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 Northern Metropolitan Res Health Care Facility Inc during CMS and state inspections, most recent first.
A resident with dementia and heart failure, whose MDS documented severely impaired cognition and wheelchair use for mobility, was observed in the dining room seated in a wheelchair labeled for a former resident. The wheelchair was too wide, had one missing and one frayed armrest pad, and the resident appeared visibly upset and pointed to the armrests. An RN Unit Manager on the unit did not know how the resident came to be in that chair and acknowledged it was damaged and not assigned to the resident. A CNA later stated the resident had been in that same wheelchair since the start of the shift, including during and after a shower, and admitted they had not checked the name label or noticed the damage. The Director of Therapy confirmed the wheelchair was not appropriate for any resident and should not have been on the unit, while the Director of Maintenance reported there were no routine wheelchair inspections and that maintenance relied on nursing staff to report damaged equipment.
The facility failed to complete a comprehensive facility-wide assessment that determined necessary staffing resources for routine operations, weekends, and emergencies. The assessment identified a resident population with behavioral health needs, substance use disorders, IV medications, dialysis, oxygen therapy, and ADL assistance needs, but did not specify staffing levels required to meet these needs or to provide behavioral health services. The attached staffing breakdown listed zero RNs on all shifts across three units, each housing about 40 residents, and did not distinguish minimum staffing requirements for weekends. Interviews revealed that weekends are generally less staffed, staff callouts occur, and aides are shifted between units, while the Administrator confirmed that the documented minimum staffing levels were not separated by weekday/weekend and did not address behavioral health staffing.
The facility failed to maintain a clean and homelike environment on one unit, with observations of dirty floors, chipped paint, and neglected maintenance in resident rooms and common areas. Staff interviews revealed inadequate housekeeping resources and a general acceptance of the unclean conditions.
The facility did not follow meal tickets for several residents, resulting in missing food items such as split pea soup, yogurt, and desserts. The Food Service Director cited food shortages and communication issues as contributing factors. An LPN confirmed that missing items were reported weekly.
A Recertification Survey identified deficiencies in food storage and safety practices, including undated and unlabeled food, unclean equipment, and incomplete chemical testing logs. The Food Service Director and Administrator were unaware of some issues, attributing them to recent changes and meal preparation activities.
A resident with multiple malignant neoplasms did not receive consistent pain management due to inadequate documentation and assessment of pain levels. Despite being on a scheduled pain regimen, there was no evidence of consistent pain assessments or monitoring of medication effectiveness. An LPN admitted to administering medication without proper documentation, and the DON confirmed the absence of a supplemental order for pain assessment, leading to ineffective pain management.
The facility failed to maintain the dignity of two residents by not covering their urinary catheters with privacy bags, as observed during a survey. Despite care plans indicating the need for privacy, the catheters were visible to others. Staff interviews confirmed the expectation to use privacy bags, but they were not always available, and the DON was unaware of this issue.
The facility failed to notify the LTC Ombudsman of resident transfers, as required. Two residents were transferred to the hospital without documented evidence of notification. The Director of Social Work and the Admission/Finance Coordinator confirmed the lack of documentation, and the DON acknowledged the issue.
A facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter. Despite the resident's admission with obstructive uropathy and the presence of a catheter, there was no care plan or progress notes addressing its care. The RN Supervisor and DON acknowledged the oversight, noting the absence of necessary documentation and care planning.
The facility did not ensure proper labeling and storage of drugs and biologicals, as observed during a survey. A treatment cart contained expired dressings labeled for a discharged resident, and a medication storage room had expired ear drops. LPNs acknowledged that expired items should be removed and discarded according to policy.
A facility failed to maintain an effective infection control program, with deficiencies including improper PPE use by an LPN for a resident with C. Difficile, an outdated Legionella risk assessment, and inadequate infection tracking. The LPN did not wear a gown as required, and the facility lacked a real-time infection surveillance system, preventing timely outbreak identification.
A facility failed to monitor and track antibiotic use for a resident with a UTI, despite having a policy for antibiotic stewardship. The resident, with chronic kidney disease and diabetes, was on Levaquin, but no tracking form was completed. Interviews revealed that the Infection Control Practitioner did not document daily, and the Medical Director was unaware of this lapse.
Resident Placed in Damaged, Misassigned Wheelchair Contrary to Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for a resident who relied on a wheelchair as the primary mode of locomotion. The facility’s own policy stated that the Rehabilitation Department would identify appropriate wheelchairs and that unsafe equipment would be removed from service until repaired or discarded. Despite this, a resident with anemia, dementia, and heart failure, whose most recent MDS documented severely impaired cognition and wheelchair use for mobility, was observed seated in a wheelchair that was labeled with the name of another resident who no longer resided in the facility. During the observation in the dining room, the resident appeared visibly upset and pointed to the armrests of the wheelchair. The wheelchair was too wide for the resident and had damaged armrest padding, including one missing armrest pad and one frayed armrest pad. The RN Unit Manager present at the time stated they did not know how the resident came to be seated in that wheelchair, acknowledged that the wheelchair was damaged and did not belong to the resident, and indicated that the assigned CNA was on lunch and they would need to investigate how the resident was placed in that chair. The CNA later reported that at the start of the shift the resident was already in that wheelchair, that they used the same wheelchair throughout the morning for care and after a shower, and that they had not checked the name on the wheelchair or noticed the damage. The Director of Therapy confirmed that the wheelchair was not assigned to the resident, was too wide, and was not suitable for any resident due to its damaged condition, and stated that no resident should be seated in that wheelchair and that it should not have been on the unit. The Director of Therapy also stated that when a resident is discharged, the resident’s wheelchair should be removed from the unit and that all wheelchairs should be labeled with the resident’s name, but they were unable to locate the resident’s actual wheelchair. The Director of Maintenance reported being unaware that the resident’s wheelchair was damaged and stated that maintenance does not perform routine inspections of wheelchairs, relying instead on nursing staff to report damage, and that there was no system in place to routinely identify damaged wheelchairs.
Failure to Conduct Comprehensive Facility-Wide Assessment of Staffing Needs
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that determined the resources necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. The facility’s written policy stated that a facility assessment would be conducted at least annually and as needed to determine and update the facility’s capacity to meet resident needs during routine operations and emergencies. The Facility Assessment provided during the onsite survey identified a resident population that included individuals with behavioral health needs, substance use disorders, IV medications, dialysis, oxygen therapy, and assistance needs with activities of daily living, and it documented facility resources for emergencies. However, the assessment did not determine the staffing resources necessary to meet these care needs, did not identify staffing levels needed during emergencies, and did not address what was considered sufficient staffing, particularly on weekends. The staffing breakdown attached to the Facility Assessment showed that for all three resident units (1 West, 2 West, and 2 East), with approximately 40 residents per unit and a total census of about 120 residents, there were zero RNs listed on day, evening, and night shifts. The breakdown listed only LPNs and CNAs for each shift and did not identify minimum staffing requirements specific to weekends or the number of staff needed to provide behavioral health care and services. During interviews, the staffing coordinator stated that weekends are generally less staffed, that staff call out, and that aides are moved between units to balance staffing, and also reported that staffing concerns had been discussed with nursing administration. When questioned about the absence of RN staffing and the lack of weekend and behavioral health staffing detail in the Facility Assessment, the Administrator stated that supervisors are RNs and acknowledged that the minimum staffing levels in the assessment were not separated by weekday or weekend shifts and did not identify staffing specific to behavioral health care and service needs.
Deficiency in Maintaining a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on one of its units, specifically 2 West, as observed during a Recertification and Abbreviated Survey. Multiple resident rooms and common areas were found to have various cleanliness and maintenance issues. Observations included dull and dirty floors with food crumbs, wrappers, and other debris scattered throughout resident rooms, hallways, and dining areas. Additionally, several rooms had walls with chipped paint, missing moldings, and other signs of neglect, such as a mattress with a shredded top and a strong urine smell. Interviews with staff revealed a lack of adequate housekeeping resources and a general acceptance of the unclean conditions. A Certified Nurse's Assistant mentioned that they would report issues like a damaged mattress to the manager, but it was unclear why the mattress in question had not been replaced. The Director of Housekeeping acknowledged the challenge of maintaining cleanliness with limited staff, particularly in the evenings. The facility's Administrator admitted to becoming accustomed to the unclean floors and recognized the need for improvement in room maintenance and cleanliness.
Failure to Follow Meal Tickets for Residents
Penalty
Summary
The facility failed to ensure that menus were followed as per the meal tickets for five residents during the recertification survey. Specifically, residents did not receive the food items documented on their meal tickets. For instance, one resident did not receive a hardboiled egg and split pea soup, while another resident did not receive strawberry yogurt. Additionally, a resident did not receive split pea soup, ice cream, and a frosted cupcake, and another resident did not receive split pea soup and a tossed salad. These discrepancies were observed during meal times and were confirmed through resident interviews. The facility's policy required nursing personnel to ensure residents received the correct food trays and to report any discrepancies to the Food Service Director. However, the Food Service Director acknowledged that sometimes the kitchen ran out of food items, and substitutes were used, which may have contributed to the missing items. Furthermore, communication issues among kitchen staff were noted as a potential factor in the failure to provide the correct meals. An LPN confirmed that missing food items were reported to the Food Service Director and documented weekly.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards for food safety practice during a Recertification Survey. Observations revealed several deficiencies, including undated and unlabeled food items in the dairy and walk-in refrigerators, a mixer with dried food residue, and peeling paint above the pot storage shelves. Additionally, the logs for testing chemicals in the 3-bay pot sink were incomplete, and refrigerator temperatures were recorded above the acceptable range. These issues were identified during an initial tour and a follow-up tour of the kitchen. Interviews with the Food Service Director and the Administrator highlighted a lack of awareness and oversight regarding these deficiencies. The Food Service Director admitted to being aware of some issues, such as the broken tile in the meat freezer and incomplete chemical testing logs, but attributed the refrigerator temperature issues to frequent door openings during meal preparation. The Director also acknowledged that the cleaning schedule had only recently been instituted, and there was no documentation of previous staff education on cleaning and labeling practices. The Administrator was unaware of the undated food storage and believed the temperature issues were due to meal service activities, placing responsibility on the Food Service Director for maintaining food safety standards.
Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to provide consistent pain management for a resident with multiple malignant neoplasms, including those of the prostate, bone, brain, and liver. The resident, who had severely impaired cognition, was on a scheduled pain regimen and frequently vocalized moderate pain. However, there was no documented evidence of a consistent pain assessment or monitoring of the effectiveness of pain medications administered. The facility's policy required documentation of pain assessments, including pain level prior to medication, pain scale used, and effectiveness of pain medication, but these were not consistently recorded for the resident. Licensed Practical Nurse #1 admitted to administering pain medication without a documented pain assessment and was unable to find an order for such assessments. The Director of Nursing confirmed that there was no supplemental order for pain assessment, which hindered the ability to document and evaluate the effectiveness of pain management. This lack of documentation and communication resulted in the facility's inability to ensure effective pain management for the resident, as required by professional standards and the resident's care plan.
Failure to Maintain Resident Dignity with Uncovered Catheters
Penalty
Summary
The facility failed to maintain the dignity of two residents by not ensuring their urinary catheters were covered with privacy bags, as observed during a recertification survey. Resident #109, who had diagnoses including Nephrogenic Diabetes Insipidus, Morbid Obesity, and Diabetes Mellitus, was observed multiple times with a urinary drainage bag visible from the door without a privacy bag. The resident's care plan specifically documented the need to maintain a privacy bag, yet this was not adhered to during observations on three separate occasions. Similarly, Resident #84, with diagnoses including Traumatic Brain Injury, Schizoaffective Disorder, and Obstructive and Reflux Uropathy, was also observed with an uncovered urinary drainage bag visible to roommates and visitors. Despite the care plan indicating catheter care every shift, the privacy bag was not used. Interviews with staff, including a Certified Nurse Aide and an LPN, confirmed the expectation to use privacy bags, but it was revealed that privacy bags were not always available on the unit. The Director of Nursing was unaware of the lack of privacy bag usage, indicating a lapse in ensuring resident dignity.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that the Office of the Long-Term Care Ombudsman was notified in writing about the transfer or discharge of residents, as required by regulations. This deficiency was identified during a recertification survey conducted from July 23, 2024, through July 30, 2024. Specifically, the facility did not provide documented evidence of notification for two residents who were transferred to the hospital. Resident #2, who had diagnoses including Diabetes, Hyperlipidemia, and Hypertension, was transferred to the emergency room on April 1, 2024, due to a change in medical status and generalized weakness. The Director of Social Work confirmed the lack of documentation for Ombudsman notification during an interview on July 30, 2024. Similarly, Resident #96, with diagnoses including Malignant Neoplasm of the Prostate, Joint Replacement Surgery, and Diabetes, was transferred to the hospital on March 18, 2024, after experiencing fever and drainage from a surgical wound. The Admission/Finance Coordinator admitted that they did not have copies of the transfer and discharge notices sent to the Ombudsman, despite sending monthly notifications. The Director of Nursing also acknowledged the absence of proof that the required notifications had been sent, indicating a systemic issue in the facility's process for notifying the Ombudsman of resident transfers and discharges.
Lack of Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including fractures and obstructive uropathy, had a catheter placed at the hospital. Despite documentation in the Nursing Admission Evaluation and physician notes indicating the presence of the catheter and the need for monitoring, there was no care plan in place to address the catheter's care and monitoring. Observations and interviews revealed that the resident had a urinary leg bag and reported no discomfort from the catheter. However, the Registered Nurse Supervisor acknowledged the absence of progress notes, orders, or a care plan for the catheter, stating it was their responsibility to ensure the care plan was completed. The Director of Nursing confirmed the lack of a care plan and progress notes, emphasizing that there should have been documentation regarding the catheter's care.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards, as observed during a recertification survey. In one of the medication storage rooms and one of the treatment carts reviewed, deficiencies were noted. Specifically, the treatment cart on one unit contained two boxes of DynaGinate AG, Silver Calcium Alginate rope dressings labeled with the name of a resident who had been discharged. One box had an expired date, and the other was also past its expiration date. During an interview, an LPN acknowledged that medications and treatment supplies should be removed from the cart once a resident is discharged. Additionally, in the medication storage room on another unit, a box of Ear Wax Removal Drops was found with an expired date. An LPN interviewed at the time was unaware of why the expired drops were still in the cabinet and confirmed that expired medications and treatment supplies should be discarded. The facility's policy on medication storage, revised on a specific date, mandates that expired, discontinued, or contaminated medications be removed and disposed of according to facility policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a recertification survey. One incident involved a nurse who did not adhere to the required contact precautions while administering medication to a resident with Clostridium Difficile. Despite the presence of signage and personal protective equipment (PPE) outside the resident's room, the nurse did not wear a gown, contrary to the facility's policy, which mandates the use of gloves, gowns, and masks for such cases. The nurse believed that a gown was unnecessary for medication administration, a misunderstanding that was later clarified by the Assistant Director of Nursing. Another deficiency was identified in the facility's environmental risk assessment for Legionella, which was not updated as required. The facility's water management plan designated the Administrator as responsible for the assessment, but the Administrator admitted to being aware of the requirement without ensuring its completion. This oversight left the facility without a current assessment to identify potential areas of risk for Legionella and other waterborne pathogens. Additionally, the facility's infection surveillance plan was found lacking. The Infection Preventionist did not track infections in real-time, instead compiling data at the end of each month. This approach prevented timely identification and response to potential outbreaks, as there was no system in place to monitor infections as they occurred. Consequently, the facility was unable to determine the prevalence of infections such as urinary tract infections or pneumonia among residents during the survey period.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program, as evidenced by the lack of monitoring and tracking of antibiotic use for a resident with a urinary tract infection. The resident, who had chronic kidney disease, type 2 diabetes, and obesity, was prescribed Levaquin for the infection. Despite the facility's policy requiring adherence to antibiotic stewardship principles, there was no documented evidence of an antibiotic tracking form for July 2024, indicating a failure to monitor the resident's antibiotic use. Interviews with facility staff revealed that the Infection Control Practitioner did not track or document antibiotic use daily, contrary to the expectations outlined by the Director of Nursing. The Medical Director was also unaware of the lack of tracking. This deficiency was identified during a recertification survey, highlighting the facility's non-compliance with the requirement to have a system in place to monitor antibiotic use in real-time.
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 991 citations issued within 25 miles in the last 12 months — including the 13 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 Monsey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Valley Center For Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 13 | 0 |
| Northern Manor Geriatric Center Inc | 2.9 mi | ★★★★★ | 0 | 0 |
| Friedwald Center For Rehab And Nursing, L L C | 3 mi | ★★★★★ | 4 | 0 |
| The Willows At Ramapo Rehab And Nursing Center | 3.2 mi | ★★★★★ | 17 | 0 |
| Woodcliff Lake Health & Rehabilitation Center | 4.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Northern Metropolitan Res Health Care Facility Inc.
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.