Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glen Island Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Advance directive wishes were not accurately reflected for two residents. One resident with dementia had conflicting documentation after the family requested Full Code, but the physician orders remained DNR/DNI. Another resident with intact cognition had a MOLST for DNR/DNI/DNH, yet active physician orders still included Full Code along with the DNR/DNI/DNH orders, leaving the record inconsistent.
A resident with hemiplegia after CVA and diabetes was ordered a left resting hand splint to help maintain ROM and prevent contractures, but staff repeatedly observed the resident without the splint in place. CNA staff reported the splint was missing from the room, could not locate it, and documented it as refused because there was no other option, while the splint remained unavailable during subsequent checks.
Failure to provide timely written Medicare non-coverage notices to three residents. The facility notified designated representatives by phone before skilled coverage ended, but the written notices were mailed later by regular mail and there was no documented proof they were received. One resident remained in the facility after skilled services ended, and two residents were discharged home.
Late MDS Assessment Submission: The facility failed to ensure that MDS assessments were completed and transmitted within required time frames. Record review showed that quarterly and annual assessments for multiple residents were submitted after the allowed window, and staff interviews confirmed that the MDS Coordinator was responsible for completion and submission but some assessments were late because they were not completed on time.
Surveyors found that the facility did not thoroughly investigate or accurately document multiple resident falls. One resident with dementia and a history of falls had an unwitnessed fall where the incident report lacked supervisor notification time, physician and family notification, and complete investigation details, and a CNA statement omitted when the resident was last seen. Another cognitively intact resident with neurologic conditions had a reported fall that was documented without physician notification, without attached staff statements, and with a CNA statement missing the time and name, while the investigation conclusion lacked the Administrator’s signature. A third resident with dementia and Parkinson’s was found on the floor with an abrasion, yet the incident report recorded that no injuries were observed, creating a discrepancy between the assessment and the documented injury status.
A resident with COPD, anxiety, muscle wasting, and dependence for bathing and other ADLs was observed lying in bed partially undressed, covered only from the waist down, with the chest fully exposed and visible from the hallway while a CNA provided morning personal care with the room door open. The facility’s policy required that residents be treated with dignity and respect and that privacy be maintained during care, and the resident’s care plan emphasized supporting psychosocial wellbeing and participation in care. The CNA reported leaving doors ajar due to difficulty breathing in the heated room and concerns about residents coughing, while also acknowledging awareness that both the curtain and door should be closed during personal care; an RN stated that the process is to always provide privacy when personal care is given.
The facility failed to properly review and revise care plans after falls for two residents. One resident with dementia, severe cognitive impairment, mobility impairment, and a history of falls had a fall risk care plan that listed a chair/bed alarm and directed staff to ensure the device was in place, yet there was no documentation or staff recollection of any alarm ever being used, and the DON stated alarms are not used in the facility. Another resident with stroke sequelae, seizures, and hemiplegia was found on the floor after sliding from bed; although the post-fall investigation stated the care plan was reviewed and revised, the fall risk care plan only documented that the resident was found on the floor and did not include any new safety interventions, which the DON confirmed were absent without explanation.
A resident with dementia, severe cognitive impairment, gait imbalance, and a high fall-risk score, who required a wheelchair and assistance with mobility and transfers, did not have documented position-change alarms or other assistive safety devices in place despite facility policy and care plans referencing such interventions. The resident had a known history of multiple falls and unsafe attempts to stand and walk without supervision. The resident was later found on the hallway floor after an unwitnessed fall while attempting to stand from a wheelchair, subsequently reporting back pain and being diagnosed with a T12 compression fracture. Staff interviews confirmed the absence of a wheelchair alarm or other consistent safety devices, while leadership acknowledged the resident as a frequent faller under close monitoring but without documented, effective fall-prevention measures at the time of the incident.
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development of facility-acquired pressure ulcers. One resident developed a Stage III pressure ulcer on the sacrum and bilateral heels due to inconsistent care. Another resident developed a Stage III pressure ulcer on the right buttocks after not receiving consistent incontinence care. A third resident, at high risk for pressure ulcers, developed a Stage III pressure ulcer on the sacrum due to inconsistent turning and positioning.
The facility failed to notify the representatives of three residents about the development and treatment of pressure ulcers. A resident developed multiple pressure ulcers, another had a sacral ulcer worsen from Stage II to III, and a third developed a Stage III ulcer. In each case, there was no documented evidence that the representatives were informed of these significant changes, violating the facility's notification policy.
A facility failed to provide appropriate incontinence care for four residents, as evidenced by numerous omissions in certified nurse assistant accountability reports. Residents reported being left in soiled briefs for extended periods, and interviews with staff revealed care was often undocumented due to forgetfulness. The Director of Nursing acknowledged the expectation for complete documentation, but no recent complaints were noted. This deficiency highlights a failure in ensuring proper care and documentation.
The facility was found to have insufficient nursing staff to meet resident needs consistently, with staffing levels frequently below the facility's own assessment requirements. Despite efforts to address shortages through a CNA training program, staffing shortfalls persisted across various shifts and units, particularly during night shifts.
Two residents developed facility-acquired pressure ulcers, but their care plans were not updated to reflect these changes. One resident with moderate cognitive impairment developed a stage II ulcer, and another with severe cognitive impairment developed a stage III ulcer. Despite a transition in wound care providers, the responsibility to update care plans was not fulfilled, leading to deficiencies in care planning.
The facility failed to conduct annual performance reviews and provide regular in-service education for CNAs as required. Two CNAs lacked documented evaluations for 2023 and 2024, and their training was not completed per facility requirements. The facility's policy mandates annual reviews, but evaluations were not aligned with in-service education needs.
The facility's QAPI committee failed to document and implement action plans for identified quality deficiencies, including facility-acquired pressure ulcers and issues discussed in previous meetings. Inconsistencies in meeting documentation further highlighted the lack of a structured approach to addressing these deficiencies.
A resident with a history of diabetes and recent surgical amputation did not receive consistent wound care as ordered, with multiple instances of missed documentation and administration. Interviews revealed that nursing staff either forgot to document or were unsure if treatments were administered, indicating a lapse in following professional standards of practice.
A resident with left-sided weakness due to a stroke was not provided with a reachable call bell, as required by their care plan. Despite staff acknowledging the need for the call bell to be on the resident's right side, it was repeatedly placed out of reach, leading to a deficiency in accommodating the resident's needs.
The facility failed to develop comprehensive care plans for three residents, leading to unmet medical and care needs. A resident with a urinary catheter and hand splint had no care plan for these devices, resulting in inconsistent use. Another resident lacked a care plan for palm guards and a hip abductor cushion, which were not used due to staff unawareness. A third resident's toileting schedule was not documented, leaving staff unaware of the need for assistance. These deficiencies highlight a lack of proper documentation and communication within the facility.
A resident's care plans were not updated to reflect the discontinuation of Lorazepam and the replacement of Apixaban with Xarelto. Despite facility policy requiring regular review and revision of care plans, these changes were not documented. Interviews with nursing staff confirmed the oversight.
Two residents with limited mobility did not receive necessary devices to maintain or improve their range of motion. One resident was observed without palm guards and a hip abductor, while another was without hand splints or palm guards. Staff were unaware of the orders, and the devices were not documented in care plans or Kardex. Interviews revealed confusion about responsibility for applying the devices.
A resident with limited mobility and incontinence was not toileted as per their care plan, leading to potential health issues. The resident was left to manage their incontinence independently, unaware of the scheduled assistance. Staff interviews revealed a lack of documentation and communication regarding the toileting schedule, which was not correctly entered into the system.
A resident did not receive an influenza vaccine despite having consent and a physician's order. The resident, who required assistance with daily activities, had a signed consent dated November 2023, but the December Medication Administration Record lacked evidence of vaccine administration. Staff interviews revealed oversight due to the resident's hospitalizations, highlighting lapses in the facility's vaccination process.
Advance directive wishes were not accurately reflected in the medical record
Penalty
Summary
The facility failed to ensure that residents’ advance directive wishes were accurately reflected in the medical record for two residents reviewed. The facility policy stated that residents’ advance directive wishes would be identified and honored, and that advance directives would be reviewed on admission, readmission, quarterly, annually, or at the resident/surrogate’s request. However, the records for two residents showed conflicting code status documentation and incomplete alignment between the Medical Orders for Life-Sustaining Treatment (MOLST) forms and physician orders. One resident with hypertension, non-Alzheimer’s dementia, and diabetes mellitus had moderately impaired cognition. The hospital record documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, and physician orders initiated after admission also documented DNR/DNI. Later, the social services note documented that the family requested rescinding the hospital advance directive order and requested Full Code, and the care plan was revised to Full Code. Despite this, the physician orders reviewed afterward still showed DNR/DNI, and there was no documented evidence that the resident’s advance directive status had been changed to match the family’s request. A second resident with diabetes mellitus, hypertension, and deep venous thrombosis had intact cognition. The physician note documented that the MOLST was reviewed and completed with DNR, DNI, and Do Not Hospitalize status, with the family in agreement, and the MOLST form was signed accordingly. The advance directive care plan also documented DNR, DNI, and Do Not Hospitalize. However, the resident’s active physician orders still included Full Code in addition to DNR, DNI, and Do Not Hospitalize orders, showing that the code status documentation was not consistent in the medical record.
Missing ordered hand splint for resident with hemiplegia
Penalty
Summary
The facility failed to ensure that Resident #16, who had hemiplegia following a cerebral infarction affecting the left non-dominant side and diabetes mellitus, received the ordered left resting hand splint and related services to maintain range of motion. The resident’s quarterly MDS documented relatively intact cognition, dependence in upper and lower body dressing, and impairment on both sides of the upper and lower extremities. The care plan and physician’s order both required use of a left resting hand splint, with removal for ADL care and skin checks, and the facility policy stated that splinting and orthotic management are intended to prevent worsening contractures and increase ROM. Resident #16 was observed multiple times in the room without the left-hand splint in place. CNA #4 stated the splint was missing from the resident’s room and could not be located, and reported this to Nurse Manager #4, who said rehab would obtain another splint. CNA #4 and RN #3 searched the resident’s drawers and still did not find the splint. CNA #4 also stated they had documented the splint as refused because there were no other options to indicate it was missing. The Nurse Manager stated that the resident wears the splint to prevent contractures and that staff are encouraged to ensure assistive devices are applied, but the splint was not in place during the observations.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility did not ensure residents or their designated representatives received timely written notice of Medicare Part A non-coverage at the termination of skilled services. This was identified for three residents reviewed for beneficiary notification: Resident #95, Resident #204, and Resident #205. The facility policy on Medicare Beneficiary Notices stated that advance written notice of noncoverage should be issued to and understood by the Medicare beneficiary or representative far enough in advance of potentially noncovered services so the beneficiary can consider available options. Resident #95 was discharged from Medicare skilled services with no remaining days and remained in the facility. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage showed the representative was notified one day before the last coverage date, but the written notice was mailed by regular mail after that date. Resident #204 was discharged from Medicare skilled services with 62 remaining days and discharged home; the Notice of Medicare Non-Coverage showed the representative was notified before the last coverage date, but the written notice was mailed on the last coverage date. Resident #205 was discharged from Medicare skilled services with 41 remaining days and discharged home; the notice showed the representative was notified two days before the last coverage date, but the written notice was mailed the day before the last coverage date. For these residents, the notices were not mailed on the same date notification was made, and there was no documented evidence that the resident or designated representatives received the notices sent by regular mail.
Late MDS Assessment Submission
Penalty
Summary
The facility failed to ensure that MDS 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted to IQIES/ASAP within the required time frames. Record review showed that quarterly, discharge, and comprehensive MDS assessments for 3 of 12 residents reviewed for resident assessment were not submitted within 14 calendar days after completion, including residents #19, #32, and #48. The cited guidance stated that non-admission assessments must be submitted within 14 days of the MDS completion date, and comprehensive assessments must be transmitted within 14 days of the care plan completion date. The facility policy also required MDS assessments to be completed, encoded, and submitted within established time frames. For resident #19, the quarterly MDS had an ARD of 08/14/2025, was completed on 08/28/2025, and submitted on 09/19/2025. For resident #32, the quarterly MDS had an ARD of 08/07/2025, was completed on 08/21/2025, and submitted on 09/19/2025. For resident #48, the annual MDS had an ARD of 08/13/2025, was completed on 08/27/2025, and submitted on 09/19/2025. The facility MDS submission report documented that the submission dates for the residents reviewed were more than 14 days after assessment. Interviews with the RN, Director of Social Services, MDS Coordinator, DON, and Administrator confirmed that the MDS Coordinator was responsible for completion and submission, that some assessments were transmitted late because they were not completed timely, and that the facility was aware of late submissions.
Incomplete Investigation and Documentation of Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and completely document alleged violations related to resident falls, contrary to its Accident/Incident Reporting policy and 10 NYCRR 415.4(b)(1)(ii). For one resident with dementia, bipolar disorder, severe cognitive impairment, lower extremity impairment, wheelchair use, and a history of multiple falls, an unwitnessed fall occurred. The accident/incident report lacked the time of supervisor notification and did not document whether the physician or family representative were notified. The CNA statement did not include the time the resident was last seen and incorrectly documented that the resident used alarms, despite the record indicating no bed, chair, floor mat, or motion sensor alarms. The post-occurrence investigation conclusion form dated the next day had its section titled “Steps taken that led to conclusion of investigation” left blank by nursing administration. For a second resident with sequelae of cerebral infarction, seizures, and left-sided hemiplegia who was cognitively intact and required supervision for ADLs but had no prior fall history, the resident’s representative called to report that the resident had fallen. The RN documented that staff immediately went to the room and found the resident in bed, with the resident reporting they had slid off the bed and gotten up independently, denying head impact and pain. The accident/incident report did not include documentation of physician notification and had no staff statements attached. A CNA occurrence statement completed two days later omitted the time of occurrence and the CNA’s name. The post-occurrence investigation report documented that the resident’s site of injury was re-assessed, despite there being no documented evidence in the accident/incident report that the resident sustained any injury. The post-occurrence investigation conclusion was not signed and dated by the Administrator. For a third resident with dementia, Parkinson’s disease, and a history of falling, staff found the resident lying on the floor on their back to the left side of the bed. The resident was assisted back to bed by three staff members and assessed, with an abrasion noted on the right outer back, denial of head impact and pain, and normal range of motion in all extremities. The accident/incident report, however, documented that no injuries were observed at the time of the incident, despite the abrasion being recorded elsewhere in the same report. Interviews with the DON and Administrator confirmed that required elements such as staff statements, times, notifications, and completion and signing of investigative conclusions were missing or incomplete, and an RN acknowledged that documenting “no injury” despite an abrasion was an error.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
A deficiency occurred when a resident’s right to dignity and privacy during personal care was not maintained. The facility’s Resident Rights policy, last reviewed on 10/01/2025, stated that each resident has the right to be treated with dignity and respect, and that all staff interactions must focus on maintaining and enhancing the resident’s self-esteem, self-worth, and individuality. Resident #5 had diagnoses including Chronic Obstructive Pulmonary Disease, General Anxiety Disorder, and Muscle Wasting and Atrophy, and was cognitively intact with no behaviors noted. The resident used a wheelchair for locomotion and required moderate assistance for eating and total dependence for bathing, toileting, bed mobility, and transfers. A psychosocial wellbeing care plan identified the resident as at risk related to anxiety and major depressive disorder and included interventions to encourage the resident’s participation in decision-making and care. During surveyor rounds on 12/05/2025 at 11:13 AM, the door to Resident #5’s room was observed open while Certified Nurse Aide (CNA) #2 was providing morning personal care. The resident was lying in bed undressed, covered only from the waist down with a sheet, with the chest fully exposed and visible from the hallway. After the surveyor notified the unit manager, CNA #2 pulled the curtain around the bed but left the room door open while continuing care. CNA #2 stated they kept the door open because they could not breathe in the room due to the heater and later reported that, for the past couple of weeks, residents had been coughing and not covering their mouths, so they sometimes left doors ajar when providing care. CNA #2 acknowledged knowing that both the curtain and the door should be closed when providing personal care. Registered Nurse #2 stated that residents should always be provided privacy when personal care is given and that the door should be closed during such care.
Failure to Accurately Review and Revise Care Plans After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were accurately reviewed and revised following falls for two residents. For one resident with dementia, bipolar disorder, a history of falls, severe cognitive impairment, unilateral lower extremity impairment, and dependence on a wheelchair and extensive assistance for ADLs, a fall risk care plan initiated after an unwitnessed fall documented the use of a chair/bed alarm and directed staff to ensure the device was in place as needed. However, the resident’s record showed no evidence that any alarm was ever in use during the stay, and a CNA interview confirmed the resident did not have a wheelchair alarm. The DON stated that the chair/bed alarm intervention was entered erroneously and that the facility does not use alarms. For another resident with sequelae of cerebral infarction, seizures, and left-sided hemiplegia who required supervision for mobility and ADLs and used a walker or wheelchair, an incident report documented that the resident was found on the floor in a sitting position after sliding off the bed. The post-occurrence investigation stated that the resident’s care plan was reviewed and revised. However, review of the fall risk care plan, last revised on the date of the fall, showed only a notation that the resident was found sitting on the floor at the foot of the bed and did not include any new safety interventions implemented after the fall. During interview, the DON acknowledged that no intervention was present on this resident’s care plan and could not explain why it was not entered.
Failure to Implement Effective Fall-Prevention Measures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents for a resident with a known high fall risk. The facility’s own Accidents/Incidents Reporting policy required implementation, monitoring, and modification of interventions to reduce hazards and risks, including the use of position change alarms such as chair and bed sensor pads, floor mats, and motion detectors. Despite this, documentation showed that the resident, who had a history of two or more prior falls and a high fall risk score of 16, did not have any position change alarms or other documented safety measures in place to prevent falls when attempting to stand or walk unsupervised. The resident had severe cognitive impairment, dementia, bipolar disorder, impaired lower extremity function requiring a wheelchair, and was dependent or required moderate assistance for bed mobility, transfers, and toileting. A behavior care plan noted the resident’s potential to attempt unsafe maneuvers such as standing and trying to walk without supervision, with poor cognition, poor safety awareness, and poor impulse control. The fall risk care plans identified the resident as high risk for falls related to confusion and gait/balance problems and, in one version, listed use of chair/bed alarms as an intervention; however, there was no documented evidence that such alarms or other assistive devices were actually in place for this resident. On the date of the incident, the resident was found sitting on the floor in the hallway with their wheelchair on its side after an unwitnessed fall, having attempted to stand and lost balance. The resident complained of back pain, and subsequent imaging showed osteopenia and a T12 vertebral body compression fracture of undetermined age. Staff interviews indicated that the resident did not have an alarm on their wheelchair or other safety devices during their stay, although a CNA recalled bedside floor mats and reported that the resident was typically seated outside their room near the nurse’s station and would edge toward the edge of the wheelchair and end up on the floor. The DON and Administrator acknowledged that the resident was a frequent faller and was on close supervision/monitoring, but there remained no documentation of specific assistive devices or effective fall-prevention measures in place at the time of the fall.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development of facility-acquired pressure ulcers. One resident, initially assessed as low risk for pressure ulcers, developed a Stage III pressure ulcer on the sacrum and bilateral heels due to inconsistent implementation of physician-ordered interventions such as turning, positioning, and the use of heel protectors. Documentation revealed multiple instances where care was not provided as per the care plan, and there was a lack of consistent wound assessment and monitoring. Another resident developed a Stage III pressure ulcer on the right buttocks after not receiving consistent incontinence care. The resident's treatment records showed that physician-ordered treatments were not documented as completed on several occasions. The care plan for bladder incontinence was not updated, and there was a lack of documentation for skin observations and incontinence care, indicating that these were not consistently performed. A third resident, who was at high risk for pressure ulcers, developed a Stage III pressure ulcer on the sacrum. The resident was dependent on staff for mobility and required regular turning and positioning, which was not consistently documented as completed. The facility's failure to provide consistent care and documentation contributed to the development and worsening of pressure ulcers in these residents.
Failure to Notify Representatives of Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that the representatives of three residents were informed of significant changes in their physical status, specifically the development of pressure ulcers. Resident #1 developed multiple facility-acquired pressure ulcers on their right buttocks and bilateral heels, but there was no documented evidence that the resident's representative was notified until they inquired about the condition. The representative noticed bandages and inquired about them, only to be informed by a nurse that the resident had bed sores. Despite daily visits, the representative was not informed of the condition changes until they asked. Resident #6 developed a facility-acquired sacral pressure ulcer, which worsened from Stage II to Stage III over time. There was no documented evidence that the resident's representative was informed of the initial development of the ulcer, the ordered treatment, or the changes in the ulcer's size and stage. The facility's failure to notify the representative of these significant changes in the resident's condition was a clear deficiency in communication and adherence to the facility's notification policy. Resident #7 also developed a Stage III pressure ulcer on the right buttock, but there was no documented evidence that the resident's representative was informed of this development or the treatment ordered. Although a phone conference was held with the representative, it did not include information about the pressure ulcer. The facility's policy required immediate notification of significant changes in a resident's condition, but this was not adhered to, resulting in a deficiency in communication with the residents' representatives.
Deficiency in Incontinence Care Documentation and Provision
Penalty
Summary
The facility failed to provide appropriate incontinence care for four residents, leading to a deficiency in care. Resident #6, who was severely cognitively impaired and dependent on staff for toileting, had numerous omissions in their certified nurse assistant accountability report for bladder incontinence care in July and August 2024. This resident also had a facility-acquired Stage III pressure ulcer, indicating a lack of proper care. Similarly, Resident #9, who was frequently incontinent of urine and always incontinent of bowel, had multiple instances in June and July 2024 where bladder incontinence care was not documented as provided. Resident #3, who was cognitively intact but dependent on staff for toileting, reported that they were often left in a soaked incontinence brief overnight without assistance. Their accountability reports for August and September 2024 showed numerous occasions where bladder incontinence care was not signed off by staff. Resident #4, also cognitively intact and frequently incontinent, reported being left in their incontinence brief for extended periods. Their accountability reports for August and September 2024 also showed many instances where care was not documented. Interviews with certified nurse assistants revealed that care was often not documented due to forgetfulness or being caught up in work, despite the facility's policy requiring documentation before the end of each shift. The Director of Nursing acknowledged the expectation for complete documentation but noted no recent complaints from residents or families. The facility's failure to ensure proper documentation and provision of incontinence care led to the deficiency identified in the survey.
Inadequate Staffing Levels in Facility
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of all residents consistently. The facility's own assessment determined specific staffing levels necessary for each unit and shift, but the actual staffing levels frequently fell below these requirements. This was evident from the review of unit staff assignment sheets for several months, including June, July, August, and September 2024, which showed that the number of certified nurse assistants (CNAs) on duty was often less than what was deemed necessary by the facility's assessment. The facility's Staffing Assignments policy, last reviewed in July 2024, mandates that staffing levels be determined based on the census, acuity, shift, and resident needs. However, the review of staffing sheets revealed numerous instances where the number of CNAs on duty was below the required levels across various shifts and units. For example, on multiple days in June, July, August, and September 2024, the number of CNAs on duty was consistently lower than the facility's assessment indicated was necessary, particularly during the night shifts. Interviews with facility staff, including the Administrator and Payroll/Accounts payable staff, highlighted challenges in maintaining adequate staffing levels. The Administrator noted that a certified nursing assistant training program had been initiated to help address staffing shortages, with students being hired as support staff and eventually as CNAs. Despite these efforts, the facility continued to experience staffing shortages, as evidenced by the review of the schedule during an on-site visit in November 2024, which showed a shortfall in CNA staffing for the night shift.
Failure to Update Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in a timely manner for two residents who developed facility-acquired pressure ulcers. Resident #7, who had a history of chronic pulmonary embolism, gastrointestinal hemorrhage, and other lack of coordination, developed a stage II pressure ulcer on their right buttocks. Despite the presence of a care plan for potential pressure ulcer development, there was no documented evidence that the care plan was updated to reflect the actual pressure ulcer. Similarly, Resident #8, who had severe cognitive impairment and was at high risk for pressure ulcers, developed a stage III pressure ulcer on their sacrum. The care plan for this resident also failed to include the actual pressure ulcer. Interviews with facility staff revealed that there was a transition period with wound care providers, during which Registered Nurse #2 was responsible for documenting wound findings and updating care plans. However, the care plans for both residents were not updated to reflect the significant changes in their conditions. The Director of Nursing confirmed that the wound rounds were conducted by Registered Nurse #2, and the attending physician was notified of the findings, but the necessary updates to the care plans were not made.
Deficiency in Annual Performance Reviews and In-Service Education for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews were completed for every nurse aide at least once every 12 months, and that regular in-service education was provided based on the outcome of these reviews. Specifically, two Certified Nurse Assistants (CNAs) did not have documented annual performance evaluations in their personnel files for the years prior to and including 2023 and 2024. CNA #7, hired in 2015, and CNA #8, hired in 2014, both lacked documented performance evaluations for the specified periods. Additionally, the in-service education logs for these CNAs showed that their training was not completed according to the facility's requirements. The facility's Performance Review policy, last reviewed in September 2024, mandates annual written performance reviews based on job responsibilities, conduct, demeanor, and attendance. However, the facility's performance evaluations were not aligned with the required in-service education. Interviews with the Human Resources Director and the Director of Nursing revealed that the facility had previously identified issues with timely completion of performance evaluations and had initiated a process to address this. However, at the time of the survey, the facility had not yet completed the necessary evaluations for all staff, and there was no established tracking system prior to November 2023.
Lack of Documented Action Plans for Quality Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address identified quality deficiencies. Specifically, there was no documented evidence of actionable plans being implemented for the facility's identified issue with acquired pressure ulcers. Additionally, there was no documentation of continued performance improvement plans for two areas discussed in the second quarter meeting, namely call light audits and delayed Minimum Data Set assessments. During the review of the facility's QAPI documentation, it was found that the agenda for the third quarter meeting referenced facility-acquired pressure ulcers, but the facility did not provide a QAPI plan for addressing these ulcers. Furthermore, the meeting documentation was inconsistent, with the sign-in sheet dated for a meeting that did not occur on the scheduled date. The Administrator confirmed that the meeting was rescheduled, and the documentation was dated accordingly, but there was still no documented action plan for the identified issues from the rescheduled meeting.
Deficiency in Wound Care Administration and Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of wound care treatments. The resident, who had a history of diabetes mellitus, COVID-19, pneumonia, and a recent surgical amputation, required daily wound care for a trans metatarsal amputation on the right foot. Despite physician orders for specific wound care treatments, the Treatment Administration Record showed multiple instances where the treatments were not signed as administered over several months. Interviews with nursing staff revealed inconsistencies in the administration and documentation of the resident's wound care. Several nurses admitted to either forgetting to document the treatments or being unsure if they administered them. The Director of Nursing confirmed that there were no documented reasons for the missed treatments in the resident's electronic health record. The responsibility for administering and documenting treatments was shared among various staff members, including the treatment nurse, unit manager, and supervisor, depending on the day and availability of staff. The lack of proper documentation and administration of the resident's wound care treatments highlights a deficiency in the facility's adherence to professional standards of practice. The facility's policy on skin integrity required that residents with pressure ulcers or injuries receive necessary treatment to promote healing and prevent infection. However, the failure to consistently administer and document the ordered treatments for the resident's surgical wound indicates a lapse in following these standards, potentially compromising the resident's care.
Failure to Accommodate Resident's Call Bell Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #57, who was affected by left-sided weakness due to a cerebral vascular accident. The resident's comprehensive care plan indicated a high risk for falls and required that a working and reachable call light be provided. However, during multiple observations, the call bell system was not within the resident's reach. On several occasions, the call bell was placed on the left side of the bed, which the resident could not access due to their left-sided weakness. The resident expressed difficulty in reaching the call bell and indicated a preference for it to be placed on their stronger side. Interviews with facility staff, including a registered nurse and a certified nurse aide, confirmed that the call bell should always be within the resident's reach. The Director of Nursing also acknowledged that the call bell should be placed on the right side of the bed to accommodate the resident's left-sided weakness. Despite these acknowledgments, the facility did not ensure that the call bell was consistently placed within reach, leading to a deficiency in accommodating the resident's needs and preferences.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, as identified during a recertification survey. Resident #47, who had diagnoses including heart failure and obstructive uropathy, did not have a care plan addressing the use of an indwelling urinary catheter and a left resting hand splint. Observations revealed the resident was often without the hand splint, and interviews with staff indicated a lack of awareness and documentation regarding these needs. Resident #51, diagnosed with adult failure to thrive and cerebral infarction, lacked a care plan for the use of bilateral palm guards and a soft hip abductor cushion. Observations showed the resident was without these devices, and staff interviews revealed a lack of awareness and documentation of the orders for these devices. The devices were not included in the care plan or the Kardex, leading to their non-use. Resident #66, with a history of anxiety disorder and osteoarthritis, was on a toileting schedule that was not properly documented or communicated to staff. The resident was frequently incontinent and required assistance, but the care plan did not reflect the toileting schedule, and staff were unaware of it. Interviews revealed that the care plan was not updated correctly, resulting in the omission of the toileting schedule from the certified nurse aide documentation.
Failure to Update Care Plans for Medication Changes
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for a resident who was no longer receiving certain medications. Specifically, the resident had discontinued the use of Lorazepam and Apixaban, with the latter being replaced by Xarelto. However, the care plans were not updated to reflect these changes. The facility's policy requires that care plans be regularly reviewed and revised to reflect any changes in a resident's status, but this was not adhered to in this case. The resident involved had a medical history that included a cerebral vascular accident, dementia, and hemiplegia and hemiparesis following a cerebral infarction. The resident had moderately impaired cognition and required assistance with daily activities. Despite these needs, the care plans for anticoagulant and anti-anxiety medications were not updated to reflect the discontinuation and changes in medication. Interviews with the Registered Nurse Unit Manager and the Director of Nursing confirmed that the care plans should have been updated to reflect the current medication regimen.
Failure to Provide Necessary Mobility Devices for Residents
Penalty
Summary
The facility failed to ensure that necessary services, care, and equipment were provided to maintain or improve the range of motion and mobility for two residents. Resident #51, who had diagnoses including adult failure to thrive, muscle wasting, and cerebral infarction, was observed multiple times without the required bilateral palm guards and soft hip abductor in place. The care plan for Resident #51 did not include these interventions, and staff members, including a Certified Nurse Aide and a Registered Nurse, were unaware of the orders for these devices. The devices were not found in the resident's Kardex, and the Assistant Rehab Coordinator confirmed that the devices should have been endorsed for use by the staff. Resident #46, diagnosed with quadriplegia, diabetes insipidus, and traumatic brain injury, was also observed without the necessary bilateral resting hand splints or palm guards. The care plan and physician's orders specified the use of these devices, but they were not applied. Interviews with staff, including a Certified Nurse Aide, the Director of Nursing, and an Occupational Therapist, revealed a lack of clarity regarding responsibility for applying the splints. The Occupational Therapist noted that Resident #46 could be resistant to wearing the splints, but they were not applied earlier in the week.
Failure to Implement Toileting Schedule for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with bladder and bowel incontinence, as outlined in their care plan. The resident, who had diagnoses including anxiety disorder, limited mobility due to Charcot's joint, and osteoarthritis, was supposed to be on a toileting schedule every two hours and as needed. However, observations and interviews revealed that the resident was not being toileted according to this schedule. The resident was left to manage their incontinence independently, despite needing assistance, and was unaware of the toileting schedule. This lack of assistance led to the resident sometimes putting on briefs incorrectly, resulting in urine leakage onto their clothes and bed. Interviews with staff indicated a lack of proper documentation and communication regarding the resident's toileting schedule. A certified nurse aide admitted to not documenting the toileting schedule due to the absence of a designated place for such documentation. The Registered Nurse Unit Manager acknowledged that the toileting schedule was not correctly entered into the computer system, preventing certified nurse aides from documenting it. This oversight potentially contributed to the resident developing a urinary tract infection, as noted by the Unit Manager.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to administer an influenza vaccination to a resident, despite having obtained consent and a physician's order for the vaccine. The resident, who was cognitively intact and required assistance with daily activities, had a signed consent for the influenza vaccine dated November 29, 2023. The physician's order for the vaccine was documented on December 1, 2023, specifying the administration of Afluria Quadrivalent. However, the December 2023 Medication Administration Record showed no evidence that the vaccine was given. Interviews with facility staff revealed lapses in the vaccination process. The Infection Preventionist, responsible for ensuring vaccines were administered, acknowledged that the resident's frequent hospitalizations led to oversight in tracking the vaccination. The Director of Nursing emphasized the importance of accurate immunization tracking and obtaining vaccine history upon admission. Despite these procedures, the facility failed to ensure the resident received the influenza vaccine as ordered, resulting in a deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Rochelle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| United Hebrew Geriatric Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Bayberry Nursing Home | 0.2 mi | ★★★★★ | 0 | 0 |
| Dumont Center For Rehabilitation And Nursing Care | 0.4 mi | ★★★★★ | 7 | 0 |
| Schaffer Extended Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Sutton Park Center For Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.