not reflect the resident's refusal to wear the splint. This lack of documentation and oversight contributed to the deficiency in providing appropriate care for residents with limited range of motion.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that certified nurse aides received performance reviews at least once every 12 months, as required. Specifically, five out of seven certified nurse aides did not have documented performance reviews within the required timeframe. Certified Nurse Aide #7 and #17 had their last evaluations completed in 2008 and 2010, respectively, while there was no documented evidence of performance evaluations for Certified Nurse Aides #24, #25, and #26. Interviews with the Human Resources Director and the Director of Nursing revealed that the annual performance evaluations were not conducted, and the facility was in the process of reinstating them with a new administrator. Additionally, interviews with several certified nurse aides indicated a lack of recent performance evaluations, although in-services were conducted. This deficiency was identified during a recertification survey conducted from July 9, 2024, through July 16, 2024, and was in violation of 10NYCRR 415.26(c)(1)(IV).
Improper Medication Storage and Labeling
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure proper storage and labeling of medications for two residents. Resident #378, who was cognitively intact and had diagnoses including Diabetes, Chronic Kidney Disease, and Peripheral Vascular Disease, was found to have a tube of Nystatin-Triamcinolone cream on their bedside table. This cream was not prescribed at the time of observation, as confirmed by interviews with two Licensed Practical Nurses (LPNs). The LPNs acknowledged that medicated creams should not be left at the bedside without a current physician's order. Similarly, Resident #425, also cognitively intact and diagnosed with Asthma, Hypertension, and Hypothyroidism, had Fluticasone and Albuterol inhalers on their bedside table. These inhalers were labeled with another facility's name, indicating they were not properly stored or labeled according to the facility's standards. A Certified Nurse Aide and an LPN confirmed the presence of these inhalers and admitted they were unaware of the resident having their own medication at the bedside. The facility's policy required staff to report any medications found at the bedside, which was not adhered to in these instances.
Infection Control Deficiencies in PPE Use
Penalty
Summary
The facility failed to ensure proper infection control prevention measures were followed, specifically regarding the use of personal protective equipment (PPE) and enhanced barrier precautions. In the case of Resident #130, who was admitted with diagnoses including Diabetes Mellitus, End Stage Renal Disease, and Clostridium Difficile infection, contact precautions were not adhered to. Despite a sign outside the resident's room indicating the need for gloves and a gown, Recreation Aide #9 entered the room without donning the required PPE and touched the resident's overbed table. The aide was under the impression that a gown was not necessary for dropping off items and was incorrectly informed by nursing staff to use antibacterial hand sanitizer instead of washing hands with soap and water, which is required for Clostridium Difficile infections. In another instance, Resident #72, who had severe cognitive impairment and an indwelling feeding tube, was not provided with the necessary enhanced barrier precautions during a transfer. Certified Nurse Assistants #10 and #11 transferred the resident from a chair to bed without wearing gowns, despite a sign indicating the requirement for gowns and gloves during high-contact activities. The CNAs believed gowns were only necessary during wound dressing changes, not for transfers. The Infection Preventionist stated that in-services had been provided regarding enhanced barrier precautions, but the CNAs did not follow the protocol during the observed transfer.
What surveyors are citing around you — mapped
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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 940 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Valley Center For Rehabilitation And Nursing | 1 mi | ★★★★★ | 13 | 0 |
| Northern Manor Geriatric Center Inc | 2.8 mi | ★★★★★ | 0 | 0 |
| Northern Metropolitan Res Health Care Facility Inc | 3 mi | ★★★★★ | 2 | 0 |
| Helen Hayes Hospital R H C F | 4.6 mi | ★★★★★ | 0 | 0 |
| Helen Hayes Hospital T C U | 4.6 mi | ★★★★★ | 0 | 0 |
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