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 Isabella Geriatric Center Inc during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nursing staff in accordance with its own acuity-based facility assessment and par level staffing plan. The assessment set specific RN/LPN and CNA par levels for each House Building and SNF floor on all shifts, which the DON confirmed. However, review of staffing schedules over an extended period showed repeated day-shift shortfalls of at least one nurse and/or one CNA on multiple SNF floors and several House Building floors, while residents, resident representatives, the Resident Council, and staff reported ongoing staffing concerns. These documented staffing deficits demonstrate that the facility did not consistently provide enough nursing staff each day to meet residents’ needs and support their highest practicable physical, mental, and psychosocial well-being.
A resident with complex medical conditions and impaired cognition was prescribed medications for constipation prevention, but staff failed to develop and implement a person-centered care plan addressing this risk. Instead, an outdated care plan was used, and interviews confirmed that required care planning procedures were not followed by nursing staff.
A resident with multiple serious conditions did not receive timely implementation of an oncologist's medication recommendations due to a breakdown in communication between nursing staff and the attending physician. The LPN who received the consult did not notify the physician, and the RN supervisor was unaware of the recommendations, resulting in a delay in the resident receiving prescribed dexamethasone.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a laceration and later an acute humeral neck fracture. The incident and injury were not reported to the Department of Health as required, as facility leadership believed the fracture was attributable to the fall and not of unknown origin.
The facility failed to provide adequate nursing staff, leading to unmet care needs for residents. A resident did not receive scheduled showers due to staff shortages, while another was often left in bed due to insufficient assistance. Resident Council meetings and staff interviews highlighted long wait times and difficulty in providing care, despite efforts to recruit and retain staff.
The facility was found deficient in food storage and safety practices, with expired and unlabeled food in the kitchen and pantry refrigerators, improper refrigerator temperatures, and dietary staff not wearing head coverings during food preparation.
A facility failed to maintain infection control practices, as policies were not reviewed annually, and an LPN did not sanitize a blood pressure cuff between residents or perform hand hygiene during medication administration. The DON acknowledged the lapse in policy updates, and the Infection Control Preventionist noted that staff received ongoing education and supplies were available.
The facility did not post notifications of survey result availability in prominent areas accessible to residents, staff, and visitors, as required by policy. Observations revealed that notifications were only in the lobby entrance, not on residential units or the 1st floor. Residents were unaware of the survey result locations, and the Administrator was unaware of the lack of notifications in residential areas.
The facility failed to mail the Notice of Medicare Non-Coverage (NOMNC) to representatives of two residents on the same date as telephone notifications, as required by policy. The MDS Coordinator confirmed that notices are not mailed when telephone notification is made, resulting in a deficiency in compliance with Medicare notification requirements.
Two residents in an LTC facility did not receive necessary assistance for activities of daily living due to staffing shortages. One resident, requiring two-person assistance for bathing, missed scheduled showers for two months. Another resident, needing maximal assistance to transfer out of bed, was observed in bed multiple times without being transferred. Staff interviews confirmed difficulties in meeting residents' needs due to limited staff availability.
A resident with a right-hand contracture was not consistently wearing a carrot splint as ordered by the physician, despite having a care plan in place. The resident, diagnosed with dementia and cerebral vascular accident with right hemiplegia, was observed multiple times without the splint. Staff interviews revealed a lack of adherence to the physician's order, which required the splint to be worn at all times except during specific activities.
A resident with mild cognitive impairment sustained burns on both upper thighs after using a microwave unsupervised in the dining room, contrary to facility policy. The resident warmed water and spilled it on their lap, resulting in burns that required medical treatment. Staff interviews revealed a lack of awareness and supervision, as residents were not supposed to use microwaves without assistance.
Two residents were prescribed psychotropic medications without documented evidence of necessary conditions or attempts at non-pharmacological interventions. One resident was given Risperdal for unspecified psychosis without documented behaviors, while another was prescribed the same medication without evidence of psychosis or non-pharmacological attempts. Staff interviews revealed a lack of documentation and adherence to facility policy regarding psychotropic medication administration.
Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on multiple units and shifts to meet residents’ needs as defined by its own facility assessment and nursing staffing plan. The facility assessment, last updated in March 2026, established specific par levels of RNs/LPNs and CNAs for each floor and shift in both the House Building and Skilled Nursing Facility (SNF) units, based on census and acuity. The Director of Nursing (DON) confirmed these par levels, including additional par levels for the SNF 12th floor and House Building 10th floor that were not yet reflected on the written par level sheet because residents had recently been removed from those units. Interviews with residents, resident representatives, the Resident Council, and staff indicated ongoing concerns about staffing adequacy in the facility. A review of actual staffing schedules for the lookback period from 12/15/2025 through 03/24/2026 showed repeated instances where the facility did not meet its established par levels for both nurses and CNAs, particularly on the day shift. On numerous dates in December 2025, multiple SNF floors were short at least one nurse and/or one CNA compared to the par levels, including days when several floors (such as the 3rd through 9th, 11th, and 13th SNF floors) were simultaneously short of one nurse, one CNA, or both. House Building floors, especially the 4th and 7th floors, were also documented as short of CNAs on several of these days. These shortfalls occurred across consecutive days, including holidays, and affected a wide range of units with varying bed capacities. The pattern of insufficient staffing continued into January and February 2026. On many day shifts in January, multiple SNF floors were short of one nurse, one CNA, or both, with some dates showing nearly all SNF floors below par nurse staffing and several also below par CNA staffing. House Building 3rd, 4th, 7th, and 8th floors were repeatedly short of CNAs on day shifts. In February, the schedules again documented that several SNF floors, particularly the 3rd, 5th, 6th, 7th, 8th, and 9th floors, were short of one nurse on multiple day shifts, and House Building floors were short of CNAs on several occasions. These documented staffing shortages, in combination with interview reports of staffing concerns, demonstrate that the facility did not consistently ensure sufficient nursing staff were available each day to provide nursing and related services necessary to assure resident safety and to help residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. No specific individual resident medical histories or conditions are detailed in the report. The deficiency is based on the facility-wide failure to meet its own acuity-based staffing par levels across numerous units and dates, as evidenced by the staffing schedules and corroborated by interviews with residents, their representatives, the Resident Council, and staff.
Failure to Initiate Person-Centered Care Plan for Constipation Risk
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a newly admitted resident with multiple complex medical diagnoses, including chronic pulmonary embolism, coronary heart disease, moderate pericardial effusion, and small cell lung cancer complicated by superior vena cava syndrome. The resident, who had moderately impaired cognition, was prescribed medications to prevent constipation, specifically MiraLAX and Senna, as per physician's orders. However, there was no documented evidence that a care plan addressing the risk for constipation was created or implemented for this resident. Interviews with facility staff revealed that the admitting nurse did not initiate a new care plan upon the resident's admission and instead retrieved an outdated care plan from a previous admission. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that a current care plan for constipation risk was not in place and acknowledged that it was the responsibility of the admitting nurse and other nursing staff to ensure care plans were completed. This failure was found during an abbreviated survey and was cited as noncompliance with facility policy and regulatory requirements.
Failure to Timely Implement Oncologist Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received appropriate treatment and care according to physician orders and consultation recommendations. The resident, who had multiple complex diagnoses including chronic pulmonary embolism, coronary heart disease, moderate pericardial effusion, and small cell carcinoma of the lung with superior vena cava syndrome, was seen by an oncologist who recommended stopping cyclobenzaprine, considering a reduction in olanzapine dosage, and starting dexamethasone. Although the olanzapine dosage was adjusted and dexamethasone was eventually ordered, there was no documented evidence that the attending physician was notified of the oncologist's recommendations in a timely manner following the initial consult. Nursing progress notes did not show that the medical doctor was informed of the oncologist's recommendations between the date of the consult and the date the orders were implemented. Interviews with staff revealed that the LPN who received the consult only reviewed it and notified a nursing supervisor, but did not recall notifying the physician. The RN supervisor was unaware of the recommendations and stated that unit nurses are responsible for reviewing consults. The physician confirmed that they were not notified until several days later, at which point the recommended medication was ordered. This delay resulted in the resident not receiving the prescribed dexamethasone as recommended by the oncologist.
Failure to Timely Report Serious Injury Following Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident who experienced an unwitnessed fall resulting in a laceration and an acute humeral neck fracture. According to the facility's policy, all alleged violations involving abuse, neglect, or injuries of unknown source must be reported to the New York State Department of Health immediately, but not later than 2 hours if the event involves abuse or results in serious bodily injury, or within 24 hours if it does not. In this case, the incident was not reported as required. The resident, who had diagnoses including dementia and breast cancer and was assessed as severely cognitively impaired, was found on the floor with a bleeding laceration and later diagnosed with a fracture after returning from the emergency room. The Director of Nursing and the Administrator both acknowledged responsibility for reporting such incidents but stated that the event was not reported because they believed the fracture was directly correlated with the fall and not of unknown origin. Documentation showed that the resident had impaired vision and bony demineralization, which staff believed could have contributed to the injury. Despite these findings, the incident and resulting injury were not reported to the Department of Health as required by regulation and facility policy.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by a review of staffing levels and resident care. The facility's staffing plan indicated a need for 328 nurse aides and 116 nurses to provide direct care, but the actual staffing levels fell short, particularly on weekends. Observations and interviews revealed that the facility consistently operated below the required staffing levels, with significant shortages in certified nursing assistants across various shifts. This shortage led to inadequate care for residents, as staff struggled to meet the demands of their assignments. Resident #175, who was cognitively intact and required assistance for bathing and toileting, did not receive scheduled showers during December 2023 and January 2024 due to staff shortages. Interviews with the resident and staff confirmed that the lack of sufficient staff made it difficult to adhere to the resident's care plan. Similarly, Resident #210, who required maximal assistance for daily activities, was often left in bed due to insufficient staff to assist with transfers. Observations over several days confirmed that the resident was not consistently taken out of bed, highlighting the impact of staffing shortages on resident care. The Resident Council meetings further underscored the staffing issues, with residents reporting long wait times for assistance and difficulty identifying their assigned caregivers. Staff interviews corroborated these concerns, with multiple staff members expressing frustration over the inability to provide adequate care due to staffing constraints. The facility's efforts to recruit and retain staff, including the use of agency staff and offering incentives, were noted, but the persistent staffing challenges continued to affect the quality of care provided to residents.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to ensure food storage and preparation adhered to professional standards for food service safety, as observed during a recertification survey. In the kitchen walk-in refrigerator, several food items were found to be expired, undated, or unlabeled, including diced pineapples, wheat tortillas, white bread, orange juice, and sliced corned beef. The facility's policy required that opened and stored leftover food be labeled and dated, with a discard date set 48 hours after preparation or opening. However, the Food Service Director acknowledged inconsistent food dating practices, leading to the presence of expired items. Additionally, the 9th floor pantry refrigerator was found to be at an improper temperature of 44 degrees Fahrenheit, above the required 40 degrees Fahrenheit or less, and contained undated and unlabeled food items such as rice, noodles, and a cucumber. The unit staff, including a registered nurse, were responsible for ensuring food items were labeled, dated, and stored correctly, as well as monitoring refrigerator temperatures. Furthermore, dietary staff were observed not wearing head coverings while preparing food, contrary to professional standards for food safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices and procedures, as observed during a recertification survey. Specifically, the facility did not review and update its infection control policies annually. The policies in question included those related to general infection control, influenza vaccination requirements for healthcare workers, a mandatory COVID-19 vaccination program, and an antibiotic stewardship program. The Director of Nursing acknowledged that the policies were supposed to be updated annually, but the responsibility for this task was not assigned to the Nursing department. Additionally, a Licensed Practical Nurse (LPN) on Unit 10W was observed failing to sanitize a blood pressure cuff between resident uses and not performing hand hygiene during medication administration. The LPN applied the blood pressure cuff to multiple residents without sanitizing it and handled various items at the medication cart without washing hands before administering medication to a resident. Interviews with the LPN and a Registered Nurse (RN) revealed that the LPN was aware of the need to sanitize equipment and perform hand hygiene but failed to do so. The Infection Control Preventionist stated that staff received ongoing education and competency evaluations on infection control practices, and that sanitizing supplies were readily available on the units.
Failure to Post Survey Result Notifications in Prominent Areas
Penalty
Summary
The facility failed to ensure that notice of the availability of survey results was posted in prominent areas accessible to the public, as required by their policy on Resident Rights and Responsibilities. During observations conducted on two separate occasions, it was noted that the notification of survey result availability was only posted in the lobby entrance of the main building and not on the 18 residential units or the 1st floor, which are frequented by residents, staff, and visitors. During a Resident Council Meeting, all ten resident attendees stated they were unaware of where the survey results were posted and had not seen any notification regarding their location. The Administrator confirmed that the survey results were located in the lobby and believed that signs were posted throughout the facility, but was unaware that the residential units lacked such notifications.
Failure to Mail Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide appropriate notices to Medicare beneficiaries when they were discharged from skilled services, as required by their policy and federal regulations. Specifically, for two residents, the facility did not mail a copy of the Notice of Medicare Non-Coverage (NOMNC) to the residents' representatives on the same date that telephone notifications were made. The facility's policy requires that the NOMNC be issued to the patient and/or responsible party, with a copy kept in the clinical compliance office. If the representative cannot be reached by phone, proof of mail delivery must be secured in the patient's medical record. However, there was no documented evidence that the NOMNC was mailed on the same date as the telephone notification for the two residents involved. The Minimum Data Set Coordinator confirmed during an interview that the facility contacts the resident or their representative to explain the NOMNC and provide contact information for LIVANTA to appeal the discharge. The coordinator also stated that they fill out the telephone notification area on the form with the time, date, and signature when telephone communication is made. However, the coordinator admitted that they do not mail or email notices when telephone notification is made, and thus could not provide evidence that the NOMNC was mailed as required. This oversight was evident for two residents, where the NOMNC was not mailed on the same date as the telephone notification, leading to a deficiency in the facility's compliance with Medicare notification requirements.
Deficiencies in Resident Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living to two residents, leading to deficiencies in personal hygiene and mobility. Resident #175, who was cognitively intact and required the assistance of two staff members for bathing, did not receive scheduled showers in December 2023 and January 2024 due to staffing shortages. Despite the Certified Nursing Assistant Accountability Record indicating assistance was provided, there was no documented evidence of showers being given during this period. Interviews with staff confirmed the difficulty in adhering to shower schedules due to insufficient staffing levels. Resident #210, who was severely cognitively impaired and required maximal assistance to transfer out of bed, was observed in bed on multiple occasions without evidence of being transferred. The Certified Nursing Assistant Accountability Record for May 2023 lacked documentation of transfers, and staff interviews revealed challenges in meeting the needs of residents requiring two-person assistance due to limited staff availability. The Director of Nursing acknowledged the responsibility of Registered Nurses to ensure resident needs were met, including scheduled showers and daily transfers out of bed.
Failure to Apply Carrot Splint for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This deficiency was identified during a recertification survey, where it was observed that a resident with a right-hand contracture was not wearing a carrot splint as per the physician's order. The resident, who had diagnoses of dementia and cerebral vascular accident with right hemiplegia, was supposed to always wear the carrot splint to prevent new contractures, except during range of motion exercises, hygiene care, and skin checks. Despite the physician's order and the comprehensive care plan, multiple observations between March 26 and April 1 revealed that the resident was without the carrot splint. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse, confirmed that the splint was not consistently applied as required. The Director of Nursing also acknowledged that Registered Nurses were responsible for ensuring that care was provided according to physician orders, including the application of splints.
Resident Sustains Burns Due to Lack of Supervision with Microwave Use
Penalty
Summary
The facility failed to ensure a resident remained free from accident hazards, as evidenced by an incident involving Resident #494. The resident, who had diagnoses of diabetes mellitus and anemia, and mild cognitive impairment, sustained burns on both upper thighs after using a microwave in the unit dining room without supervision. The facility's policy required nursing and nutrition staff to handle microwaving food, but Resident #494 independently warmed water and spilled it on their lap while self-propelling back to their room. The incident was not reported to staff immediately, and the resident was later found to have burns that required medical attention. The comprehensive care plans for Resident #494 included measures to provide a safe environment and encourage the resident to ask for assistance, but these were not effectively implemented. The care plan did not specify the level of assistance needed for activities of daily living, and the resident was not supervised while using the microwave, contrary to facility policy. Interviews with staff revealed that the microwave was easily accessible to residents, and there was a lack of awareness among staff that the resident had used it unsupervised. The Director of Nursing confirmed that residents were not supposed to use microwaves without staff assistance, indicating a lapse in supervision and adherence to safety protocols.
Deficiency in Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that psychotropic drugs were administered to residents only when necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified during a recertification survey, where it was found that two residents were prescribed psychotropic medications without documented evidence of behaviors or attempts to use non-pharmacological interventions. Specifically, Resident #190 was prescribed Risperdal without evidence of behavior or staff attempts to use non-pharmacological interventions, and Resident #141 was placed on psychotropic medication without documented evidence of behavior, non-pharmacological interventions, or a medical assessment. Resident #190, diagnosed with Alzheimer's disease, dementia, depression, and insomnia, was prescribed Risperdal for unspecified psychosis. Despite a psychiatrist's note indicating severe psychotic disturbance, there was no documented evidence of behaviors, delusions, or hallucinations from November 2023 to January 2024. Interviews with staff revealed that Resident #190 did not display inappropriate behavior, and non-pharmacological interventions were not documented prior to the medication order. The psychiatrist and medical doctor justified the prescription based on hallucinations and agitation, but the facility's policy required documentation of behaviors and non-pharmacological interventions before prescribing psychotropic medications. Resident #141, with diagnoses including heart failure, atrial fibrillation, malnutrition, and osteoporosis, was also prescribed Risperdal without documented evidence of psychosis or non-pharmacological interventions. Observations showed that Resident #141 displayed no behaviors, and interviews with staff indicated that non-pharmacological interventions were attempted, but not documented. The psychiatrist and medical doctor cited hallucinations and psychotic disturbances as reasons for the medication, but the facility failed to document a medical workup to rule out underlying medical conditions or attempts at non-pharmacological interventions before administering the medication.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,608 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New York
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fort Tryon Center For Rehabilitation And Nursing | 0.4 mi | ★★★★★ | 5 | 0 |
| Hope Center For Hiv And Nursing Care | 0.8 mi | ★★★★★ | 0 | 0 |
| Casa Promesa | 1.3 mi | ★★★★★ | 0 | 0 |
| University Center For Rehabilitation And Nursing | 1.5 mi | ★★★★★ | 0 | 0 |
| Highbridge Woodycrest Center | 1.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Isabella Geriatric Center Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.