Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Martine Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with COPD, vasculitis, and cellulitis had a sacral pressure injury that was initially documented by an admission nurse as a stage 2 ulcer, while a wound care provider shortly thereafter assessed it as unstageable with necrosis and the care plan identified it as stage 4. Because the wound care provider’s assessments were uploaded into the record after the MDS ARD 7‑day look‑back period, the staff member completing the MDS only saw the earlier stage 2 assessment and coded the wound accordingly, resulting in inaccurate MDS coding of the resident’s pressure injury status.
A resident with COPD, vasculitis, cellulitis, and multiple wounds was admitted with a sacral pressure injury initially documented by an admission nurse as stage 2, but a wound care provider assessed it as unstageable with necrosis and it was later care-planned as stage 4. Wound care assessments by the specialist were uploaded late, so the MDS was completed using only the initial stage 2 documentation. There were no EMR treatment orders for the sacral wound for several days after admission, and although an RN obtained a Santyl dressing order from an on-call PA and performed a dressing change, this treatment was not documented in a nursing note, resulting in incomplete and delayed documentation and orders for wound care.
Unlabeled, undated, and expired food items were found throughout kitchen storage areas, including refrigerators, freezers, the seasoning area, and dry storage. Surveyors observed items such as plantains, cupcakes, goat meat, salmon, cheeses, tortilla wraps, cooked beef, diced apples, and seasonings that lacked required labels, dates, use-by dates, or proper sealing, with several items also showing freezer burn. Staff and the DFD acknowledged that food items should be labeled, dated, and properly sealed before storage.
A resident with bipolar disorder and schizoaffective disorder, and documented cognitive impairment, was observed sitting in common areas and later in the dining room wearing only a hospital gown and holding it over the genital area. The resident remained in public view among other residents while staff stated no personal clothing was available, donated clothing had not been obtained, and the DON said residents in hospital gowns may be placed in view for safety and supervision.
Failure to Refer Resident With Serious Mental Illness for Level II PASARR Review: A resident with PTSD, schizoaffective disorder, anxiety, and major depressive disorder was admitted for what was initially identified as a brief, finite stay after a hospital discharge and PASARR Level I screen noted a community discharge plan. When it became clear the resident could not return to the prior group home, there was no documented referral for Level II specialized services, and staff confirmed the resident remained in the facility mainly for medication management.
An LPN documented wound care as completed for a resident with a venous wound and cellulitis-related skin breakdown, even though the treatment was not actually provided or observed. The resident kept the triamcinolone cream in the room and applied it independently to the right foot and lower leg, while the LPN later admitted the care was not performed by staff and should not have been charted as completed.
Ordered wound care and pressure injury prevention measures were not consistently provided for three residents. One resident with a stage 2 buttock pressure ulcer received zinc oxide instead of ordered calcium alginate, and two residents at risk for pressure injuries were repeatedly observed with heels resting on the mattress despite care plan directions for heel offloading. Staff also admitted documenting heel offloading when it had not been done.
Two residents did not receive oxygen at the ordered flow rates. One resident with a tracheostomy and a history of acute respiratory failure had oxygen observed at higher settings than the ordered 6 L/min, and the unit manager confirmed it was not the correct amount. Another resident with COPD and a history of chronic respiratory failure was ordered 3 L/min via NC but was repeatedly observed at 2 L/min after independently changing the portable tank setting; a CNA saw the resident adjusting the dial and an LPN knew the flow rate had been changed.
Medication storage and labeling were not maintained properly. An insulin pen for one resident had no open or discard date on the label, despite facility policy requiring dating when opened. In another resident’s room, topical medications including diclofenac and triamcinolone were left on the bed, bedside table, and in a basin with no staff present; the resident said the meds were kept in the room, and an LPN acknowledged medications should not be left there.
Surveyors identified widespread environmental deficiencies, including chipped paint, dirt, scuff marks, foul odors, missing fixtures, and evidence of pests throughout the facility. Interviews confirmed that while cleaning and maintenance routines exist, the facility did not maintain a consistently clean, functional, and comfortable environment for residents, staff, and the public.
Three residents did not have their care plans updated or implemented as required: one experienced a fall without a documented fall risk or post-fall care plan, another developed a pressure injury that was not reflected in the care plan, and a third had a change to two-person assist for all cares that was not documented. Nursing staff and the DON confirmed that care plans were not updated as per facility policy.
A resident with cognitive impairment and limited mobility told a CNA they would jump out of bed if left alone. The CNA left the resident unattended, and upon return, found the resident on the floor with skin tears. The resident's care plan required supervision and assistance, but these were not provided at the time, leading to a fall and injury.
A resident with impaired cognition due to dementia and schizophrenia, identified as at risk for elopement, left the facility undetected during a busy holiday week day. The facility staff did not notice the resident's absence until dinner time, and the incident was reported to the state agency the following day, beyond the required two-hour window. The investigation found reasonable cause for potential abuse, neglect, or mistreatment, but the delay in reporting constituted a deficiency.
A resident with schizophrenia and dementia, identified as high risk for elopement, exited the facility undetected due to inadequate supervision. The resident was last seen in the lobby and was not accounted for until hours later. The facility's cameras were non-functional, and there was no documentation of the required frequent monitoring. The resident was later found by police in Los Angeles.
The facility did not complete annual performance evaluations for two CNAs, as required by their policy. One CNA had no evaluation since their hire date, and another had not been evaluated since 2018. The Director of Nursing and the Director of Human Resources confirmed the oversight, acknowledging that evaluations were not conducted according to policy.
A resident with Parkinson's, Schizophrenia, and Dementia had inconsistent MDS assessments regarding the level of assistance needed for daily activities. CNAs reported varying levels of assistance required, and the MDS Coordinator admitted to offsite assessments, leading to inaccuracies. This resulted in a deficiency due to the facility's failure to ensure accurate assessments.
A resident with severe cognitive impairment and dependency for all activities of daily living did not have a comprehensive care plan accurately reflecting their needs, leading to a fall and injuries. Staff provided conflicting accounts of the required assistance level, and assessments were sometimes conducted offsite, causing discrepancies. Facility leadership maintained that the care plan was appropriate, but the incident revealed communication and assessment gaps.
A resident with severe cognitive impairment and mobility dependence experienced a fall, but the facility failed to update the resident's care plan to reflect this incident. Despite documentation of the fall and subsequent actions, the care plan was not revised as required by facility policy. The RN Unit Manager acknowledged responsibility for updating the care plan but did not document the fall, leading to a deficiency.
A resident with severe cognitive impairment and total dependence on staff fell off the bed during care, resulting in serious injuries. The care plan required a one-person assist, but staff interviews indicated a need for more assistance. The facility's policies on side rails and supervision were questioned, revealing a lack of preventive measures and communication among staff.
Inaccurate MDS Coding of Sacral Pressure Injury Due to Late Wound Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Minimum Data Set (MDS) accurately reflected a resident’s pressure injury status. During an abbreviated survey, record review showed that the admission MDS, with an Assessment Reference Date (ARD) of 12/15/2025, coded the resident’s sacral wound as a stage 2 pressure ulcer in Section M, based on an admission nurse’s assessment from 12/08/2025. However, wound documentation showed that the wound care provider assessed the same sacral wound as unstageable due to necrosis on 12/09/2025, and a wound evaluation management summary dated 12/15/2025 also identified the sacral wound as unstageable. Additionally, the resident’s care plan for alteration in skin integrity documented an actual pressure injury identified as a sacral stage 4 with necrotic tissue, initiated on 12/09/2025. The resident had diagnoses including COPD, vasculitis limited to the skin, and cellulitis of an unspecified limb. During interview, the MDS Coordinator stated they did not complete the assessment for this resident and primarily performed administrative tasks. The MDS Coordinator acknowledged that the 12/08/2025 admission nurse assessment documenting a stage 2 sacral wound was significantly different from the 12/09/2025 wound care provider assessment documenting an unstageable sacral wound. The MDS Coordinator further explained that the 12/09/2025 and 12/15/2025 wound care provider assessments were not uploaded into the system until 12/21/2025 and 12/22/2025, after the ARD 7‑day look‑back period, so the person completing the MDS only had access to the earlier stage 2 assessment. As a result, the MDS did not accurately capture the resident’s true wound status during the assessment period, contrary to facility policy and RAI manual guidelines.
Failure to Ensure Timely Orders and Accurate Documentation for Sacral Pressure Injury Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for a resident admitted with multiple wounds, including a sacral pressure injury. On admission, the nurse assessed the sacral wound as a stage 2 pressure ulcer, and there were no corresponding treatment orders entered into the EMR for this wound until several days later. The resident’s diagnoses included COPD, vasculitis limited to the skin, and cellulitis of an unspecified limb. The facility’s skin and pressure injury prevention policy required Braden risk assessments on admission and at specified intervals, and the admission MDS documented a stage 2 pressure ulcer under Section M. However, a wound care provider’s assessment on the day after admission identified the sacral wound as unstageable due to necrosis, and a subsequent wound evaluation documented the sacral wound as unstageable, later reflected in the care plan as a sacral stage 4 pressure injury with necrotic tissue. The wound care provider’s assessments dated shortly after admission were not uploaded into the record until well after the MDS assessment reference date look-back period, so the MDS assessor only had access to the initial admission nurse’s stage 2 documentation when completing the MDS. A medication order for Santyl ointment and associated dressing care to the sacrum was obtained by a supervising RN from an on-call PA and entered into the EMR to start the following day, but the RN reported performing a dressing change on the date the order was obtained without documenting this treatment in a nursing note. These documentation gaps and delays in entering wound assessments and treatment orders resulted in the resident not having timely, clearly ordered, and consistently documented wound care in accordance with professional standards and the facility’s own skin integrity procedures.
Unlabeled, Undated, and Expired Food Items Found in Kitchen Storage
Penalty
Summary
The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional food safety standards. During the recertification survey, surveyors observed multiple food items in the kitchen refrigerators, freezers, seasoning area, and dry storage area that were expired, unlabeled, undated, or not properly sealed. Examples included plantains with freezer burn that were not dated when opened and had no expiration date, cupcakes with no prepared or use-by date, goat meat and raw salmon that were not labeled and showed freezer burn, and several prepared foods such as cooked beef, toasted cheese sandwiches, diced apples, shredded cabbage, and vanilla pudding that lacked required labels, dates, or use-by dates. The seasoning area also contained containers of curry powder, seasoning product, and moss that were not labeled and did not have dates or expiration dates. Additional observations showed dairy and freezer items that were not dated when opened or prepared, including American cheese, cheddar cheese, cottage cheese, Parmesan cheese, tortilla wraps, French toast sticks, and diced onions. Some items were observed with freezer burn or improperly stored, including goat bones in a plastic bag that was not properly sealed and cooked beef wrapped only in cling wrap. The facility policy required foods to be covered, labeled, dated, and checked to ensure they were consumed by safe use-by dates or discarded. Staff interviewed during the survey stated food items should be labeled, dated when opened or prepared, and properly sealed before being placed in refrigerators or freezers, and the Director of Food Services acknowledged the unlabeled, undated, expired, and freezer-burn observations.
Resident placed in common areas wearing only a hospital gown
Penalty
Summary
The facility did not ensure that Resident #206 was treated with dignity and respect when the resident was placed in common areas of the unit while wearing only a hospital gown. Resident #206 had diagnoses of bipolar disorder and schizoaffective disorder and was documented as cognitively impaired. On 01/05/2026 at 11:24 AM, the resident was observed sitting in a common area among four other residents and in public view of anyone entering or leaving the unit, wearing a hospital gown and using their left hand to hold the bottom of the gown over their genital area. Resident #206 remained in the common area until 12:30 PM, when a CNA wheeled the resident to the dining room for lunch. The resident was seated with seven residents eating lunch and continued to hold the hospital gown in place while sitting and eating. The Unit Manager stated the resident was wearing a hospital gown because no personal clothing was available and that donated clothing was usually obtained by the Concierge, who did not work over the weekend; the Unit Manager also stated no donated clothing had been obtained before the resident was taken out of the room. The DON stated residents in hospital gowns may be placed in public view for safety and supervision, and that a blanket or sheet could be used if the resident had nothing else to wear.
Failure to Refer Resident With Serious Mental Illness for Level II PASARR Review
Penalty
Summary
The facility did not ensure that a resident with a mental disorder was evaluated and received care and services in the most integrated setting appropriate to the resident’s needs. Resident #85 was admitted with diagnoses including attention deficit disorder, PTSD, schizoaffective disorder, anxiety, and major depressive disorder. The hospital discharge summary documented that the resident had lived in a group home and used a rolling walker at home, and the Preadmission Screening and Resident Review Level I screen documented that the resident had a home in the community to return to and would be admitted for a very brief, finite stay. The resident’s records also showed supervision needed with toileting and chairfast or wheeled mobility at the time of the PRI. The resident’s stay later exceeded brief and finite status, but there was no documented evidence that the resident was referred for Level II specialized services once it was determined the resident could no longer return to the former group home. A social work note documented that the family requested the resident not return to the previous group home, and staff interviews confirmed the resident could not be discharged there. The RN stated the resident was mainly at the facility for medication management and did not receive therapy or other skilled services, while the Social Worker stated the resident should have been referred for Level II specialized services after it was determined the resident could no longer return to the former residence.
Wound care documented as completed without being provided or observed
Penalty
Summary
Wound care was not provided as ordered for Resident #108, who had diagnoses including unspecified cellulitis, chronic venous insufficiency, and idiopathic gout. The resident’s care plan identified impaired skin integrity related to a venous wound of the right dorsal foot and directed staff to apply treatment as ordered. A physician order dated 12/12/2025 directed triamcinolone acetonide 0.1% cream to the right foot twice daily and as needed for wound care, with cleansing using normal saline, patting dry, and then applying the ointment. During observations, the resident had reddened open areas on the dorsal right foot and stated they kept the wound care medication in their room and applied it to the right lower leg and foot a couple of times a day, receiving the topical medications from nursing staff. Licensed Practical Nurse #1 documented wound care completion from 01/05/2026 through 01/07/2026, but later stated they did not apply or observe the resident applying the triamcinolone ointment during that time and that the resident completed wound care independently. The LPN acknowledged they should not have documented task completion if they did not actually complete the wound care. Registered Nurse Unit Manager #2 stated the resident did not have a physician order or care plan to perform wound care independently and that the LPN should not have documented completion of wound care if it was not actually done; they also stated the nurse should have reported that the resident completed their own wound care.
Failure to Provide Ordered Wound Care and Heel Offloading
Penalty
Summary
The facility did not ensure appropriate pressure ulcer care and prevention measures were provided for three residents reviewed for pressure ulcers or pressure ulcer risk. The survey found that Resident #12, who had multiple sclerosis, paraplegia, acute respiratory distress, moderate cognitive impairment, and a left buttock stage 2 pressure ulcer, had a physician order for calcium alginate to the wound daily. However, during observation, the wound was treated with zinc oxide instead of the ordered calcium alginate, and the wound care nurse confirmed the resident had an order for calcium alginate while the RN stated they applied zinc oxide even though they saw the calcium alginate order. Resident #8, who had severe cognitive impairment, bilateral lower extremity impairment, dependence for bed mobility and transfers, and a stage 2 pressure ulcer present on admission, had a care plan directing heel protection and offloading with pillows or boots as tolerated. During multiple observations, the resident was in bed with both heels resting on the mattress and no pillows or boots in place to offload the heels. A CNA stated they forgot to apply heel boots and admitted documenting heel offloading on two occasions even though the task was not completed. An LPN and the unit manager stated the heels should be offloaded, and the unit manager stated staff should not document completion of tasks if they did not complete them. Resident #169, who had hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, severe cognitive impairment, and dependence for bed mobility, was also assessed at risk for pressure ulcers with a care plan and CNA Kardex directing heel offloading with pillows or boots as tolerated. During repeated observations, both heels were resting on the mattress with no offloading devices present. A CNA stated the heels were not offloaded and could not recall when they were last offloaded, while another CNA stated they had not applied booties or used pillows to offload the heels. The unit manager confirmed the heels were on the mattress and not offloaded, and an LPN could not recall whether the resident had a heel offloading intervention or booties.
Incorrect Oxygen Flow Rates for Two Residents
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for two residents reviewed for respiratory care. The facility’s policy stated oxygen therapy is to be administered by licensed nurses or respiratory therapists in accordance with provider orders. Resident #12, who had diagnoses including acute respiratory failure, multiple sclerosis, and paraplegia, had a physician order for continuous oxygen at 6 liters per minute with 35% humidification via tracheostomy. However, during multiple observations, the bedside oxygen concentrator was set at 10 liters per minute and later oxygen via tracheostomy was observed at 8 liters per minute. The unit manager confirmed the resident was not receiving the correct oxygen amount per the physician order and stated it was their responsibility to ensure the ordered oxygen was provided. Resident #149, who had chronic obstructive pulmonary disease, type II diabetes mellitus, and a history of chronic respiratory failure with hypoxia, had a physician order for supplemental oxygen via nasal cannula at 3 liters per minute. During several observations, the resident was receiving oxygen at 2 liters per minute while ambulating and while seated in the dining room. The resident stated they independently changed the oxygen flow rate on the portable tank from 3 liters to 2 liters without discussing it with staff. A CNA observed the resident frequently adjusting the oxygen dial but did not report it, and an LPN stated they were aware the resident changed the flow rate and had educated the resident, while also noting they were not sure whether the issue was documented in the electronic medical record.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices. During observation of the fifth-floor medication cart, an insulin pen for Resident #144 was found with no open date or discard date written on the label. Resident #144 had diagnoses of Type 2 Diabetes Mellitus, chronic systolic heart failure, and end stage renal disease, and the quarterly MDS documented that the resident received seven insulin injections in seven days observed. The facility policy required the expiration date to be checked before administration and, when opening a multi-dose container, the date to be recorded on the container. The insulin administration policy also required the expiration date and time to be recorded when opening a new vial or pen. Drugs were also left unsecured in Resident #108's room. Resident #108 had diagnoses of unspecified cellulitis, chronic venous insufficiency, and idiopathic gout, and the quarterly MDS documented the resident was cognitively intact. Observations showed a tube of diclofenac sodium topical gel and a tube of triamcinolone cream/gel on the resident's bed, bedside table, and in a basin in the room with no staff present. The resident stated the medications were kept in the room and were received from nursing staff. An LPN stated the medications were left in the room because the resident liked to apply skin care medications, and acknowledged that medication should not be left in a resident room. The RN unit manager stated they were not aware the topical medications were left in the room.
Environmental Deficiencies and Sanitation Issues Identified Facility-Wide
Penalty
Summary
Surveyors found that the facility failed to maintain a functional, sanitary, and comfortable environment for residents, staff, and the public. Observations during environmental rounds revealed multiple deficiencies across all units, including chipped paint, scuff marks, visible dirt and stains on walls and floors, peeling baseboards, bubbling wallpaper, and foul odors. Specific rooms were noted to have clutter, crumbs on the floor, missing shower heads, and missing radiator covers. Mouse traps were observed in some rooms, and the presence of mice was acknowledged by staff, particularly on the second and third floors. Additionally, sticky floors, likely due to the wax product used, and a hole in a bathroom wall were documented. A metal panel in a hallway was missing screws, and some areas had not yet been renovated. Interviews with the Administrator and the Director of Environmental/Housekeeping confirmed that environmental rounds are conducted daily, and staff are expected to report maintenance issues through a logbook or direct communication. The Director of Environmental/Housekeeping oversees 15 housekeeping and 2 maintenance staff, with a daily cleaning schedule that includes deep cleaning and waxing of rooms. Pest control services are provided twice weekly, and sightings are logged and addressed. Despite these processes, the observed conditions indicated that the facility did not ensure a consistently clean, safe, and comfortable environment as required by regulations.
Failure to Update and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three out of five residents reviewed during an abbreviated survey. For one resident with multiple diagnoses and moderate cognitive impairment, there was no documented fall risk or actual fall care plan in place before or after the resident experienced an unwitnessed fall that resulted in skin tears. The incident report noted the bed was in the lowest position and the call bell was within reach, but there was no evidence of a care plan addressing fall risk or interventions to prevent future falls. Interviews with nursing staff and the DON confirmed that care plans should have been updated to reflect the fall and any resulting injuries, but this was not done. Another resident, admitted with a history of impaired mobility and at risk for pressure injuries, developed an eschar on the left heel. Although the presence of the eschar was documented in a nurse's progress note, the resident's care plan was not updated to reflect the new pressure injury, its measurements, or tracking. The responsible RN acknowledged that the care plan should have been updated with this information but confirmed it was not completed. The facility's policy requires that care plans be updated with measurable objectives and interventions when new issues arise, but this was not followed in this case. A third resident, who required assistance due to lower extremity impairment, had a care plan that was not updated to reflect a change to two-person assistance for all cares after a meeting with the resident's representatives. The DON and Administrator both confirmed that the care plan did not include this updated intervention, despite the change being made to ensure the resident's safety. The lack of timely updates to care plans for these residents demonstrates a failure to ensure that services were provided to maintain each resident's highest practicable physical, mental, and psychosocial well-being, as required by facility policy and regulation.
Resident Left Unattended After Expressing Intent to Exit Bed, Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, limited mobility, and a history of depression expressed to a Certified Nurse Aide (CNA) an intent to jump out of bed if left alone. Despite this clear verbalization of risk, the CNA left the resident unattended in their room to respond to another situation elsewhere in the facility. Upon returning, the CNA found the resident on the floor, having sustained skin tears to both upper extremities. The resident's care plan indicated a need for assistance with self-care and mobility, as well as monitoring for cognitive changes, but these interventions were not adequately followed at the time of the incident. The facility's policy required a systems approach to safety, considering both environmental hazards and individual resident risk factors. The resident's care plans documented the need for supervision and assistance due to their cognitive and physical limitations. However, the CNA did not use the call bell or seek immediate help before leaving the resident, despite the resident's explicit statement of intent to get out of bed. This failure to provide adequate supervision and to follow established safety protocols resulted in the resident's fall and subsequent injuries.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an incident involving a resident's elopement in a timely manner to the New York State Department of Health. The resident, who had impaired cognition due to dementia and schizophrenia, was identified as being at risk for elopement. Despite this, the resident left the facility undetected on a busy holiday week day. The facility staff did not realize the resident was missing until dinner time, several hours after the resident had left. The incident was not reported to the state agency until the following day, which was beyond the required two-hour reporting window. The facility's policy requires that all occurrences of accidents or incidents be evaluated and investigated, with the Director of Nursing and Administration responsible for determining if an incident requires reporting to outside agencies. In this case, the investigation revealed that the resident exited through the front door during a high traffic period while the reception staff was occupied. The facility determined that there was reasonable cause to believe that abuse, neglect, exploitation, or mistreatment may have occurred, making the incident reportable. However, the delay in reporting the incident constituted a deficiency in the facility's compliance with state regulations.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 The elopement incident for resident # 1 was reported on 11/27/24. All facility DOH reportable events have the potential to be affected by this deficient practice. All DOH reported incidents were reviewed for the past 30 days. Facility policy on Accident/Incidents was reviewed by the Administrator and Director of Nursing and determined to be in compliance with state and federal guidelines. No revision made. Staff Educator/designee will educate all staff on facility policy of Accident and Incidents and timely reporting requirements. The in-service will focus on reporting incidents to the Administrator and DON immediately, reporting requirements of 2 hours to the DOH for reportable events. The Administrator/designee will audit all reported incidents for compliance with the 2-hour reporting time frame. The audits will be completed weekly x 4 weeks, then monthly until compliance is met. The results of these audits will be submitted at monthly QAPI to the committee for review. The administrator is responsible for the execution of this plan of correction.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident identified as being at high risk for elopement. The resident, who had diagnoses including schizophrenia, unspecified dementia, and atherosclerotic heart disease, was able to exit the facility undetected. The resident was known to have impaired cognition and was assessed as high risk for elopement, with a care plan that included enhanced monitoring for exit-seeking behavior. However, there was no documented evidence of close supervision or frequent monitoring prior to the resident's elopement. On the day of the incident, the resident was last seen in the lobby around 11:30 am, waiting for the mailman, which was part of their usual routine. The receptionist observed the resident handing mail to the mailman and then walking past the desk, but did not see the resident again. The resident was not accounted for during the afternoon, and it was not until after 5:00 pm that staff realized the resident was missing. A Code Gray was initiated, but the facility's search was unsuccessful, and the resident was later found by the Los Angeles Police Department. The facility's investigation revealed that the resident exited through the front door during a busy holiday period when the reception staff was occupied. The facility's cameras in the lobby were not functional, and there was no live feed or recordings to assist in the investigation. The facility's policy required residents at risk for elopement to be closely supervised and frequently monitored, but there was no documentation to support that this was done for the resident prior to their elopement.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 Resident #1 remains in Los Angeles. Upon return to the facility, resident will be re-evaluated for elopement risk with updated care plan and interventions. All residents with wander guards, exiting seeking behaviors, and those spending excessive time off the unit in the lobby or recreation room have the potential to be affected. All residents with wander guards, high risk for elopement, exit seeking behaviors, and those who spend excessive time off units were re-evaluated for elopement risk, and audits and chart reviews completed. Elopement Binders, Care plans, and interventions were updated accordingly. The facility policy on Elopement Prevention was reviewed by the Administrator and Director of Nursing and determined to be in compliance with state and federal guidelines. No revision made. Staff Educator/designee will educate all staff on facility policy on Elopement Prevention with a focus on closely supervising residents high risk for elopement. Unit sign-in/out sheets at nursing stations were implemented to account for residents being taken on or off the unit by rehab, recreation, etc. Staff rounding tool was implemented to account for unit residents during the shift, indicating resident location. Residents identified as high risk for elopement and are non-compliant with wander guard will receive enhanced monitoring/supervision every 1-3 hours. Staff Educator/Designee will in-service all staff on implemented procedures and forms. Front desk staff re-educated on emergency codes, monitoring of lobby, elopement policy, and awareness of door alarms. Facility elopement drills will be conducted weekly for 4 weeks and then monthly. The audit results will be submitted to the monthly QAPI meeting for review and recommendations. The Responsible Party: Assistant Administrator.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance appraisals were completed at least once every 12 months, as required by their policy. Specifically, the personnel records for two CNAs, hired on 7/1/2022 and 6/20/2017 respectively, lacked documented evidence of annual performance evaluations. CNA #2 had no performance evaluation since their hire date, and CNA #3 had not received an evaluation since 9/5/2018. This deficiency was identified during an abbreviated survey (NY00362050) through record reviews and interviews. Interviews with the Director of Nursing and the Director of Human Resources revealed that the responsibility for conducting these evaluations lies with the nursing department, while Human Resources reviews and notifies the nursing department if evaluations are not completed. The Director of Nursing, who had been in the facility for two months, admitted to not having completed any performance evaluations. The Director of Human Resources confirmed the absence of recent evaluations for the two CNAs, acknowledging that the evaluations were not completed according to the facility's policy.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 Certified Nurse Aide #2 yearly performance review was conducted on 12-20-24. Certified Nurse Aide #3 yearly performance review was conducted on 12-20-24. The facility conducted an audit of all employees’ files. Director Human Resources/Designee and department manager will ensure all identified employees with outstanding yearly evaluation be completed by 1/8/25. Policy and Procedure was reviewed on 12/19/24 for yearly evaluations. No revisions made. Director of Human Resources, Department Heads and Managers were educated on 12/20/24 on the importance of conducting employee yearly evaluation. The Director of Human Resources/Designee will conduct weekly audits and to track and meet with all employees who are due for yearly evaluations. Director of Human Resources/Designee will meet with department manager and employee to complete evaluation in accordance with the facility policy and procedure. Director of Human Resources will conduct weekly audit x3 months, then monthly x3 months. The audit results will be submitted to the monthly QAPI committee for review. The Responsible Party: Director of Human Resources.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, leading to a deficiency. Specifically, the MDS assessments for a resident with Parkinson's disease, Schizophrenia, and Dementia showed inconsistencies in the level of assistance required for daily activities. The assessments varied between requiring a one-person assist and a two-person assist for tasks such as bed mobility, which did not accurately represent the resident's dependence level. Interviews with Certified Nurse Assistants (CNAs) revealed discrepancies in the care provided to the resident. Some CNAs recalled that the resident required assistance from two people due to their immobility and the absence of bed rails, while others believed a one-person assist was sufficient. This inconsistency in staff understanding and documentation contributed to the inaccurate MDS assessments. The Registered Nurse Minimum Data Set Coordinator admitted that assessments were sometimes completed offsite, relying on unit nurses' documentation. This practice, along with the lack of direct observation and communication with care staff, led to the inaccurate reflection of the resident's needs in the MDS. The facility's failure to ensure accurate assessments and consistent care instructions resulted in the identified deficiency.
Failure to Implement Comprehensive Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed and implemented for a resident who was dependent on assistance for all activities of daily living. The deficiency was identified during an abbreviated survey, where it was found that there was no documented evidence of a comprehensive care plan being initiated after a Quarterly Minimum Data Set assessment. This assessment indicated that the resident had severe cognitive impairment and was dependent on assistance for eating, toileting, bed mobility, and transfers. Despite this, the care plan did not accurately reflect the required assistance level, leading to an incident where the resident fell out of bed and sustained injuries. Interviews with various staff members revealed inconsistencies in the understanding and implementation of the resident's care needs. Certified Nurse Assistants (CNAs) provided conflicting accounts of whether the resident required one or two-person assistance for bed mobility and care. Some CNAs stated that they would seek additional help due to the resident's physical condition, while others believed the resident was a one-person assist. The Registered Nurse Minimum Data Set Coordinator mentioned that assessments were sometimes conducted offsite, relying on unit nurses' documentation, which could lead to discrepancies in care planning. The facility's leadership, including the Medical Director, Director of Nursing, and Administrator, maintained that the care plan was appropriate and followed protocol. They stated that there was no change in the resident's condition that warranted an update to the care plan. However, the incident highlighted a gap in communication and assessment processes, as staff members were not aligned on the resident's care needs, and the care plan did not reflect the necessary assistance level, contributing to the resident's fall and subsequent injuries.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised for a resident who experienced a self-reported fall. The resident, who had severe cognitive impairment and was dependent on assistance for mobility and toileting, reported a fall on 07/24/2024. Despite the incident being documented, the resident's fall care plan was not updated to reflect this event. The facility's policy requires care plans to be revised as the resident's condition changes, but this was not adhered to in this case. The incident report noted that the resident was found in a left lateral position with a bump on the back of their head, and several actions were taken, including assessments and referrals. However, the care plan was not updated to include the fall. Interviews with the facility staff revealed that the Registered Nurse Unit Manager was responsible for updating the care plan but failed to document the fall in the care plan, although they did update the enabler section. This oversight led to a deficiency in the care planning process for the resident.
Inadequate Supervision and Safety Measures Lead to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to a significant accident. The resident, who was totally dependent on staff for all activities and had severe cognitive impairment, fell off the bed while being turned by a Certified Nursing Assistant (CNA). The resident sustained serious injuries, including an unstable cervical spine fracture and a possible femoral neck fracture, along with lacerations and swelling. The care plan indicated the resident required a one-person assist, but the incident revealed that the resident's condition might have necessitated more assistance. Interviews with staff highlighted discrepancies in the understanding of the resident's care needs. While the CNA involved in the incident believed the resident required two-person assistance, they did not communicate this to the nurse or supervisor. Other CNAs also expressed that they would typically seek additional help when caring for the resident due to their immobility and contractures. Despite these observations, the facility's documentation and care plan continued to reflect a one-person assist requirement. The facility's policies and procedures, including the use of side rails, were also scrutinized. The Registered Nurse Unit Manager and the Medical Director both stated that side rails were not appropriate for the resident, citing safety concerns and CMS guidelines. However, the lack of side rails and the resident's immobility contributed to the fall. The incident report and subsequent interviews revealed a lack of preventive measures and communication among staff regarding the resident's care needs, ultimately leading to the accident.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near White Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Plains Center For Nursing Care, L L C | 0.5 mi | ★★★★★ | 29 | 0 |
| The Knolls | 3.2 mi | ★★★★★ | 0 | 0 |
| The Grove At Valhalla Rehab And Nursing Center | 3.2 mi | ★★★★★ | 20 | 0 |
| Sprain Brook Manor Rehab | 4 mi | ★★★★★ | 0 | 0 |
| Greenwich Woods Rehabilitation | 5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.