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 New Vanderbilt Rehabilitation And Care Center, Inc during CMS and state inspections, most recent first.
The facility failed to maintain food safety standards, with undated and unlabeled items in the refrigerator, improper temperature control in the dry storage room, and cold food items not held at proper temperatures during tray line service. The Dietary Chef and Food Service Director acknowledged lapses in labeling and equipment functionality.
The facility failed to maintain proper infection control practices during wound care and medication administration. A nurse did not perform hand hygiene or change gloves appropriately while providing wound care to a resident with a Stage 4 pressure ulcer. Another nurse demonstrated inadequate infection control during wound care for a resident with an unstageable pressure ulcer, failing to sanitize the bedside table and not performing hand hygiene after cleaning the wound. Additionally, a nurse did not perform hand hygiene between glove changes while administering medications via a gastrostomy tube and instilling eye drops for a resident.
The facility did not honor the shower preferences of three residents, impacting their self-determination. A resident with cognitive impairment was not showered as scheduled, while two cognitively intact residents were unable to receive showers as frequently as desired due to scheduling and staffing constraints. Staff interviews revealed a lack of awareness and flexibility in accommodating these preferences.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as broken furniture, mismatched paint, and an unresolved ceiling leak affecting multiple units. Staff interviews revealed that maintenance issues were reported but not promptly addressed, and the maintenance team was understaffed, impacting repair times.
The facility did not accommodate residents' dietary preferences, failing to meet nutritional, religious, cultural, and ethnic needs. A resident was denied ice cream due to kosher restrictions, another did not receive their chosen meal, and a third expressed dissatisfaction with limited non-kosher options. The facility's adherence to kosher laws restricted menu choices, causing resident dissatisfaction.
The facility's QAPI program failed to effectively identify and prioritize problems, resulting in repeated deficiencies from a previous survey. Issues included resident rights, advance directives, and professional standards. Despite having a QAPI plan and reporting system, the facility struggled with compliance, partly due to a new Director of Nursing.
A resident with cognitive impairments was sprayed with hand sanitizer by a Dayroom Attendant in an attempt to stop the resident's behavior, leading to a physical altercation with another resident. The incident, captured on video but not retained, showed the Attendant's inappropriate action, which violated the facility's abuse prevention policy. Staff interviews confirmed the events, and the Attendant was terminated following the investigation.
A resident-to-resident altercation was not reported to the NY State Department of Health within the required 2-hour timeframe. The incident involved two residents with cognitive impairments, where one resident flipped the other from their wheelchair. The delay in reporting was attributed to the incident occurring on a Sunday when the DON was not present, resulting in a deficiency.
A facility failed to thoroughly investigate an alleged staff-to-resident abuse incident involving a Dayroom Attendant and a cognitively impaired resident. The Dayroom Attendant was seen on video spraying the resident with hand sanitizer, but the facility did not conduct a comprehensive investigation, lacking interviews or witness statements. The Director of Nursing and Administrator reviewed the footage but did not preserve it or complete a separate investigation, resulting in a deficiency.
A facility failed to revise a resident's Comprehensive Care Plan for Activities of Daily Living quarterly, despite completed assessments. The resident, diagnosed with Cerebrovascular Accident, Hypertension, and Hyperlipidemia, had their care plan last revised several months prior. Staff interviews confirmed that the responsibility for updating care plans lies with the nurse supervisor, but the necessary updates were not made.
A resident with Major Depressive Disorder and Alzheimer's disease exhibited worsening behavioral symptoms, leading to an increase in psychotropic medication without assessing for underlying medical causes. Despite severe cognitive impairment and routine antipsychotic medication, there was no documented medical workup before the dosage increase. Interviews with staff revealed fluctuating behavior over two months, with the psychiatrist adjusting medication without confirming an assessment for potential infections.
A facility failed to accurately document a resident's participation in a floor ambulation program. Despite records indicating the resident was engaged in the program, interviews revealed the resident was not receiving the care. The resident, with a history of cerebrovascular accident and hypertension, expressed a desire for increased mobility. Staff were unaware of the program, and the Director of Nursing acknowledged the discrepancy between documented and actual care.
A resident with intact cognition and multiple diagnoses, including Diabetes Mellitus, was subjected to a blood glucose monitoring procedure in a public dining area, violating their right to privacy and dignity. The LPN involved was instructed to perform the procedure whenever they encountered the resident, but typically in private areas. Both the RN Supervisor and the DON confirmed that the procedure should have been conducted in the resident's room to maintain privacy.
The facility failed to ensure that two residents were provided the option to formulate and document advance directives. One resident, who was moderately cognitively intact, had no orders for advance directives in their medical records, and another resident had no advance directive options selected in their care plan. Interviews with staff revealed inconsistencies in the process of documenting advance directives, with unclear responsibilities among staff members.
A resident with diabetes had a blood sugar level below the required threshold, but the physician was not notified as per the facility's policy. The LPN claimed to have sent a text to the physician, but the physician did not receive it. The DON confirmed that the LPN should have followed the physician's orders and notified the physician and their supervisor.
A resident with a feeding tube received medications improperly when an LPN used a pistol syringe to force medications through the tube, contrary to the facility's policy of administering by gravity flow. This inconsistency in procedure understanding among staff led to a deficiency in professional standards.
Two residents with indwelling catheters were observed with their catheter bags improperly positioned above bladder level, compromising drainage and increasing the risk of urinary tract infections. Despite having care plans and physician orders, staff failed to adhere to facility policies, and interviews revealed inadequate monitoring and supervision by nursing staff.
A facility failed to ensure timely action on a pharmacist's drug regimen review for a resident with Alzheimer's and Anxiety Disorder. Despite the attending physician's agreement to check Depakote levels, no lab tests were ordered or conducted. Interviews revealed a lack of follow-through, with the attending physician deferring responsibility to a psychiatrist and the Medical Director emphasizing the attending physician's responsibility.
A resident with a history of cerebrovascular accident and other conditions was not provided with a prescribed Floor Ambulation Program to maintain mobility. Despite a physician's order and discharge recommendations from physical therapy, the program was not implemented due to a lack of communication and awareness among nursing staff. The resident expressed a desire for more activity, but the facility failed to execute the necessary care plan.
The facility failed to submit MDS 3.0 assessments within the required timeframe, affecting all residents reviewed. Delays ranged from 38 to 63 days due to late documentation by interdisciplinary team members and staffing issues. The MDS/Rehabilitation Department head and Secretary acknowledged the delays, and the Administrator was aware but uncertain about the responsible parties.
The facility did not ensure proper disposal of garbage, as the compactor door was left ajar, attracting flies. During a kitchen inspection, a Dietary Worker was observed bringing garbage to the disposal area, where the compactor door was open. Staff interviews confirmed that the compactor is used by housekeeping and food service staff, who are expected to keep the door closed. The facility's policy requires all kitchen waste to be properly disposed of in the compactor.
A resident at the facility was involved in an altercation with a staff member, leading to the use of excessive force. The incident was deemed to be abusive, and the staff member was terminated as a result. The incident was reported to the facility's administration, and an investigation was conducted, revealing that the staff member had used excessive force against the resident.
A resident with severe cognitive impairment and aggressive behavior was physically restrained and slapped by a CNA during an altercation. The facility's surveillance footage confirmed the abuse, which violated the facility's policy against physical restraint. Staff interviews supported the findings, highlighting inappropriate actions taken by the CNA.
A resident with severe cognitive impairment and multiple diagnoses, including Disorganized Schizophrenia, exhibited aggressive behavior towards staff and other residents. The facility's Comprehensive Care Plan lacked individualized interventions and was not updated or evaluated after incidents of aggression. Staff interviews revealed a lack of documented instructions for monitoring the resident's behavior or guidance on handling aggression, highlighting a failure to provide necessary behavioral health care and services.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a kitchen observation, it was noted that the dairy walk-in refrigerator contained undated and unlabeled food items, specifically leftover scrambled eggs and boiled eggs covered with aluminum foil. Additionally, the dry storage room was found to be humid, lacking ventilation, and excessively hot, with a temperature of 87.7 degrees Fahrenheit. This room contained expired items, including bottles of sweet chili sauce past their best-by date and salsa bottles that required cool storage. The Dietary Chef acknowledged responsibility for labeling and dating prepared foods but admitted that this was missed for the leftover breakfast items. Further observations during a tray line service revealed that cold food items were not held at the proper temperatures. A cheese sandwich, a plate of lettuce and tomato, and a tuna fish sandwich were all found to be above the required temperature, registering at 59, 64, and 63.5 degrees Fahrenheit, respectively. The Food Service Director confirmed that sandwiches are typically made and stored in the freezer before being placed on ice for lunch service, but the freezer was not functioning properly on the day of the observation. The Director of Maintenance also noted the lack of ventilation in the dry storage room, attributing the high temperature to the hot summer weather, which should ideally be below 75 degrees Fahrenheit.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care and medication administration, as observed during the recertification survey. Registered Nurse Supervisor #8 did not perform hand hygiene or change gloves appropriately while providing wound care to a resident with a Stage 4 pressure ulcer. The nurse removed the soiled dressing and proceeded to clean the wound and apply treatment without washing hands or changing gloves, contrary to the facility's infection control policy. Licensed Practical Nurse #4 also demonstrated inadequate infection control during wound care for a resident with an unstageable pressure ulcer. The nurse failed to sanitize the bedside table, did not clean the wound from inner to outer aspects, and did not perform hand hygiene after cleaning the wound. Additionally, the nurse returned an opened multipack of gauze to the medication cart, further compromising infection control standards. Licensed Practical Nurse #5 did not perform hand hygiene between glove changes while administering medications via a gastrostomy tube and instilling eye drops for a resident. Despite being taught to wash hands between glove changes, the nurse admitted to forgetting this step during the procedure. The Director of Nursing confirmed that staff are instructed to perform hand hygiene after every glove change, highlighting a lapse in adherence to infection control protocols.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not adhering to the residents' preferences for the number of showers per week. Resident #143, who has a diagnosis of cerebrovascular accident and hypertension, expressed a desire to be showered twice a week as per their schedule. However, documentation revealed that the resident was only showered on three occasions in June and twice in early July, with no evidence of refusal on other scheduled days. Interviews with staff indicated a lack of awareness and documentation regarding the resident's shower schedule and preferences. Resident #63, who is cognitively intact and requires moderate assistance with bathing, expressed a desire to shower more frequently than the scheduled twice a week. Despite this, the resident was told to wait until their designated shower days. The staff confirmed that the resident had not requested additional showers during the day shift but had requested bed baths, which were accommodated. The facility's policy did not appear to support flexibility in accommodating the resident's preferences for more frequent showers. Resident #39, who is cognitively intact and requires dependent-level assistance for bathing, was unable to shower on Wednesdays due to dialysis appointments, leaving only Saturdays for showers. The resident expressed dissatisfaction with the thoroughness of the staff's cleaning and the inability to have their hair washed due to time constraints. Staff interviews revealed that the shower schedule was rigid, with changes requiring approval from the social worker and Director of Nursing, and that additional shower requests were only accommodated if staffing allowed.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the recertification survey. On Unit 5, a wooden closet was found with scuff marks and scratches, and the lock was broken. Unit 6 had several issues, including missing name plaques, mismatched and scuffed paint, cracked armrests on wheelchairs, rusted lockers, and a black substance on the shower room floor grout. Unit 7 exhibited mismatched paint, scuff marks, and scratched furniture, while Unit 2 had an active ceiling leak in a resident's room. Unit 8 had mismatched paint, stained walls, a chipped radiator, a broken nightstand, dusty furniture, and improperly hung privacy curtains. Interviews with staff revealed that maintenance issues were reported in a maintenance book at the nurse's station, and broken furniture was either fixed or discarded. The Director of Nursing mentioned that weekly rounds were conducted with the Administrator, Maintenance, and Housekeeping Director to address maintenance and housekeeping issues. However, the ongoing ceiling leak in a resident's room on Unit 2 was not resolved despite maintenance examining it, and the resident reported that the leak had been an ongoing issue. Further interviews indicated that maintenance requests were managed via a computer ticketing system, and housekeepers were not responsible for identifying when curtains needed cleaning or fixing. The Director of Housekeeping stated that daily rounds were made to identify concerns, but specific issues were communicated by nurses. The Director of Maintenance acknowledged the leak in the resident's room and mentioned that the maintenance team was limited in number, which affected the speed of repairs. These deficiencies were documented in the New York State Department of Health Complaint Intake, which noted the facility's uncleanliness and broken furniture.
Failure to Accommodate Dietary Preferences
Penalty
Summary
The facility failed to ensure that menus met the nutritional, religious, cultural, and ethnic needs of residents, as evidenced by several incidents during the survey. Resident #37, who has intact cognition and does not follow a kosher diet, was denied ice cream during a lunch service because dairy was not allowed to be served with meat at a special barbecue event. This denial visibly upset the resident, highlighting a failure to accommodate individual dietary preferences. Additionally, Resident #143, who has severely impaired cognition, did not receive their chosen alternative menu item, a cheeseburger, as it was served without cheese, contrary to their request. Resident #58, with intact cognition and a member of the Resident Council, expressed dissatisfaction with the facility's strict adherence to kosher dietary laws, which limited their food choices. The resident reported that the regular menu did not accommodate their cultural preferences, and they were forced to order from a limited alternative menu daily. During a pre-planned Super Bowl event, some menu items were not initially ordered due to lack of approval from the Rabbi, causing dissatisfaction among residents. The Food Service Director confirmed that the kitchen follows kosher dietary laws, which restricts the preparation of certain foods, and stated that alternative menu options are available but must adhere to these laws.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems and opportunities for improvement, as evidenced by seven repeated deficiencies from the previous survey. These deficiencies included issues related to resident rights, advance directives, notification, environment, investigation of allegations, professional standards, activities of daily living, communication, catheter care, drug regimen review, food and nutrition services, garbage disposal, resident records, and QAPI itself. The facility's QAPI plan, dated January 1, 2024, outlined a system for monitoring care and services, incorporating feedback from various stakeholders, and using performance indicators to identify opportunities for improvement. However, the facility did not adequately address these areas, leading to repeated deficiencies. During the survey, it was observed that the facility's QAPI program did not effectively track and monitor adverse events or implement action plans to prevent recurrence. The Administrator acknowledged that when deviations from expected performance or negative trends occur, they are brought to the attention of the Quality Assurance committee. Despite having a system in place for reporting quality concerns and conducting weekly rounds with department heads, the facility continued to struggle with compliance in several areas. The Administrator also noted that the Director of Nursing was new to the facility, which may have contributed to the ongoing challenges in addressing the deficiencies.
Resident Abuse by Dayroom Attendant
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Dayroom Attendant and a resident with moderately impaired cognition. The resident, who had diagnoses including Bipolar disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus, was sprayed with hand sanitizer by the Dayroom Attendant while attempting to exit the dayroom. This action was captured on video surveillance during an investigation of a separate resident-to-resident altercation. The facility's policy on abuse prevention mandates protection from abuse, mistreatment, and exploitation, which was not adhered to in this instance. The incident occurred when the Dayroom Attendant, who was the only staff present in the dayroom with about ten residents, used hand sanitizer on the resident to stop them from hitting and kicking. Following this, another resident flipped the resident's wheelchair, causing them to fall. The Dayroom Attendant claimed the use of hand sanitizer was a method of redirection. However, the video footage, which was not retained, showed the Dayroom Attendant flicking hand sanitizer at the resident, contradicting the facility's abuse prevention policy. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse Supervisor, confirmed the sequence of events and the lack of injuries to the resident. The Director of Nursing and the Administrator reviewed the video footage and confirmed the abuse, leading to the termination of the Dayroom Attendant. Despite the facility's policy and procedures, the incident was not documented in the resident's medical record, highlighting a lapse in adherence to regulatory requirements.
Delayed Reporting of Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the New York State Department of Health within the required 2-hour timeframe. This incident involved two residents, one with moderately impaired cognition due to Bipolar disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus, and the other with severely impaired cognition due to Major Depressive Disorder, Alzheimer's disease, and Diabetes Mellitus. The altercation occurred when one resident flipped the other from their wheelchair, as documented in an Accident/Incident Report. The Director of Nursing was informed of the incident on the same day it occurred, but the report to the Department of Health was delayed until the following day. The Director of Nursing stated that the delay was due to the incident occurring on a Sunday when they were not present at the facility. The Administrator believed the incident was reported within the required timeframe, but the documentation showed otherwise, leading to a deficiency under 10 NYCRR 415.4(b)(2).
Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged staff-to-resident abuse incident involving a Dayroom Attendant and a resident with moderately impaired cognition due to Bipolar Disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus. The incident was captured on video surveillance during an investigation of a separate resident-to-resident altercation, where the Dayroom Attendant was seen spraying the resident with hand sanitizer. Despite the immediate suspension and subsequent termination of the Dayroom Attendant, the facility did not conduct a comprehensive investigation as required by their policy. There was no documented evidence of interviews or witness statements from staff or residents present at the time of the incident. The Director of Nursing and the Administrator both reviewed the video footage, which was not preserved, and acknowledged the Dayroom Attendant's actions. However, the Director of Nursing included the staff-to-resident abuse summary in the resident-to-resident altercation report and did not complete a separate investigation. The Administrator could not explain the lack of staff statements and indicated that the Director of Nursing was responsible for the investigation. This oversight resulted in a deficiency as the facility did not adhere to its policy of thoroughly investigating all allegations of abuse.
Failure to Revise Comprehensive Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, specifically for a resident with a diagnosis of Cerebrovascular Accident, Hypertension, and Hyperlipidemia. The care plan related to Activities of Daily Living was not revised quarterly as required. The Quarterly Minimum Data Set assessments were completed on two occasions, but there was no documented evidence that the Comprehensive Care Plan had been reviewed and revised after these assessments. Interviews with facility staff revealed that the responsibility for updating care plans lies with the nurse supervisor. However, the care plan for the resident's Activities of Daily Living had not been updated after the care plan meetings, as confirmed by the Registered Nurse Supervisor. This oversight was evident for one resident out of the five reviewed for Activities of Daily Living, indicating a lapse in the facility's adherence to its policy and procedure for maintaining individualized interdisciplinary plans of care.
Failure to Assess Underlying Causes Before Increasing Psychotropic Medication
Penalty
Summary
The facility failed to ensure that psychotropic drugs were administered to residents only when necessary to treat a specific condition, as diagnosed and documented in the clinical record. This deficiency was identified during a survey conducted from July 9, 2024, to July 16, 2024, involving Resident #102, who exhibited worsening behavioral symptoms. Despite these changes, the resident was not assessed for possible underlying medical causes before an increase in psychotropic medication was prescribed. Resident #102, diagnosed with Major Depressive Disorder, Alzheimer's disease, and Diabetes Mellitus, displayed severe cognitive impairment and received antipsychotic medications routinely. The resident's behavior included yelling profanity, crying out for their child, and exhibiting paranoia and confusion. Despite these symptoms, there was no documented evidence of a medical workup to rule out underlying medical conditions before increasing the resident's antipsychotic medication dosage. Interviews with facility staff, including the psychiatrist and the Director of Nursing, revealed that the resident's behavior had been fluctuating for two months. The psychiatrist adjusted the medication dosage due to increased behaviors without confirming whether the attending physician had assessed the resident for potential infections. The Director of Nursing emphasized the importance of ruling out medical conditions when residents exhibit increased behaviors, but acknowledged that such behavior was not new for Resident #102.
Inaccurate Documentation of Resident Ambulation Program
Penalty
Summary
The facility failed to maintain accurate and complete medical records for Resident #143, as required by professional standards. Despite documentation indicating that Resident #143 was participating in a floor ambulation program, interviews and observations revealed that the resident was not receiving such care. The resident, who had a history of cerebrovascular accident and hypertension, expressed a desire to be more mobile to prevent further decline. However, the resident reported not engaging in any walking or ambulation activities with staff, contrary to the documented records. The facility's records inaccurately reflected that Resident #143 was participating in a floor ambulation program, with tasks documented as completed despite staff being unaware of such a program. Certified Nursing Assistants interviewed stated they were not informed of any ambulation program for the resident and could not explain why the tasks were recorded as completed. The Director of Nursing acknowledged that care should be accurately documented and that staff should only document tasks that have been performed, highlighting a discrepancy between documented care and actual care provided.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, specifically in the case of a resident with intact cognition and diagnoses including Schizophrenia, Depression, and Diabetes Mellitus. During a recertification survey, it was observed that a Licensed Practical Nurse (LPN) performed a blood glucose monitoring procedure on the resident in the Unit 3 Dining Room, in front of other staff and residents who were eating lunch. This action was contrary to the facility's policy, which emphasizes the importance of privacy and dignity in resident care. Interviews conducted during the survey revealed that the LPN was instructed to collect the fingerstick from the resident whenever they encountered them, but typically in areas where privacy could be maintained. Both the Registered Nurse Supervisor and the Director of Nursing acknowledged that the procedure should have been conducted in the resident's room to ensure privacy and maintain dignity. The facility's policy on resident rights, dated April 2023, clearly states the importance of promoting resident independence and a positive quality of life, which was not adhered to in this instance.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that residents were provided the option to formulate an advance directive and that these directives were documented for each resident. This deficiency was identified during a recertification survey, where it was found that two residents, out of six reviewed for advance directives, did not have documented evidence of discussions or decisions regarding their advance directives. Specifically, Resident #502, who was moderately cognitively intact, had no orders for advance directives in their medical records, and there was no documentation in the social service notes indicating that advance directives had been reviewed with them. Similarly, Resident #233, who was cognitively intact, had no advance directive options selected in their care plan, and there was no evidence of discussions with the resident or their representative. Interviews with facility staff revealed a lack of clarity and consistency in the process of documenting advance directives. Registered Nurse Supervisor #9 was unsure of the responsibility for placing Medical Orders for Life-Sustaining Treatment forms in the chart, while Registered Nurse #3 indicated that the social worker was responsible for discussing and documenting advance directives upon admission. The Director of Social Work confirmed that discussions should occur on admission, but acknowledged the absence of documentation for the two residents in question. The Director of Nursing stated that admission nurses should verify and document advance directive preferences, but this process was not followed for the residents identified in the report.
Failure to Notify Physician of Low Blood Sugar
Penalty
Summary
The facility failed to immediately inform the physician when a resident's blood sugar level was below the specified parameter. This deficiency was identified during a recertification survey, where it was found that a resident with diagnoses including Schizophrenia, Depression, and Diabetes Mellitus had a physician's order to notify the physician if their blood sugar was below 70 mg/dL. On a specific date, the resident's blood sugar was recorded at 64 mg/dL, but there was no documented evidence that the physician was notified as required. The facility's policy on diabetic management required notifying the primary medical doctor of any signs of hypoglycemia. Despite this, the LPN responsible for the resident's care claimed to have texted the physician with the low blood sugar result, but the physician stated they did not receive any notification. The Director of Nursing confirmed that the LPN should have followed the physician's orders and notified both the physician and their supervisor about the low blood sugar reading.
Improper Medication Administration via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that services provided met professional standards, as evidenced by the improper administration of medications via a gastrostomy tube for one resident. The facility's policy required medications to be administered separately and by gravity flow, but a Licensed Practical Nurse (LPN) was observed using a pistol syringe to force medications through the tube. This method of administration was contrary to the facility's policy, which specified that medications should be delivered slowly by gravity. The resident involved had a feeding tube and was receiving medications such as Acidophilus, multivitamins, and Vitamin C through this route. During the observation, the LPN crushed the medications, diluted them, and used a pistol syringe to push them through the tube, rather than allowing them to flow by gravity. Interviews with the LPN and a Registered Nurse Supervisor revealed a lack of clarity and consistency in the understanding of the correct procedure for administering medications via a gastrostomy tube, contributing to the deficiency.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper catheter care for two residents, leading to a deficiency in preventing urinary tract infections. Resident #20, who has a neurogenic bladder and an indwelling catheter, was observed multiple times with the Foley catheter bag improperly positioned above the bladder level, compromising the drainage system. Despite having a comprehensive care plan and physician's orders for catheter care, the staff did not adhere to the facility's policy of keeping the drainage bag below the bladder to prevent urine reflux. Similarly, Resident #160, who also has a neurogenic bladder and a history of urinary tract infections, was observed with their catheter bag improperly positioned above the bladder level. The resident, dependent on staff for toileting hygiene, had their catheter bag hanging loosely from their wheelchair and placed on the upper side rail of the bed. The staff, including Certified Nursing Assistants and a Registered Nurse Supervisor, failed to ensure the catheter bag was positioned correctly, despite being trained on proper catheter care. Interviews with staff revealed a lack of consistent monitoring and supervision to ensure catheter bags were positioned correctly. The Director of Nursing acknowledged that staff were trained on catheter care but expressed surprise at the lack of proper monitoring by unit nurses and supervisors. This deficiency highlights a failure in staff adherence to established protocols and inadequate supervision, leading to improper catheter care for the residents.
Failure to Act on Pharmacist's Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a drug regimen review performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This deficiency was identified during a recertification survey, specifically affecting one resident who was reviewed for unnecessary medications. The resident, diagnosed with Alzheimer's Disease and Anxiety Disorder, was receiving antipsychotics and Divalproex (Valproic acid) as part of their treatment. The Consultant Pharmacist recommended checking the serum level of Depakote, but there was no evidence that this laboratory test was ordered or conducted, despite the attending physician's agreement to do so. Interviews with facility staff revealed a lack of follow-through on the pharmacist's recommendations. The Registered Nurse Supervisor could not find documentation of the lab order or any refusal by the resident to have the test done. The attending physician deferred responsibility to the psychiatrist, who did not receive a copy of the drug regimen review. The Medical Director emphasized that the attending physician is responsible for ordering labs if they agree with the pharmacist's recommendations. The Director of Nursing stated that the process involves the attending physician reviewing and agreeing to the pharmacist's recommendations, after which the nurses are expected to carry out the orders. However, this process was not followed, leading to the deficiency.
Failure to Implement Ambulation Program for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ambulation ability of a resident, identified as Resident #143. The resident, who was admitted with diagnoses including Cerebrovascular Accident, Hypertension, and Hyperlipidemia, had intact cognition and required supervision for walking. Despite a physician's order for a Floor Ambulation Program, which included ambulating 100 feet using a rolling walker with supervision, the program was not implemented. The resident expressed a desire to be more active to prevent further decline in mobility, but reported not engaging in any walking or ambulation activities with staff. The facility's policy on Restorative Nursing Services indicated that residents should receive care to promote safety and independence. However, the Comprehensive Care Plan for Resident #143 lacked documentation of a floor ambulation program. The Certified Nursing Assistant (CNA) documentation showed that the resident's ambulation tasks were infrequently completed, with no evidence of refusal from the resident. Interviews with CNAs and a Licensed Practical Nurse (LPN) revealed a lack of awareness about the resident's ambulation program, indicating a communication breakdown between the rehabilitation and nursing staff. The Director of Rehabilitation confirmed that Resident #143 was discharged from physical therapy with a recommendation to continue a Floor Ambulation Program to maintain functional ability. The responsibility for implementing this program was assigned to the nursing staff, but it was not executed. The Registered Nurse Supervisor acknowledged the existence of the order for the ambulation program but could not explain why it was not carried out. This oversight resulted in the resident not receiving the necessary care to maintain their mobility, as required by the facility's policies and physician's orders.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System Assessment Submission and Processing system in a timely manner. Specifically, admission, annual, and quarterly assessments were not submitted and transmitted within the required 14 calendar days after completion. This deficiency was identified during a recertification survey conducted from July 9, 2024, to July 16, 2024, and affected all 53 residents reviewed for the Resident Assessment facility task. The report highlights several instances of late submissions, including a resident whose quarterly assessment was completed and signed on May 18, 2024, but not transmitted until July 8, 2024, resulting in a 51-day delay. Another resident's assessment was completed on May 7, 2024, but transmitted 48 days late. Similar delays were noted for other residents, with transmission delays ranging from 38 to 63 days. These delays were attributed to the late completion of documentation by some interdisciplinary team members involved in the assessments. Interviews with facility staff revealed systemic issues contributing to the delays. The Minimum Data Set/Rehabilitation Department head acknowledged that some team members completed their documentation late, affecting the timely submission of assessments. The Minimum Data Set Secretary indicated that assessments were submitted late because they were not marked as ready to submit by the department head. Additionally, the Director of Social Work cited staffing issues as a factor in the late submissions. The Administrator was aware of the issue but uncertain about who was responsible for signing the assessment books.
Improper Garbage Disposal in Facility
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during the Recertification survey. Specifically, the garbage compactor door was found ajar, allowing multiple flies to gather on top of the garbage inside the compactor. This observation was made during a kitchen inspection when a Dietary Worker was seen bringing garbage to the disposal area outside the building. The facility's policy, dated 1/8/2024, mandates that all kitchen waste be properly disposed of in the compactor, with the door kept closed. Interviews with staff revealed that the compactor is used by both housekeeping and food service staff, and all are expected to keep the door closed after use. The Dietary Worker acknowledged that the door should have been closed, and both the Food Service Director and the Director of Housekeeping confirmed that staff are required to adhere to this procedure. The Director of Housekeeping also mentioned collaborating with the Food Service Director to educate staff on the proper garbage disposal process.
Resident Abuse Incident
Penalty
Summary
A resident at the facility was involved in an altercation with a staff member, leading to a series of events that were deemed abusive. The incident began when the resident, who was in a wheelchair, attempted to remove items from the wall. The staff member, in an attempt to prevent the resident from doing so, engaged in a physical altercation. The situation escalated, resulting in the resident being restrained on the floor by the staff member. This was considered an inappropriate use of force and restraint, leading to the classification of the incident as abuse. The staff member involved in the incident was observed to have used physical force against the resident, which was deemed excessive and inappropriate. The use of force was not in accordance with the facility's policies and procedures, and the staff member's actions were considered to be abusive. The incident was further exacerbated by the fact that the resident was restrained on the floor, which was deemed to be an inappropriate use of force. The incident was reported to the facility's administration, and an investigation was conducted. The investigation revealed that the staff member had used excessive force against the resident, and that the use of force was not in accordance with the facility's policies and procedures. The incident was classified as abuse, and the staff member was terminated as a result of their actions.
Resident Restraint and Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraint, as observed during an abbreviated survey. The incident involved a resident with diagnoses of Intellectual Disability, Disorganized Schizophrenia, and Depression, who exhibited severe cognitive impairment and aggressive behavior. On the night of the incident, the resident became agitated and physically aggressive, attempting to throw objects and strike a CNA. The CNA, in an attempt to control the situation, engaged in physical restraint by holding the resident's arms and using their knee to prevent the resident from getting up after a fall. The facility's surveillance footage revealed that the CNA slapped the resident during the altercation, which was confirmed by the facility's internal investigation. The CNA's actions were deemed abusive and constituted the use of physical restraint, which is against the facility's policy. The Director of Nursing and the Administrator both reviewed the footage and concluded that the CNA's actions were inappropriate and abusive. Interviews with staff members present during the incident corroborated the findings from the surveillance footage. The CNA involved stated that their intention was to prevent the resident from injuring themselves, but the actions taken were not in line with the facility's policies on handling aggressive behavior. The facility's policy emphasizes that staff should not restrain residents and should instead call for help when a resident becomes aggressive.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident received the necessary behavioral health care and services to maintain their highest practicable well-being. The resident, diagnosed with Intellectual Disability due to [NAME]-Will Syndrome, Disorganized Schizophrenia, and Depression, exhibited several incidents of aggressive behavior towards staff and other residents. Despite having a Comprehensive Care Plan (CCP) in place, the facility did not evaluate the effectiveness of the interventions to address the resident's aggression. The CCP lacked individualized interventions related to the resident's behavior, and there was no documented evidence that the interventions were reviewed and evaluated after each incident of physical aggression. The facility's policy required that each resident receive necessary behavioral health care and services, but the interventions documented in the CCP were not updated or evaluated after incidents of aggression. Interviews with staff revealed that there were no documented instructions for monitoring the resident's behavior or guidance on what to do if the resident became physically aggressive. The Director of Nursing and other staff members acknowledged that the CNA Accountability should specify actions to take when a resident becomes aggressive, and it is the unit manager's responsibility to update the care plan with new interventions after each episode of aggressive behavior.
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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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Nursing homes near Staten Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richmond Ctr For Rehab And Specialty Healthcare | 0.2 mi | ★★★★★ | 11 | 0 |
| Verrazano Nursing And Post-acute Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Silver Lake Specialized Rehab And Care Center | 1.2 mi | ★★★★★ | 7 | 0 |
| Staten Island Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Carmel Richmond Healthcare And Rehabilitation Cent | 1.8 mi | ★★★★★ | 4 | 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.