Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Menorah Home & Hospital For Aged & Infirm during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a high risk for falls, who had a physician's order for one-to-one supervision, was not provided with the required supervision during an understaffed overnight shift. The resident was observed attempting to get out of bed, later reported severe leg pain, and was ultimately diagnosed with an acute right hip fracture. Staff interviews confirmed that the lack of one-to-one supervision was due to staffing shortages, and the required monitoring was not provided, resulting in actual harm.
A resident with severe cognitive impairment and a history of falls, who had a physician's order for one-to-one supervision, was left without dedicated supervision overnight due to understaffing. The resident was later found to have suffered an acute right hip fracture, with staff failing to promptly assess reported pain. Facility leadership and staff confirmed that the required supervision was not provided and that the physician was not notified of the lapse.
A resident with severe cognitive impairment and a physician's order for one-to-one supervision was not provided with the required supervision during a night shift due to understaffing. Staffing records and interviews confirmed that only two CNAs were present, and the resident was instead monitored hourly, resulting in the resident sustaining a hip fracture. The facility's assessment and staffing plans did not account for real-time changes in resident needs or ensure proper documentation and notification when supervision could not be provided.
A resident with severe cognitive impairment and a history of falls reported right hip pain to a home health aide, but an LPN failed to assess or escalate the complaint, resulting in a 40-minute delay before pain medication was given. The resident was later found to have a swollen, painful right leg and was diagnosed at the hospital with an acute right hip fracture. The facility's pain management policy was not followed, and required interventions were not implemented promptly.
Two residents in an LTC facility did not receive their prescribed medications as documented, despite the narcotic logbook showing they were dispensed. An LPN failed to document the administration of medications in the electronic record, leading to an investigation that revealed other residents were also affected. The facility could not rule out narcotic diversion, resulting in the LPN's termination.
A resident with severe cognitive impairment reported being mishandled by a CNA, who allegedly threw them onto the bed, causing them to hit their head. Despite the resident's report, assessments by nursing staff found no visible injuries. The facility's investigation concluded that mishandling occurred, although the CNA denied the allegations.
A resident reported missing cash after care from a CNA, but the facility failed to report the alleged misappropriation to the state within the required 2-hour timeframe. The Director of Nursing misunderstood the reporting requirements, leading to a delay in notifying the New York State Department of Health.
A resident with Alzheimer's and severe cognitive impairment eloped from the facility after attending an event, due to inadequate supervision and failure to identify them as an elopement risk. The resident exited the facility unnoticed by distracted security staff and was later redirected back inside.
The facility did not ensure survey results were readily accessible to residents and visitors, as they were placed behind a glass partition at the security desk, requiring individuals to ask for access. This was contrary to the facility's policy, which required survey results to be available without request in accessible areas.
A facility failed to mail a Notice of Medicare Non-Coverage to a resident's representative on the same day as a phone notification, as required by policy. Interviews revealed that staff often rely on verbal communication and leave notices in residents' rooms if requested, rather than mailing them promptly. This practice resulted in a deficiency during the survey.
A facility failed to develop a comprehensive care plan for a resident taking anticoagulant medication, despite the resident's diagnoses of Chronic Atrial Fibrillation and Dysrhythmias. The resident was prescribed Pradaxa, but no care plan was documented. Interviews with staff revealed that the responsibility for creating such plans lies with the RNs, and the absence of a care plan was acknowledged by both an RN and the DON, who could not explain the oversight.
A resident in a persistent vegetative state did not consistently receive the required bilateral hand splints as per physician's orders. Observations showed the resident without splints on multiple occasions, and staff interviews revealed a lack of proper in-service training and documentation regarding the application and schedule for the splints. This deficiency was noted during a survey, highlighting the facility's failure to ensure necessary care for maintaining or improving the resident's range of motion.
The facility failed to update comprehensive care plans for two residents, one with dementia and depression and another with Alzheimer's and a history of fracture, as required by their policy. Despite having a system for alerts, care plans were not reviewed or revised after assessments. Nursing staff interviews revealed inconsistencies in following the update process, leading to missed updates.
A resident with Diabetes, peripheral neuropathy, and impaired cognition suffered burns after spilling hot tea during a recreational social hour in the dining room. The Recreation Leader placed a Styrofoam cup with hot tea within reach of the resident, who attempted to pick it up and spilled it. The resident sustained burns on the lower abdomen and upper inner thigh, which were treated by the Medical Doctor. The incident highlighted the need for careful supervision and appropriate handling of hot beverages during recreational activities.
Failure to Provide Required One-to-One Supervision Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, high fall risk, and a physician's order for one-to-one supervision was not provided with the required supervision during an overnight shift. The resident had a history of restlessness, agitation, and attempts to get out of bed, as documented in behavioral monitoring notes and psychiatric assessments. The care plan and physician's order specifically required one-to-one supervision due to these behaviors and the resident's high risk for falls. On the night in question, the facility was understaffed, and no staff member was assigned to provide one-to-one supervision for the resident, despite this being documented as necessary in the care plan and physician's order. The assignment sheet for the shift did not indicate a one-to-one staff assignment, and interviews with staff confirmed that the required supervision was not provided. During the shift, the resident was observed awake and attempting to get out of bed, was transferred to a wheelchair, and remained at the nurse's station under general supervision, but not one-to-one monitoring. The resident later reported severe leg pain, which was not immediately assessed by the LPN on duty. The resident was eventually assessed by a registered nurse after a delay and found to have a swollen, painful right leg. The resident was transferred to the hospital, where an acute traumatic comminuted right femoral intertrochanteric fracture was diagnosed. Interviews with facility staff, including the DON and administrator, confirmed that the lack of one-to-one supervision was due to staffing shortages and that the required supervision was not provided during the shift in question. The incident resulted in actual harm to the resident.
Failure to Provide Required One-to-One Supervision and Timely Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically failing to assign one-to-one supervision for a resident with severe cognitive impairment, a history of falls, and a physician's order for continuous supervision. On the night in question, the assignment sheet and staffing records showed that the resident was not assigned a one-to-one staff member during the overnight shift, despite the physician's order. Only two certified nursing assistants were present on the unit, and the scheduled one-to-one aide did not show up, with no replacement found due to ongoing staffing challenges. During the overnight shift, the resident was observed awake and attempting to get out of bed. Staff transferred the resident to a wheelchair and brought them to the nurse's station for monitoring, but there was no dedicated one-to-one supervision as required. The resident remained at the nurse's station until the next shift, when a home health aide arrived and was assigned to provide one-to-one supervision. At that time, the resident reported severe leg pain, which was not immediately assessed by the outgoing LPN, who instead instructed the aide to wait for the incoming nurse. The incoming nurse and registered nurse subsequently assessed the resident, noted swelling and pain, and arranged for hospital transfer, where an acute right hip fracture was diagnosed. Interviews with staff and leadership confirmed that the lack of one-to-one supervision was due to understaffing and that the physician was not notified that the ordered supervision could not be provided. The DON and administrator acknowledged that the resident did not receive the required supervision and that staff failed to respond promptly to the resident's report of pain. The incident resulted in actual harm to the resident, as documented by the hospital diagnosis and facility investigation.
Failure to Provide Required One-to-One Supervision Due to Inadequate Staffing Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not adequately consider specific staffing needs for each resident, nor did it adjust staffing based on changes in the resident population. This deficiency was evident during a review of staffing records, which showed that on a particular night shift, a resident with a physician's order for one-to-one supervision was not assigned a dedicated staff member as required. The resident in question had severe cognitive impairment, non-Alzheimer's dementia, anxiety disorder, and respiratory failure, and was dependent on staff for transfers and bed mobility. Despite an order for one-to-one supervision due to high fall risk and behavioral issues, staffing records and interviews confirmed that no staff member was assigned to provide this supervision during the night shift in question. Only two certified nursing assistants were present on the unit, and the resident was instead monitored hourly by available staff. The absence of one-to-one supervision resulted in the resident sustaining a right femoral fracture, which was later diagnosed at the hospital. Interviews with staff and facility leadership confirmed that the lack of one-to-one supervision was due to understaffing and unfilled shifts. The facility's assignment sheets and staffing plans did not reflect real-time adjustments for residents requiring enhanced supervision. Additionally, there was no dedicated documentation for one-to-one supervision assignments, and the physician who ordered the supervision was not notified when it could not be provided. This lapse led to actual harm to the resident.
Failure to Provide Timely Pain Assessment and Management
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls reported pain in their right hip to a home health aide. The aide notified an LPN, who did not immediately assess the resident or escalate the concern to a registered nurse, instructing the aide to wait for the incoming shift. As a result, the resident was not assessed or provided pain management in a timely manner, with a delay of approximately 40 minutes before Tylenol was administered by the next shift's LPN. The resident, who required substantial assistance for mobility and had a care plan in place for pain management, was later found to have significant swelling and pain in the right leg. Upon assessment by a registered nurse, the resident was unable to move or bear weight on the right leg, and swelling was observed. The resident was subsequently transferred to the hospital, where an acute traumatic comminuted right femoral intertrochanteric fracture was diagnosed. Facility records and interviews confirmed that the LPN did not implement any interventions upon first being notified of the resident's pain and did not report the concern to the incoming nurse or supervisor. The facility's pain management policy required prompt assessment and management of pain, which was not followed in this instance. The delay in assessment and pain management was attributed to staff inaction and failure to follow established protocols.
Medication Administration Failure in LTC Facility
Penalty
Summary
The facility failed to ensure that all residents received the necessary care to maintain their highest practicable physical, mental, and psychosocial well-being, as evidenced by the experiences of two residents during an abbreviated survey. On a specific date, one resident reported to a Registered Nurse Supervisor that they requested pain medication at 7:30 PM but did not receive it. Another resident informed the same supervisor that they received some medication at 5:00 PM but did not receive their sleeping medication. In both cases, the narcotic logbook indicated that the medications were dispensed, but there was no documentation of administration on the electronic medication administration record. The facility's investigation revealed that the Licensed Practical Nurse responsible for administering the medications did not document the administration in the electronic medication administration record, despite the narcotic count being accurate. The investigation also identified other residents who did not receive their medications, suggesting a pattern of non-administration. The facility could not exclude the possibility of narcotic diversion, leading to the termination of the Licensed Practical Nurse involved. The residents involved had specific medical conditions that required careful medication management. One resident had diagnoses including hypertension, diabetes mellitus, hyponatremia, and malignant neoplasm, with a moderately impaired cognition score. The other resident had hypertension and a fracture, with intact cognition. Both residents had care plans that included interventions to anticipate their needs, which were not met due to the medication administration failures.
Resident Mishandled by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nursing Assistant (CNA). On the evening of July 22, 2023, a resident reported to a Registered Nurse (RN) that the CNA had thrown them onto the bed from a wheelchair, causing them to hit their head on the headboard. Despite the resident's report, an assessment by the RN revealed no visible injuries. The resident, who had severe cognitive impairment due to dementia, was admitted with diagnoses including depression and cancer. The facility's investigation documented that the resident had requested to use the bathroom and was assisted by the CNA. Upon returning to bed, the resident alleged that the CNA handled them roughly, resulting in the incident. The resident reported the incident to a Nursing Supervisor, who conducted an assessment and found no visible injuries. The CNA provided a written statement denying the rough handling, stating they assisted the resident back to bed without incident. Interviews with the RN and the Director of Nursing (DON) revealed that the resident did not initially report any discomfort or injury during the shift. However, the facility's investigation concluded that the resident was mishandled by the CNA. The facility's policy on abuse prohibition mandates reporting such incidents within two hours if they involve abuse or result in serious injury, but the report does not specify if this timeline was adhered to in this case.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged violation involving the misappropriation of a resident's property within the required timeframe. Specifically, a resident reported that after receiving care from a Certified Nursing Assistant, an envelope containing approximately $900 was missing. The facility's policy mandates that such allegations be reported immediately, but no later than 2 hours after the allegation is made. However, the facility did not report the incident to the New York State Department of Health within this timeframe, as the report was submitted the following day. The Director of Nursing and the facility Administrator acknowledged the delay in reporting. The Director of Nursing stated that they were informed of the incident early in the morning but believed that the 2-hour reporting requirement only applied to cases involving serious bodily injury, leading to a misunderstanding of the policy. The Administrator confirmed that the report was not submitted within the required 2-hour window and noted that the staff has since updated the policy to reflect the correct reporting timeframe for allegations of abuse, including misappropriation of property.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident, identified as Resident #369, who was not initially considered at high risk for elopement. On November 23, 2023, Resident #369, who has Alzheimer's Disease, Non-Alzheimer's Dementia, and Depression, managed to exit the facility through the front doors and walked to the guard booth before being redirected back inside. The resident's cognitive assessment indicated severe impairment, with occasional confusion, and they were ambulatory with a walker. Despite these factors, the resident did not have a wander or elopement alarm at the time of the incident. The incident occurred after Resident #369 attended a Thanksgiving event in the facility's auditorium. The resident was left unsupervised after the event, allowing them to leave the auditorium and exit the facility unnoticed. Security personnel at the entrance were distracted and failed to observe the resident leaving. Interviews with staff revealed that the recreation staff did not consider Resident #369 an elopement risk, as the resident had not previously exhibited exit-seeking behaviors. The security officers were occupied with other tasks and did not notice the resident's departure. The facility's elopement policy, which was last reviewed on November 27, 2023, defines elopement as a resident leaving the facility undetected and unsupervised. The policy was not effectively implemented in this case, as the resident was able to leave the facility without triggering any alarms or being noticed by staff. The incident highlighted lapses in supervision and communication among staff, as well as inadequacies in the assessment of elopement risk for residents with cognitive impairments.
Inaccessible Survey Results
Penalty
Summary
The facility failed to ensure that the survey results were posted in a location that was readily accessible to residents, visitors, or legal representatives. The survey results were placed inside a binder located behind a glass partition at the security desk, which required individuals to ask to see them. This placement was contrary to the facility's policy, which stated that survey results should be available in areas such as the lobby and resident units without the need for individuals to request access. Observations during the survey period revealed that there was a sign at the security desk indicating the availability of survey results, but the binder was not visible or accessible on the counter. Interviews with the Safety and Security Officer and the Security Supervisor confirmed that the survey results were initially behind glass, and individuals might feel they needed to ask for access. The Administrator acknowledged that the previous placement required individuals to ask for access, but the location was changed to a more accessible spot at wheelchair height on the side of the security desk.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to ensure proper notification to a Medicare beneficiary's representative regarding the termination of coverage. Specifically, for one resident, the Notice of Medicare Non-Coverage (NOMNC) was not mailed to the designated representative on the same day that telephone notification was made. The facility's policy requires that if a beneficiary cannot comprehend the information, the notice must be delivered to their representative. If personal delivery is not possible, the representative should be notified by phone, and the notice should be mailed on the same day. However, there was no documented evidence that the NOMNC was mailed after the phone notification. Interviews with the Minimum Data Set Coordinator and Supervisor revealed that the facility often relies on verbal communication and leaves notices in residents' rooms if requested by family members. The Coordinator mentioned that family members sometimes prefer to pick up the notice in person or request it by email, although the facility does not send notices via email due to encryption issues. The Supervisor acknowledged that notices are supposed to be mailed on the same day as the phone call but stated that they sometimes hold the letter if they know the family will visit the facility. This practice led to the deficiency noted in the survey.
Failure to Develop Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented to meet each resident's needs, specifically for a resident taking anticoagulant medication. Resident #64, who was admitted with diagnoses including Chronic Atrial Fibrillation and Dysrhythmias, was prescribed Pradaxa, an anticoagulant, to be taken twice daily. Despite this, there was no documented evidence of a comprehensive care plan addressing the use of anticoagulant medication for this resident. Interviews with Registered Nurse #1 and the Director of Nursing revealed that the responsibility for creating care plans related to residents' care lies with the Registered Nurses on the floor, and that such a plan should have been in place for a resident on anticoagulant medication. Both the Registered Nurse and the Director of Nursing acknowledged the absence of a care plan for Resident #64's anticoagulant use, despite the medication being administered as ordered since the resident's admission. The Director of Nursing could not explain why the care plan was not created, indicating a lapse in the facility's adherence to its policy on care plan development.
Failure to Apply Splints as Ordered for Resident
Penalty
Summary
The facility failed to ensure that Resident #382, who was in a persistent vegetative state and dependent on staff for all activities of daily living, received the necessary care to maintain or improve their range of motion. The resident had a physician's order to wear bilateral hand splints at all times, with specific instructions for removal during skin inspections and meals. However, observations during the survey revealed that the resident was frequently without the splints, contrary to the physician's orders. Certified Nursing Assistant #6, who was responsible for Resident #382, admitted to not having received proper in-service training on the application and schedule for the splints. The CNA acknowledged forgetting to reapply the splints after providing care and intended to do so after their break, but failed to follow through. Additionally, Registered Nurse #4 was aware of the requirement for the splints to be in place but could not explain why they were not consistently applied, citing incorrect removal intervals that were not in the physician's orders. Interviews with the facility's staff, including the Rehabilitation Director and the Director of Nursing, highlighted a lack of documentation and consistent in-service training regarding the application of assistive devices like splints. The Rehabilitation Director confirmed that while therapists demonstrate the application of splints to staff, there is no formal record of these in-services. This lack of documentation and training contributed to the failure to adhere to the physician's orders for Resident #382, resulting in the deficiency noted during the survey.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect the changing needs of residents, as required by their policy. This deficiency was identified during a survey, where it was found that the Psychoactive Drug Use care plan for a resident with dementia and depression was not updated after quarterly assessments. Despite having a policy that mandates care plan reviews after each assessment, the care plan for this resident had not been reviewed since April, even though assessments were completed in June and September. Interviews with nursing staff revealed that the responsibility for updating care plans was shared among all nurses, but the process was not consistently followed, leading to missed updates. Another resident, who had Alzheimer's disease and a history of a shoulder fracture, also had a care plan that was not reviewed or revised as required. The care plan related to the risk for victimization was not updated after multiple quarterly and annual assessments. Despite the facility's policy and the electronic medical record system providing alerts for due reviews, the care plan was not updated between June of the previous year and May of the current year. Interviews with nursing staff indicated that there was no documentation to show that the care plan was reviewed during this period. The Director of Nursing acknowledged the oversight in both cases, stating that the registered nurses were responsible for updating care plans and that it was an error that the updates were not completed. The facility's failure to adhere to its policy for care plan reviews and updates resulted in deficiencies in maintaining accurate and current care plans for residents, which are crucial for addressing their ongoing health needs.
Inadequate Supervision During Recreational Activity Leads to Resident Burns
Penalty
Summary
The deficiency identified during the survey was related to inadequate supervision of a resident, resulting in an accident where Resident #1 spilled hot tea on themselves during a recreational social hour in the dining room. Resident #1, who had diagnoses of Diabetes with peripheral neuropathy and impaired cognition, suffered burns on the left side of the lower abdomen and left upper inner thigh. The incident occurred when the Recreation Leader placed a Styrofoam cup with tea in front of Resident #1, who attempted to pick it up and spilled the hot tea on themselves. The Medical Doctor assessed and treated Resident #1 for the burns, which eventually healed. The facility's Policy and Procedure on Resident's safety during recreation programs involving food and beverages emphasized the importance of providing safety during such activities. Despite Resident #1 requiring setup assistance with eating and having severely impaired cognition, the Recreation Leader placed the hot tea in a Styrofoam cup within reach of Resident #1, leading to the accident. The interdisciplinary team meeting following the incident highlighted the need to discontinue the use of Styrofoam cups for serving hot beverages and to provide in-service training to staff on safe handling of hot foods and beverages. Interviews with staff members, including the Recreation Leader, Registered Nurse, and Medical Doctor, provided insights into the events leading up to the accident. The Recreation Leader used an electric kettle to boil water for the tea, and despite the tea not being hot to touch, it resulted in Resident #1 sustaining burns. The Medical Doctor's assessment revealed redness and skin burns on Resident #1, prompting immediate treatment and subsequent changes in facility protocols regarding serving hot beverages.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,175 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sheepshead Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Shore View Nursing & Rehabilitation Center | 1.4 mi | ★★★★★ | 1 | 0 |
| The Chateau At Brooklyn Rehab And Nursing Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Sea Crest Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 5 | 0 |
| Saints Joachim & Anne Nursing And Rehab Center | 2.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Menorah Home & Hospital For Aged & Infirm.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.