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 King Street Home Inc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Surveyors determined that the facility did not send the required transfer notice to the State LTC Ombudsman when a resident with vascular dementia, post-stroke sequelae, constipation, and atrial fibrillation—who had documented memory impairment, behavioral symptoms, and dependence for toileting and transfers—was sent to the hospital via ambulance. A nursing note recorded the transfer, but there was no documentation that the Ombudsman was notified. During interviews, the Director of Social Services and the Assistant Administrator stated that Ombudsman notifications for hospitalizations and discharges were usually emailed in batches and acknowledged that no email notification for this transfer could be located, characterizing the omission as an oversight.
Two residents received incorrect psychotropic medications or experienced delays in recommended medication changes due to failures in order transcription, documentation, and verification. Errors included administration of medications intended for another resident with a similar last name and delayed implementation of psychiatry consult recommendations, with incomplete documentation in the medical record.
A resident's legal representative requested medical records, but the facility did not provide the records within the required two working days, instead taking twelve days to fulfill the request. Facility policy and staff practice allowed for a seven to ten business day turnaround, which did not meet federal regulations.
The facility did not post required contact information for State agencies and advocacy groups in areas accessible to residents or their representatives. Only limited information, such as the Ombudsman contact, was posted, while other required documents were kept in a logbook and not made visible or accessible. The deficiency was confirmed through observation and staff interview.
The facility did not post the most recent Department of Health survey results in a location that was easily accessible to residents, families, or visitors. Instead, the results were kept in the back of the visitor sign-in logbook, and staff were either unaware of their location or acknowledged that visitors would not know the results were available unless specifically requested.
A resident's care plans were mistakenly sent to another resident's representative, resulting in a breach of confidentiality. The error occurred when an administrative staff member, while rushing to meet a deadline, compiled and sent the wrong medical records. The mistake was discovered when the receiving physician's office identified the error.
A resident's representative filed multiple grievances over several months regarding care, safety, and rights violations, but the facility failed to post information about the grievance process, did not provide written decisions or document specific resolutions, and staff interviews confirmed inconsistent tracking and communication regarding grievances.
A resident with multiple diagnoses and cognitive impairment had inconsistent documentation in their MDS assessments, with discrepancies in extremity impairments, assistive device use, and functional abilities. Errors were made by different staff members responsible for various MDS sections, and the MDS Coordinator acknowledged that the assessments did not accurately reflect the resident's status.
A resident with severe cognitive impairment and multiple health issues was diagnosed with pneumonia and prescribed antibiotics and oxygen therapy, but no care plans were initiated for these treatments. Staff interviews revealed confusion over responsibility for updating care plans, and the required care plans for pneumonia, antibiotic use, and oxygen therapy were not created, resulting in a deficiency.
A resident with multiple diagnoses, including vascular dementia and mood disorder, did not have their care plans for medication refusals, physical aggression, social needs, and nutritional problems reviewed or updated by the interdisciplinary team following a quarterly MDS assessment. Staff interviews confirmed that required quarterly care plan reviews and documentation were not consistently completed.
The facility did not ensure safety during a fire alarm system outage exceeding four hours, as required by NFPA 101. The alarm was offline due to renovations, but the facility failed to notify the Department of Health or conduct a fire watch. The Director of Maintenance confirmed the alarm was offline to prevent false alarms, and the Assistant Administrator acknowledged the need for future fire watch implementation.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
Surveyors found that the facility failed to ensure that a copy of the notice of transfer was sent to the State Long Term Care Ombudsman for one of three residents reviewed for hospitalization, as required by 10 NYCRR 483.15(c)(3). The resident involved had diagnoses including vascular dementia with behavioral disturbance, sequelae of cerebral infarction, constipation, and atrial fibrillation, and the quarterly MDS documented short- and long-term memory problems, verbal and physical behavioral symptoms toward others, and dependence for toileting and transfers. A nursing progress note recorded that the resident was transferred to the hospital via ambulance in the early morning hours, but there was no documented evidence that a transfer notice was sent to the New York State Ombudsman for this hospitalization. During interviews, the Director of Social Services reported that Ombudsman notifications for hospitalizations and discharges were typically sent via email on a monthly basis and acknowledged they were unable to locate the notification for this transfer, and the Assistant Administrator confirmed that both Social Services and Medical Records could not find an email notification for the transfer, describing the lack of notification as an oversight.
Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication order transcription and administration. One resident, who was cognitively intact and required assistance with mobility and daily activities, was mistakenly prescribed and administered Lexapro (an antidepressant) and Seroquel (an antipsychotic) for a period of 12 days. These medications were not part of the resident's original regimen and were intended for another resident with a similar last name. The error was discovered during a discharge medication review with the resident's family representative, who alerted the nurse that the resident had never been on those medications. The nurse confirmed the error after reviewing the medication list and contacting the prescriber, who acknowledged that the orders were made in error. There was no documentation in the progress notes regarding the verbal orders received, nor was there a physician's order noted for the verbal order given. Another resident, who had moderate cognitive impairment and required significant assistance with daily activities, did not receive recommended changes to their psychotropic medication regimen in a timely manner. Following a psychiatry consult, recommendations were made to adjust the resident's Seroquel and Lexapro dosages due to improved condition and lack of behavioral issues. However, the recommended changes were not initiated for several days, and the medication administration record did not reflect the adjustments as ordered. The resident continued to receive the previous dosages beyond the recommended change date, and the consult notes did not accurately reflect the resident's current medication regimen. The facility's policy required that all medication orders, including changes and discontinuations, be documented in the resident's medical record and that verbal orders be documented immediately and signed by the physician within 24 hours. In both cases, there was a lack of proper documentation and verification of medication orders, leading to administration errors. The errors were attributed to confusion between residents with similar last names and a lack of regular familiarity with the residents by the nurse transcribing the orders. The events were confirmed through interviews with nursing staff and the prescriber, as well as review of medical records and facility documentation.
Delayed Provision of Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with a copy of the resident's medical records within the required timeframe after a request was made. The legal representative requested the records via email, but did not receive them until twelve days after the initial request, exceeding the regulatory requirement of providing access within two working days. The delay was confirmed through review of email correspondence and interviews with facility staff. Additionally, the facility's policy on access to medical records did not align with federal regulations. The policy stated that copies of medical records would be provided within seven to ten business days, which does not meet the federal requirement for access within two working days. Interviews with the Administrative Coordinator and Assistant Administrator revealed that staff were only aware of the seven to ten business day timeframe and were not familiar with the correct regulatory timeframe.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to ensure that postings containing the names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups were accessible and understandable to residents and their representatives. During the survey, it was observed that there were no visible postings of this required information throughout the facility. The only postings observed were the staffing schedule, information about the wound care company, and contact information for the Office of Long-Term Care Ombudsman program, which were located in a glass encasement near the Assistant Administrator's office and in the elevators. No additional postings with the required information were found in other areas accessible to residents or their representatives. A review of the visitor sign-in logbook revealed that some documents, such as the New York State Department of Health complaint hotline number, Ombudsman hotline number, Residents' Rights, and survey results, were present but not posted; instead, they were kept in sheet protectors within the logbook and not accessible to residents. During an interview, the Assistant Administrator stated that the Department of Health complaint number was posted in the survey book at the front desk and included in the admission packet, but the surveyor confirmed that resident rights were not posted in the facility. The required postings were not observed in the glass encasement or elsewhere during the onsite survey.
Survey Results Not Readily Accessible to Residents and Families
Penalty
Summary
The facility failed to ensure that the results of its most recent New York State Department of Health survey were posted in a location that was readily accessible to residents, their families, and other interested parties. During the survey, it was observed that the survey results were kept in the back of the visitor sign-in logbook, which was not visible or easily accessible to visitors unless specifically requested. There was no notice posted in prominent or public areas of the facility to inform residents or visitors of the availability of these reports. Interviews with facility staff revealed a lack of awareness regarding the location of the survey results. The Assistant Administrator stated that the Department of Health complaint number was included in the survey book at the front desk and in the admission packet, but acknowledged that the survey results were not posted in prominent locations. The Receptionist confirmed that the survey results were in the back of the logbook and would not be noticed unless someone asked for them. The Director of Nursing was unaware of where the most recent survey results were located. These findings indicate that the facility did not comply with its own policy or state regulations regarding the posting of survey results.
Confidentiality Breach in Medical Record Handling
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records for one out of three residents reviewed for confidentiality. Specifically, the Administrative Coordinator sent the care plans of one resident to the representative of another resident in error. This occurred when the representative of a resident requested medical records to be forwarded to the resident's physician, but the records sent included the care plans of a different resident. The error was identified when the physician's office notified the representative about the incorrect records. The incident involved residents with significant cognitive impairments and complex medical histories, including diagnoses such as vascular dementia, cardiomyopathy, mood disorder, major depression, and pulmonary embolism. The Administrative Coordinator acknowledged that the mistake happened because they were rushed to send the documentation before a deadline, resulting in the wrong resident's information being compiled and sent. The facility's policy requires confidential treatment of all personal and medical records, but this was not followed in this instance.
Failure to Inform Residents of Grievance Process and Document Resolutions
Penalty
Summary
Surveyors found that the facility failed to ensure residents and their representatives were properly informed about the grievance process, including how to file grievances, who the grievance official was, and the contact information for independent entities such as the State agency and Ombudsman. There were no postings in prominent locations throughout the facility to notify residents of their rights to file grievances orally or in writing, nor was there information about the expected time frame for grievance review or the right to receive a written decision. The facility's policy required such notifications and prompt investigations, but these were not observed in practice. A review of grievance reports revealed that a resident's representative filed daily grievances over several months, covering issues such as care, safety, hygiene, financial matters, and rights violations. The documentation of these grievances consistently lacked specific resolutions, with reports often stating that issues remained ongoing and that the representative's expectations were considered unrealistic. The facility's records did not include written decisions confirming or denying the grievances, details of corrective actions taken, or the dates decisions were issued, as required by regulation. Interviews with facility staff, including the Director of Social Services and the Assistant Administrator, confirmed that the grievance process was not consistently followed. The Director of Social Services, who served as the grievance officer, did not keep track of grievances or their resolutions and was unsure if the grievance process was posted in the facility. The Assistant Administrator acknowledged ongoing difficulties with the resident's representative and confirmed that no satisfactory resolutions had been documented for the grievances. The lack of proper documentation and notification contributed directly to the deficiency cited.
Inaccurate MDS Assessments Due to Documentation Discrepancies
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident's status, resulting in discrepancies across multiple assessment dates. Specifically, the MDS assessments for one resident showed inconsistent documentation regarding extremity impairments, use of assistive devices, and functional abilities. For example, some assessments indicated impairment in upper and/or lower extremities and the use of a wheelchair or walker, while others documented no impairments and no assistive device use, despite the resident consistently using a wheelchair. The resident involved had diagnoses including vascular dementia, cardiomyopathy, and a mood disorder, and was noted to have varying levels of cognitive impairment and functional dependency in the MDS records. The inconsistencies were found in assessments completed by different staff members, including the Regional Director and the Director of Rehabilitation, who admitted to errors in coding the resident's use of assistive devices and functional status. The MDS Coordinator acknowledged that the information in several assessments was incorrect and that the resident's use of a wheelchair had not changed. Interviews revealed that the MDS Coordinator oversees the completion of the MDS but relies on each department to complete and sign off on their respective sections. The Coordinator stated that it was unrealistic to review all areas of the assessment and that the discrepancies should have been identified, especially when the same person completed multiple sections. The Director of Rehabilitation also confirmed an error in coding the resident's device use, further contributing to the inaccurate assessments.
Failure to Initiate Care Plans for Pneumonia, Antibiotic, and Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with pneumonia who was prescribed antibiotics and oxygen therapy. Record review showed that, despite physician orders for oxygen therapy and antibiotics, there were no corresponding care plans initiated for pneumonia, antibiotic use, or oxygen use. The resident in question had multiple diagnoses, including severe cognitive impairment, required assistance with activities of daily living, and used oxygen for shortness of breath. The facility's policy required that care plans be updated as residents' conditions changed, but this was not followed in this case. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The DON acknowledged weaknesses in the current care plan update process and noted ongoing efforts to improve it. The MDS Coordinator and nursing staff provided conflicting accounts of who was responsible for initiating and updating care plans following new orders. Ultimately, the care plans for pneumonia, antibiotic use, and oxygen therapy were not created or updated as required, resulting in noncompliance with regulatory requirements.
Failure to Review and Update Care Plans After Quarterly Assessment
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly Minimum Data Set (MDS) assessments. Specifically, the care plans addressing medication refusals, physical aggression, social needs, and nutritional problems for a resident with diagnoses such as vascular dementia, cardiomyopathy, and mood disorder were not reviewed or updated in conjunction with the quarterly MDS completed on 12/17/2024. The care plans had last been revised on various dates prior to the quarterly assessment, and there was no documentation indicating that the interdisciplinary team had reviewed or updated them at the required interval. Interviews with facility staff, including the MDS Coordinator RN and the Assistant Administrator, confirmed that the process for care plan review and updates was not consistently followed. The MDS Coordinator RN acknowledged that while care plans are supposed to be reviewed quarterly and updated as changes occur, there was no notation or documentation in the care plans to indicate that a review had taken place if no changes were needed. The Assistant Administrator stated that responsibility for updating care plans is shared among the nursing supervisor, MDS coordinator, and other team members, but the required quarterly review and documentation were not evident in the resident's records.
Failure to Implement Fire Watch During Alarm System Outage
Penalty
Summary
The facility failed to ensure occupant safety during a period when the fire alarm system was out of service for more than four hours, as required by the 2012 NFPA 101 standards. During a complaint investigation survey, it was discovered that the fire alarm system in the West Unit was offline due to ongoing renovations, which had been occurring for approximately two weeks. Signage at the nursing stations indicated that the fire alarm was out of service and instructed to call 911 in case of fire. However, the facility did not notify the Department of Health about the impairment, nor did they implement a fire watch to protect the occupants during this period. The Director of Maintenance acknowledged that the fire alarm system was intentionally placed offline to prevent false alarms due to dust from the renovation work. Despite this, the facility did not take the necessary steps to ensure safety by notifying the appropriate authorities or conducting a fire watch. The Assistant Administrator later stated that the facility would implement a fire watch on an hourly basis in the future, but at the time of the survey, these measures were not in place, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility will notify the department of health and will conduct a fire watch when/if the fire alarm is impaired for more than 4 hours at any given time. 03/01/2025 2. The facility’s Fire Safety and Alarm Impairment Policy has been revised to ensure full compliance with NFPA 101: 9.6.1.6 and NYCRR regulations. Updates include: - Mandatory notification to the Department of Health for any fire alarm impairment over 4 hours. - Immediate implementation of a fire watch whenever the fire alarm system is offline, regardless of the duration. - Documentation of fire watch rounds, including times and assigned staff, to be maintained for regulatory review. - All involved staff members have been in-serviced. 03/01/25 3. The Maintenance Director will conduct weekly audits for the next 90 days to verify compliance with fire alarm impairment protocols and fire watch implementation. Any non-compliance will be immediately addressed. 03/01/25 4. Maintenance Director will be responsible for making Environmental rounds quarterly and reporting findings to Assistant Administrator to review at QA to ensure compliance for one year. 03/01/25 5. Responsible party: Director of Maintenance and Assistant Administrator. 03/01/25
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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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How nearby facilities compare on the same public inspection record.
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| The Enclave At Rye Rehab And Nursing Ctr | 2.4 mi | ★★★★★ | 2 | 0 |
| Greenwich Woods Rehabilitation | 2.4 mi | ★★★★★ | 0 | 0 |
| Nathaniel Witherell, The | 3.3 mi | ★★★★★ | 3 | 0 |
| The Osborn | 4.4 mi | ★★★★★ | 0 | 0 |
| White Plains Center For Nursing Care, L L C | 5.6 mi | ★★★★★ | 29 | 0 |
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