Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Masonic Care Community Of New York during CMS and state inspections, most recent first.
Two residents with cardiac, thyroid, cognitive, and anxiety-related conditions did not receive multiple ordered medications, including alprazolam, diltiazem, methimazole, nadolol, hydralazine, and lisinopril, because the drugs were out of stock, pending from pharmacy, or awaiting delivery. Nursing staff did not consistently reorder medications in advance, did not always use or verify the emergency medication supply, and did not reliably notify supervisors or medical providers when medications were unavailable, despite facility policies requiring these actions. Documentation showed missed doses over several days, an elevated BP reading after a missed cardiac medication, and gaps in provider notification and progress notes, while staff interviews described frequent problems with the new pharmacy’s refill and delivery processes and inconsistent monitoring of remaining medication supplies.
Failure to deliver resident mail promptly affected all residents when mail was only distributed Monday through Friday and Saturday mail was locked up until Monday. Residents reported they never received mail on Saturdays, and the Mail Clerk confirmed there was no Saturday mail coverage while the Administrator stated weekend delivery was supposed to occur through reception and household staff.
Residents Restricted From Going Outside Independently: Two cognitively intact residents with low elopement risk and documented care plans supporting outdoor access, along with 13 residents at a council meeting, reported they were no longer allowed to go outside on their own. Staff gave inconsistent directions about whether residents could go outside, and residents said they were not always given answers about the change and felt their rights were not respected.
Surveyors found multiple medication storage and labeling failures across several neighborhoods. An LPN left pre-poured med cups in a cart, one cart contained expired and undated nasal sprays and eye drops, another had an unlabeled morphine syringe, and the narcotic boxes in two neighborhoods still held large quantities of morphine and lorazepam syringes for a resident who had died months earlier. Staff said nasal sprays and eye drops should be dated when opened, and that the DON was responsible for collecting discontinued or deceased residents’ narcotics, but the medications remained in the carts.
Food and drink were served at unappetizing temperatures, with test trays showing lukewarm or cold items and residents reporting cold meals. Meal trays were left in open carts or on counters for extended periods while residents were absent or still in bed, including trays with meat, eggs, milk, and dairy items. Staff reported there was no formal reheating process on the units and no thermometer available to verify food temperatures after microwaving.
Unlabeled food and incomplete warewashing logs were found in the kitchen. Surveyors observed multiple pans of leftover cooked foods in coolers that were not labeled, dated, or, in one case, covered. Review of the warewashing log showed many missing dish machine temperature entries across the month, and the FSD stated the temperatures were supposed to be recorded three times daily but many were absent.
Staff failed to maintain resident dignity during meal assistance when CNAs stood over three cognitively impaired residents with Alzheimer’s disease and dysphagia while feeding them, despite facility policy requiring a dignified dining experience and training to sit at eye level. Observations showed CNAs repeatedly standing while assisting residents on puree or mechanically altered diets who required maximal or total assistance with eating. In interviews, a CNA, an LPN, and an RN manager all acknowledged that staff were expected to be seated when assisting with meals and that standing while feeding residents was not dignified, even though chairs were available.
A resident with dementia, prior stroke-related weakness, and anxiety had OTC and other pills stored in the room, including acetaminophen, antacids, Neosporin, loperamide, and a cup of mixed pills, without a documented self-medication assessment, physician order, or care plan. An LPN left medications in the room when the resident delayed taking them until after eating, even though there was no bedside-medication order, and the RN manager stated meds should not be left at bedside unless care planned.
Two residents had incomplete comprehensive care plans. One resident had continuous O2 ordered for respiratory conditions, but the care plan and resident profile did not include oxygen use or related monitoring. Another resident had dementia with anxiety and was receiving risperidone and sertraline, but there was no documented care plan for psychotropic medication use, anxiety, non-pharmacological interventions, or behavioral history.
Two residents with significant skin breakdown risk and active pressure injuries did not consistently receive ordered pressure-relieving interventions. One resident with a Stage 4 ulcer and bilateral heel wounds was observed in bed without prescribed offloading boots, and the chart contained conflicting heel wound orders that were signed off as completed despite not matching the wound NP’s recommendations. Another resident with pressure-relieving boots ordered while in bed was observed in bed without the boots, even though the TAR showed the intervention as completed.
A resident with dysphagia, CKD, and a G-tube received Nepro via pump, but staff did not document the date and time the tube feeding was hung during multiple observations. The pump was running at the ordered rate on different shifts, and staff interviews confirmed the feeding should have been dated so the hang time was known.
Failure to Follow Enteric Precautions: A food service worker entered a resident’s room while the resident was on enteric precautions for C. diff without changing gloves, performing hand hygiene, or donning a gown and new gloves. The worker also left the room without removing gloves or cleaning hands, and stated they did not know what the precaution sign meant or when residents were on precautions. The resident had C. diff, diarrhea, and an order for enteric precautions.
Two residents with cognitive impairment and mobility risks exited the facility undetected on separate occasions, despite being identified as at risk for elopement or accidents. Staff failed to consistently monitor, respond to alarms, or follow protocols for supervision and notification, resulting in residents leaving the premises without detection and placing them at risk for harm.
The facility failed to ensure a proper grievance process for 6 of 8 anonymous residents, who were unaware of how to file a grievance. The facility lacked a process for anonymous grievances, and staff were generally unsure of the grievance procedures.
The facility failed to ensure that two residents' ability to safely self-administer medications was clinically appropriate. One resident was observed with eye drops and nasal sprays at their bedside without an assessment or order, while another resident with dementia and glaucoma had eye drops in their room despite being cognitively impaired and not allowed to self-administer. Staff interviews revealed a lack of clarity and adherence to the facility's policy on self-administration of medications.
A resident with a history of venous thrombosis and embolism, who was on anticoagulant therapy, did not have a care plan that included interventions related to their anticoagulant medication use. Interviews with facility staff confirmed that the care plan should have included these interventions, but the specific template for anticoagulant therapy had not been initiated.
A resident with multiple health conditions did not receive a prescribed left heel float boot for nearly two weeks, despite multiple staff observations and documentation of its absence. This delay led to additional skin issues, highlighting a failure to follow the care plan and physician's orders.
The facility failed to assess a resident for the risk of entrapment from bed rails, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent before installing the bed rails. The resident had multiple diagnoses and required assistance for various movements, but the necessary assessments and consents were not completed. Staff interviews revealed inconsistencies in following the facility's policy on bed rail use.
A resident with Parkinson's Disease missed four consecutive doses of carbidopa-levodopa due to unavailability, and the nursing staff failed to notify the medical team as required by facility policy. The missed doses were documented, and the pharmacy was contacted, but the medication was not delivered in time. Interviews revealed that the medical team was not informed, which could have led to worsening symptoms for the resident.
The facility failed to maintain proper infection control for a resident with a urinary catheter, as the drainage bag was repeatedly observed resting on the floor without a barrier. Staff interviews confirmed awareness of the policy but revealed inconsistent implementation, posing an infection risk.
Failure to Provide and Administer Ordered Medications Due to Unavailable Pharmacy Supply
Penalty
Summary
The deficiency involves the facility’s failure to ensure that routine and emergency medications were available and administered as ordered for two residents, despite policies requiring timely ordering, use of emergency supplies, and notification of supervisors and providers when medications were unavailable. Facility policy stated that if a medication was not available at the scheduled administration time, the nurse was to notify the neighborhood manager or supervisor, who would then explore alternate methods for obtaining the medication, including the emergency medication supply and contacting the pharmacy or medical provider. Another policy required nurses to order all new medications and refills electronically, monitor refill requests, address transmission errors or rejections with the pharmacy, and communicate urgency for medications needed before scheduled pharmacy runs. These processes were not consistently followed, resulting in multiple missed doses of ordered medications. One resident with atrial fibrillation, hypothyroidism, congestive heart failure, and hypertension had multiple cardiac and thyroid medications ordered, including diltiazem ER, methimazole, nadolol, hydralazine, and lisinopril. The Medication Administration Records showed that doses of hydralazine, diltiazem, lisinopril, methimazole, and nadolol were not administered on several dates because the medications were out of stock, awaiting delivery, or not available from the pharmacy. Documentation indicated that on some occasions the supervisor was aware, but on other occasions there was no evidence that a supervisor was notified. There was also no documented evidence that medical providers were notified of several missed doses, including missed doses of diltiazem, hydralazine, lisinopril, and methimazole. The emergency medication supply inventory showed that hydralazine tablets were stocked, yet a scheduled hydralazine dose was missed. On one date, after a missed diltiazem dose, the resident’s blood pressure was recorded as elevated, and there was no documentation that the provider was notified of either the missed medication or the elevated blood pressure. Another resident with Alzheimer’s disease, anxiety, and depression had an order for alprazolam four times per day. The Medication Administration Record documented that three doses of alprazolam were not administered because the medication was pending from pharmacy or not available. Staff interviews confirmed that the alprazolam was not available from the pharmacy or in the automated medication cabinet when the resident returned from the hospital. Multiple nurses and managers reported frequent issues with the new pharmacy’s timeliness in delivering medications, inconsistent use of the automated or emergency medication supplies, and late ordering of medications. They also described that not all nurses checked remaining medication supply when administering medications and that there were complications with obtaining medications from both the pharmacy and the automated medication cabinet. These actions and inactions led to residents not receiving ordered medications and to a lack of timely notification and documentation to supervisors and providers as required by facility policy. Staff interviews further detailed that medications were sometimes ordered late, that nurses sometimes failed to check the emergency medication supply, and that there were recurring problems with pharmacy delivery and insurance-related refill denials. One LPN reported that a resident’s diltiazem dose was missed because the medication was out and that the pharmacy cited an insurance timing issue with no alternative provided and no additional monitoring initiated. The RN neighborhood manager stated that medications should be reordered when a three-day supply remained and that if medications were not available in the emergency supply, medical staff should be contacted to determine whether the resident could safely miss a dose or needed an alternative, with documentation of missed doses and provider notification. However, the RN neighborhood manager was only aware of one missed nadolol dose and not the other missed medications documented in the records. The DON stated that if medications were not available, staff should check the emergency supply, notify the physician for possible alternatives, call the pharmacy for delivery timing, and document missed medications and provider notification, but the documentation reviewed showed these steps were not consistently carried out for the residents involved.
Failure to Deliver Resident Mail Promptly
Penalty
Summary
The facility failed to ensure residents had prompt access to incoming mail, including mail delivered on Saturdays, for all 296 residents. The facility policies stated incoming mail would be sorted and distributed daily, and that residents had the right to send and receive mail promptly and unopened. During an anonymous resident meeting, 13 of 13 residents stated they only received mail Monday through Friday and never on Saturdays. During interviews and observation, the Mail Clerk stated they were the only person who managed and received mail in the facility, sorted it by floor, and brought it to the mail room for unit clerks to distribute. The Mail Clerk worked Monday through Friday and stated there was no mail coverage on Saturdays; mail delivered on Saturdays was taken by the receptionist and locked up to be picked up on Monday morning. The Administrator stated that on weekends the receptionist received the mail and household staff were supposed to retrieve it and deliver it to residents, but they were unaware this was not occurring.
Residents Restricted From Going Outside Independently
Penalty
Summary
The facility failed to ensure residents’ right to choose activities and health care services consistent with their interests, assessments, and plan of care, and failed to support resident self-determination regarding going outside on facility grounds. During a resident meeting, 13 anonymous residents stated they were not always given answers to their concerns and felt their rights were not respected because they could not go outside independently as they had previously been able to do. They also reported confusion because some staff said residents could not go outside at all while others said they could go outside if they stayed right outside the front door. Resident #133 had diagnoses including diabetes, morbid obesity, and heart failure. The resident’s MDS documented intact cognition, a strong preference to go outside for fresh air when the weather was good, and independence once seated in a motorized wheelchair/scooter. The care plan and physician orders documented that the resident could independently use a personal power vehicle to designated or supervised areas outside and could independently sit outside when the weather was appropriate. The elopement risk assessment documented intact cognition, no elopement attempts, no behaviors, no dementia or mental illness, no mood-altering medications, and a low elopement risk. Despite this, the resident stated they were no longer able to go outside independently and needed a staff member, family member, or friend with them. Resident #281 had diagnoses including kidney disease, diabetes, and insomnia. The resident’s MDS documented intact cognition, no behaviors, independence with most ADLs, and use of a motorized wheelchair/scooter. The care plan included honoring preferences for daily routine and outdoor activities when weather permitted, and documented that the resident could independently use a personal power vehicle to designated or supervised areas and operate a scooter-style personal protective vehicle throughout the health pavilion and on the facility campus. The elopement risk assessment documented intact cognition, no elopement attempts, no behaviors, no dementia or mental illness, no mood-altering medications, and a low elopement risk. The resident stated they had previously been able to go outside and on the grounds but could no longer do so, felt locked up and punished because of one person, and reported inconsistent staff directions about whether they could go as far as the main entrance or not go out at all.
Unlabeled, Expired, and Improperly Stored Medications in Medication Carts
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in accordance with accepted professional principles across multiple medication carts and narcotic storage areas. Surveyors found expired eye drops and nasal sprays without open dates in one neighborhood cart, an opened undated allergy nasal spray and expired Refresh eye drops in another cart, and three pre-poured medication cups in the Westchester medication cart. In the Manhattan medication cart, a morphine syringe was present without a resident name on the label. In the Placid neighborhood, the narcotic box contained 30 morphine syringes and 57 lorazepam syringes belonging to a resident who had died in January 2026. During observation, an LPN stated nasal sprays should be dated when opened and expire 30 days after opening, and that the expired sprays should not have remained in the cart. Another LPN stated the undated allergy nasal spray needed to be discarded and the eye drops were expired because they were well past the 90-day discard period. The same LPN said they had not checked the cart when starting the shift. In Westchester, an LPN stated the medications had been poured before the residents were present because they did not want to waste anything, and they placed the residents’ names on the cups so they would not be confused. The narcotic storage issues involved medications left in carts after a resident had expired or been discharged. Staff stated the DON was supposed to collect and dispose of remaining medications and narcotics, and that nurses notified the DON by voicemail or email when medications were discontinued, expired, or when a resident died. The DON stated they were the only person who picked up narcotics no longer required and that narcotics should not remain in the neighborhood for a resident discharged from the facility months earlier. The facility policy stated controlled medications were to be placed in the double-locked drawer just before medication pass, expired medications were to be returned to the pharmacy, and expired narcotics were to be collected by the DON for destruction, but it did not address collection of medications and narcotics belonging to deceased residents.
Food Served Cold and Trays Left Out Without Temperature Checks
Penalty
Summary
The facility failed to ensure residents were provided food and drink at palatable, flavorful, and appetizing temperatures during lunch and breakfast meal service. During observations on 03/30/2026 and 04/01/2026, test trays for two residents showed food and beverages at low temperatures, including roasted sweet potatoes, apple crisp, cranberry juice, pork loin, bread stuffing, chocolate milkshake, and water. The apple crisp was described as bland with hard apples, the cranberry juice and milkshake tasted lukewarm, and the pork loin was very hard to chew. A resident also stated the food was often cold, and 13 anonymous residents reported the food was cold during a resident meeting. Meal trays were observed sitting for extended periods before residents ate them. On 03/30/2026, trays for two residents who were out of the building were left on a table in the dining room with potentially hazardous foods, including roasted turkey breast and milk, until they returned. On 04/02/2026, breakfast trays were observed remaining in an open meal cart and later on the counter while residents were still in bed or had not yet come to the dining room. Some trays contained milk, milkshakes, eggs, and other foods that were left out while staff planned to serve them later. Staff stated trays were held for residents who were not present and were sometimes left on the counter if residents were sleeping. The facility did not have a formal procedure on the units for reheating meal trays or checking food temperatures after reheating. Multiple staff members stated they reheated trays in the microwave for 30-second intervals or about one minute until the plate felt warm, but there was no thermometer available on the unit to verify temperatures. Staff also stated they did not know the required reheating temperature, and food service leadership stated they were unsure how long the plate warming base kept food warm. The report also noted that meal trays containing meat, eggs, milk, and dairy items should not remain in the cart or on the counter for over two hours, yet trays were observed left out for prolonged periods.
Unlabeled Food and Missing Warewashing Temperature Logs
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices in the main kitchen. During an observation on 03/30/2026 at 9:56 AM, surveyors found two pans of prepared and cooked food in the reach-in cooler, identified as leftover hashbrowns and ground chicken, that were not labeled or dated. In the walk-in cooler, one pan of leftover kielbasa was not covered, labeled, or dated, and three additional pans of prepared and cooked food identified as leftover fish, cooked beef, and garlic bread were not labeled or dated. Food Service Director #6 identified the foods during the observation. The facility also failed to routinely monitor dishwashing machine temperatures as required by its policy. Review of the Weekly High Temperature Mechanical Warewashing Log for March 2026 showed numerous missing entries for breakfast, lunch, and dinner across many days of the month. During an interview on 04/01/2026 at 11:30 AM, Food Service Director #6 stated the dish machine temperatures were supposed to be recorded three times a day by a kitchen supervisor and entered on the log, and acknowledged that many temperatures were missing and that they were unsure why so many were absent. The report also noted that prepared and cooked food should be covered in the cooler and labeled and dated to identify the food and when it needed to be used or discarded by.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Surveyors identified a deficiency in resident dignity related to how staff assisted residents with meals. Facility policy on Resident Dignity, revised 09/2025, stated that all residents were to be treated with dignity and provided a dignified dining experience. Three residents with Alzheimer’s disease, dysphagia, severely impaired cognition, and care plans indicating a need for substantial/maximal or total assistance with eating and mechanically altered/puree diets were observed being assisted with meals while staff stood over them. On multiple meal observations, one CNA stood while assisting two different residents with breakfast, and another CNA stood while assisting a resident with lunch; the same resident was again assisted by a standing CNA at a subsequent breakfast. Interviews with staff confirmed that they had been trained to sit at eye level with residents during feeding for dignity reasons and that the facility had enough chairs available. The CNA who was observed standing stated that they were supposed to be seated when assisting residents at meals and acknowledged that standing while feeding was not dignified, explaining that they stood because several residents required assistance at the same time. An LPN and the RN Neighborhood Manager both stated that staff should be seated when assisting residents with meals and that standing while assisting residents was not dignified. These observations and statements showed that staff did not follow the facility’s dignity policy or accepted practice regarding seated, eye-level feeding assistance for the three residents.
Unassessed self-administration and medications left at bedside
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined whether a resident could safely self-administer medications when clinically appropriate. Resident #299 had diagnoses including dementia, left-sided weakness following a stroke, and anxiety, and the 01/03/2026 MDS documented intact cognition and that the resident required set up or was independent for most ADLs. However, there was no documented evidence of a medication self-administration assessment, physician order, or comprehensive care plan related to self-administration or storage of medications in the resident’s room. During observations, the resident’s room contained a large bottle of acetaminophen, a tube of Neosporin, a bottle of antacids, a loperamide gel capsule in packaging, and a medication cup with several unidentified pills. The resident stated the antacids were taken as needed for stomach upset or heartburn, that acetaminophen had been brought in and was used only for headaches, and that the medication cup had been left by the nurse that morning because the resident wanted to eat before taking the medications. An LPN stated medications were sometimes left in the room when the resident would not take them right away, despite there being no order to leave medications at bedside, and the RN neighborhood manager stated medications should not be left at bedside unless care planned that way. The LPN also stated the resident had an acetaminophen order three times daily and should not need more, and that the resident did not have an order for loperamide.
Incomplete care plans for oxygen therapy and psychotropic medication use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents to include services needed to maintain their highest practicable physical well-being. For Resident #77, who had diagnoses including pneumonia, respiratory failure with hypoxia, and pulmonary hypertension, the 03/04/2026 MDS documented intact cognition, shortness of breath with exertion and while lying flat, and continuous oxygen therapy. A 03/03/2026 physician order directed oxygen at 4 liters per minute continuously by nasal cannula, but there was no documented evidence that the comprehensive care plan included oxygen use, and the resident profile did not include oxygen instructions. During interviews, CNA #9 stated they were unsure whether oxygen should be included in the care plan but thought it should be so staff would know whether the resident was to use oxygen continuously or as needed and could monitor use as ordered. LPN #3 stated RNs were responsible for initiating and updating care plans and said oxygen should have been included so staff would know the ordered liters per minute, whether oxygen was continuous or PRN, and when to monitor breathing and oxygen use. RN/Charge Nurse #10 stated the care plan should include everything about the resident’s care and that oxygen therapy should have been included so staff would know the ordered flow rate, frequency, and monitoring needs. For Resident #16, who had diagnoses including Alzheimer’s disease and adult failure to thrive, the 02/14/2026 MDS documented severely impaired cognition and receipt of both an antipsychotic and an antidepressant with an indication noted. The CAA Summary triggered psychotropic drug use and indicated care planning was necessary. Physician orders included risperidone 0.5 mg twice daily for dementia with anxiety and sertraline 25 mg daily for dementia with anxiety, and a psychiatric consultation recommended continuing both medications, reinforcing coping skills and non-pharmacological measures, and monitoring mood, behaviors, and medication side effects. There was no documented evidence of a care plan related to psychotropic medication use, anxiety, non-pharmacological interventions, or behavioral history, despite staff interviews noting behavioral interventions should be listed on the care plan and that psychotropic medications should be addressed on the comprehensive care plan.
Pressure Relief and Wound Care Orders Not Followed
Penalty
Summary
The facility failed to ensure pressure relieving interventions were carried out as ordered for two residents with significant skin breakdown risk and active pressure injuries. Resident #16 had diagnoses including Alzheimer’s disease and adult failure to thrive, was severely cognitively impaired, dependent for most activities of daily living, and had a Stage 4 pressure ulcer plus two unstageable pressure ulcers, one described as a deep tissue injury on the 02/14/2026 MDS. The resident’s care plan called for Prevalon boots while in bed, and physician orders included offloading heels at all times and multiple heel wound treatments. However, the resident was observed asleep in bed without the Prevalon boots on 03/31/2026 and again on 04/01/2026, with the boots placed on top of a basket. For Resident #16, the wound care orders were also inconsistent and not aligned with the wound care provider’s recommendations. The chart contained orders to apply Betadine to the left heel and leave it open to air, while other orders directed Betadine with dry dressing, heel cup, gauze, and kerlix to both heels. The March and April 2026 TARs showed these orders as completed, including the conflicting bilateral heel orders. The wound care nurse practitioner documented that the right heel eschar should be painted with Betadine and covered with Betadine-moistened gauze secured with kerlix, and later documented the right heel should be painted with Betadine, covered with dry gauze, and secured with kerlix; the record did not show that the earlier wound care recommendations for the right heel were implemented. Staff interviews reflected confusion about which heel orders were correct and that prior orders had not been discontinued when new ones were entered. Resident #304 had diagnoses including Alzheimer’s disease, adult failure to thrive, and a history of venous thrombosis and embolism, and was documented as severely cognitively impaired and at risk for pressure ulcers. The resident’s care plan and care card included Spenco boots while in bed, and the March 2026 TARs showed the boots as completed every shift. However, the resident was observed in bed without the Spenco boots on 03/30/2026 and 03/31/2026, with the boots left on the recliner. Staff interviews confirmed the boots were intended to be worn whenever the resident was in bed, but the CNA assigned to the resident did not remember placing them on the resident.
Tube feeding was not dated when hung
Penalty
Summary
Resident #4, who had diagnoses including dysphagia, chronic kidney disease, and cerebral infarction, was assessed as having severely impaired cognition, not eating by mouth, weighing 196 pounds, and receiving nutrition through a feeding tube. Physician orders directed the resident to remain nothing by mouth except for popsicles and to receive Nepro tube feeding at 45 milliliters per hour for 21.5 hours daily via gastrostomy tube. The facility policy did not document dating and timing of tube feedings when administered, and the manufacturer information for Nepro stated the product should be hung for no more than 24 hours unless a shorter hang time was specified by the set manufacturer. During observations on multiple shifts, the resident’s tube feeding pump was on and infusing at 45 milliliters per hour, but there was no documented evidence of the day and time the tube feeding had been opened and hung. On one occasion the resident was seated upright in a recliner with the pump functioning, and on another the resident was in bed with the head of the bed elevated above 30 degrees with the pump functioning. Staff interviews confirmed that tube feedings should be dated when hung so staff would know how long they had been in place, and one LPN stated the feeding had been hung on the evening shift but had not been dated.
Failure to Follow Enteric Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident reviewed. Resident #312 had diagnoses including enterocolitis due to clostridium difficile and diarrhea. The resident’s MDS documented enterocolitis due to clostridium difficile, the care plan documented a clostridium difficile infection with enteric contact precautions to remain in place for the duration of the infection, and a physician order documented the resident was on enteric precautions. During an observation, Food Service Worker #2 entered Resident #312’s room to deliver lunch while the resident had an enteric precaution sign posted outside the door. The worker entered without removing gloves worn in another resident’s room, did not perform hand hygiene, and did not don a gown and new gloves. While in the room, the worker moved the resident’s wheelchair and pulled the over-bed table closer for lunch, then left the room without removing gloves or performing hand hygiene. In interview, the worker stated they did not know when residents were on precautions or what the sign meant, and said they did not remember receiving infection control or transmission-based precautions education. The ADON, who served as the infection prevention nurse, stated enteric precautions required hand hygiene, gown and gloves before entry, removal of PPE before exit, and hand hygiene with soap and water inside the room; staff should not wear the same pair of gloves between resident rooms.
Failure to Prevent Elopement and Inadequate Supervision of Residents
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents identified as being at risk for elopement or accidents. One resident with Alzheimer's dementia, severely impaired cognition, and a history of repeated falls was assessed as high risk for elopement and was equipped with a wander detection device. Despite multiple prior incidents where this resident was found in or near stairwells and exit doors with alarms sounding, the resident was able to exit the facility undetected on two separate occasions. On both occasions, staff were either occupied providing care to other residents or did not fully investigate the source of the alarm, resulting in delayed recognition that the resident was missing. Documentation of required 15-minute checks was incomplete, and there was no evidence of additional interventions being implemented after the first elopement. Staff interviews revealed confusion about alarm response protocols, with some staff silencing alarms without fully searching the area or notifying supervisors as required by facility policy. Another resident with severely impaired cognition, multiple comorbidities, and independent use of a motorized scooter was allowed to move freely throughout the facility and its grounds. The resident was assessed as low risk for elopement and did not have a wander detection device. On one occasion, the resident left the facility grounds undetected and traveled approximately four miles away to a fast-food restaurant, where they were later found and returned by family. There was no documented plan to monitor or account for the resident's whereabouts when they left the building, and staff were unaware of specific monitoring expectations for residents using scooters independently on the grounds. The facility did not require the resident to notify staff or sign out when leaving the unit, and there was no restriction or supervision in place for off-campus mobility. Facility policies required staff to monitor residents' whereabouts, respond promptly to alarms, and notify supervisors in the event of a missing resident or elopement. However, staff interviews and documentation revealed inconsistent adherence to these protocols, including failure to expand searches beyond immediate areas, inadequate communication among staff, and incomplete documentation of supervision. These failures resulted in residents exiting the facility undetected, placing them at risk for serious harm and triggering Immediate Jeopardy and Substandard Quality of Care findings.
Removal Plan
- The facility's immediate plan was reviewed and accepted.
- 85% of staff had been educated on elopement risk and wander detection device door alarm response. The remaining staff will be educated prior to the start of their next shift or upon return from their leave.
- Staff education was verified onsite during interviews. Multiple staff including nursing, maintenance, housekeeping, and activities were interviewed.
- Staff were able to report content of education, confirmed the day they received the education, and the facility staff who presented the education.
Deficiency in Grievance Process
Penalty
Summary
The facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 6 of 8 anonymous residents. Specifically, 6 anonymous residents present at the Resident Council meeting stated they did not know how to file a grievance. Additionally, the facility did not have a process for residents to file a grievance anonymously. The facility policy on Resident Grievances, dated 11/2016, did not state how residents were informed of their right to file a grievance or how to do so anonymously. The grievance log for the year 2024 documented only one grievance in total for the facility. The grievance policy was observed in the front lobby inside a locking glass wall case in the upper right top corner, which was above head height when standing. During interviews, the Social Services Director stated they were unaware of how residents were educated on the grievance process and mentioned that grievances or concerns were a team approach. They also noted that there was no internal process to file an anonymous grievance. Licensed Practical Nurse #13 and Certified Nurse Aide #12 were both unsure of the process for residents to file a grievance. The Administrator mentioned that they had two different processes for addressing resident grievances but had never had a resident file an anonymous grievance. They also stated that if a resident had an anonymous grievance, they were encouraged to call the Ombudsman. The Administrator was unsure if the right to file grievances was addressed in the admission packet and would have to check with the admissions department and social workers to confirm this.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents' ability to safely self-administer medications was clinically appropriate. Resident #96 was observed with prescribed eye drops and nasal sprays at their bedside without documented evidence of an assessment or order to self-administer these medications. Despite having a comprehensive care plan that included self-administration of certain medications, there was no specific order for the nasal spray and eye drops. The resident was seen self-administering these medications, and staff were unsure if there was an order for self-administration. The resident had a history of non-compliance and impaired vision, which further complicated the situation. Resident #155, who had diagnoses including dementia and glaucoma, was also found with prescribed eye drops at their bedside without an assessment or order to self-administer them. The resident's care plan and physician notes indicated that the resident was not allowed to self-administer eye drops due to cognitive decline. However, the resident was observed with eye drops in their room, and staff admitted to sometimes allowing the resident to self-administer the drops under supervision, despite knowing there was no order for it. The resident's care plan was not updated to reflect the current status, causing confusion among the staff. Interviews with staff revealed a lack of clarity and adherence to the facility's policy on self-administration of medications. Licensed Practical Nurse #14 and Registered Nurse Manager #15 both acknowledged that a physician order and competency assessment were required for self-administration, but these were not consistently followed. The Assistant Director of Nursing confirmed that care plans should be accurate and up-to-date, and no medications should be left at the bedside without a specific order. The failure to follow these protocols led to the observed deficiencies.
Failure to Include Anticoagulant Therapy in Resident's Care Plan
Penalty
Summary
The facility did not ensure a comprehensive, person-centered care plan was developed and implemented to meet a resident's medical and nursing needs. Specifically, a resident with a history of venous thrombosis, embolism, and pulmonary embolism, who was on anticoagulant therapy, did not have a care plan that included interventions related to their anticoagulant medication use. The resident's care plan, dated 11/21/2022, only documented fall risk interventions and did not address the anticoagulant therapy despite physician orders indicating the resident took apixaban twice daily. Interviews with facility staff, including a Certified Nurse Aide, Licensed Practical Nurse, Nurse Manager, and Assistant Director of Nursing, revealed that the care plan should have included anticoagulant therapy interventions. The Nurse Manager confirmed that the specific template for anticoagulant therapy had not been initiated in the resident's care plan. The Assistant Director of Nursing emphasized that care plans should always be accurate and up-to-date to ensure proper care is provided to residents.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident #106 received necessary treatment and services to promote wound healing and prevent new pressure ulcers. Resident #106, who had diagnoses including peripheral vascular disease, diabetes mellitus type 2 with diabetic neuropathy, and heart failure, was ordered to have bilateral heel float boots on 4/29/2024. However, the resident did not receive the left heel float boot until 5/12/2024, despite multiple documentation entries indicating the absence of the left boot and the resident's own statements that they had never received it. This delay in providing the necessary equipment was noted by various staff members, but no immediate action was taken to rectify the situation until 5/12/2024, when the left heel float boot was finally provided from the second-floor storage room. The facility's policies required that staff review the resident care guide before delivering care and document any care not given, reporting it to the nurse. Despite these policies, the nursing staff failed to document accurately that the resident only had one heel float boot and did not take steps to obtain the second boot in a timely manner. The resident's care plan, which included interventions for high-risk skin breakdown, was not followed as ordered, leading to a delay in the provision of the necessary heel float boot. This failure was observed and documented by multiple staff members, including Licensed Practical Nurses and Registered Nurse Unit Managers, who acknowledged the oversight but did not take immediate corrective action. The delay in providing the left heel float boot resulted in the resident developing additional skin issues, including a yellow, sloughing dry scab on the left heel, a small yellow fluid-filled blister on the left great toe, and fresh blood draining from the skin between the toes. The facility's failure to follow the physician's order and provide the necessary equipment in a timely manner contributed to the resident's deteriorating skin condition. Interviews with various staff members, including the Nurse Practitioner and Assistant Director of Nursing, confirmed that the delay in obtaining the heel float boot was a significant issue that should have been addressed promptly to prevent further skin breakdown.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from bed rails prior to their installation, did not review the risks and benefits of bed rails with the resident or their representative, and did not obtain informed consent before installing the bed rails. Specifically, for Resident #40, there was no documented evidence of a bed rail assessment, no informed consent, and no physician orders for the use of bed rails. The resident had diagnoses including polyneuropathy, vascular dementia, and morbid obesity, and was dependent on assistance for various movements and transfers. Despite these needs, the required assessments and consents were not completed before the bed rails were installed and used. The facility's policy required these steps to be taken to ensure the safety and appropriateness of bed rail use, but these procedures were not followed in this case. The resident was observed on multiple occasions with half bed rails up on both sides of the bed, and staff interviews revealed a lack of clarity and adherence to the policy regarding bed rail assessments, documentation, and consent. Staff members, including a Certified Nurse Aide, Registered Nurse Unit Manager, Assistant Director of Nursing, and Director of Physical Therapy, provided inconsistent information about the procedures and documentation required for bed rail use. This inconsistency contributed to the failure to properly assess and document the use of bed rails for Resident #40, leading to a deficiency in the facility's compliance with safety regulations.
Failure to Administer Parkinson's Medication
Penalty
Summary
The facility did not ensure that a resident was free from significant medication errors, specifically failing to administer four consecutive doses of carbidopa-levodopa to a resident with Parkinson's Disease. The resident was admitted with diagnoses including Parkinson's Disease and required the medication to manage symptoms such as tremors and movement difficulties. The medication was not administered on four occasions due to it being unavailable, and the nursing staff failed to notify the medical team as required by the facility's policy. The Medication Administration Record documented that the carbidopa-levodopa was not given on 5/11/2024 at 6:00 PM, and on 5/12/2024 at 8:00 AM, 1:00 PM, and 6:00 PM. Progress notes indicated that the pharmacy was contacted multiple times, but the medication was not delivered in time. The nursing staff, including LPNs and RNs, were aware of the missed doses but did not follow the protocol to notify the medical team, which could have provided alternative instructions or medications. Interviews with the nursing staff and the physician revealed that the medical team was not informed about the missed doses, which could have led to worsening symptoms for the resident. The facility's policy required that the Nurse Manager/Supervisor explore alternative methods for obtaining the medication and notify the medical team if a resident missed a dose. However, this protocol was not followed, resulting in the resident missing critical doses of their Parkinson's Disease medication.
Infection Control Deficiency: Catheter Care
Penalty
Summary
The facility did not ensure an infection prevention and control program was properly maintained, leading to a deficiency in the care of a resident with a urinary catheter. Specifically, the resident's catheter drainage bag was observed resting on the floor without a barrier on multiple occasions during the survey. The facility's policy stated that the drainage bag should never touch the floor, yet observations on several days showed the bag on the bare floor, posing an infection risk. The resident had a history of urinary tract infections and was on long-term antibiotics for prevention, making proper catheter care crucial. Interviews with staff revealed that they were aware of the policy requiring the drainage bag to be covered and off the floor, but failed to consistently implement it. Certified Nurse Aide and Licensed Practical Nurse both acknowledged the infection risk associated with the drainage bag touching the floor. The Registered Nurse Infection Preventionist confirmed that catheter drainage bags should be off the floor and in a privacy bag to prevent contamination. Despite yearly infection control training, the staff did not adhere to the established protocols, resulting in the observed deficiency.
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.
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What surveyors actually found near you
We read the 134 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Utica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oneida Center For Rehabilitation And Nursing | 2.9 mi | ★★★★★ | 1 | 0 |
| Charles T Sitrin Health Care Center Inc | 3.2 mi | ★★★★★ | 0 | 0 |
| The Pines At Utica Center For Nursing And Rehab | 3.5 mi | ★★★★★ | 1 | 0 |
| The Grand Rehabilitation And Nursing At Utica | 3.6 mi | ★★★★★ | 0 | 0 |
| Mvhs Rehabilitation And Nursing Center | 4.5 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.