Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palatine Nursing Home during CMS and state inspections, most recent first.
Persistent odor in hallway near resident rooms. Surveyors observed a pungent sewer odor in the hallway leading to the [NAME] Unit near the Administrator's office and NS, and the same odor was still present later in the day. An LPN said the odor had been present for a while and was unsure of the source, while the Administrator stated a resident in that hallway had a nephrostomy and that it had been a persistent problem.
The facility failed to follow required timelines for reporting alleged abuse and submitting investigation results to the State Agency. In one incident, two residents with dementia were involved in an unwitnessed altercation that caused a minor injury, but the abuse report was not submitted within the required 2-hour window and the investigation findings were not sent within 5 working days. In two separate cases, residents with dementia and other cardiac and psychiatric conditions reported being hit by staff; internal investigations were completed, but no corresponding abuse reports were submitted through iQIES to the State. The Administrator later acknowledged not knowing that all allegations, even if ultimately unfounded, had to be reported within 2 hours and that full investigations had to be submitted within 5 days.
Medication administration errors exceeded the acceptable rate after surveyors observed multiple errors involving insulin handling, a missed Lidocaine patch dose, unauthorized self-administration of insulin, and mismatched MAR documentation versus actual administration times. An LPN failed to check an insulin vial expiration date, did not notify the MD or DON about a missing medication, and allowed a resident to self-administer insulin without an order. Another resident’s meds were documented as given at one time but were actually administered later than recorded.
Unassessed Self-Administration of Insulin: A resident with DM, alcoholic cirrhosis, and gait abnormality was observed self-administering insulin without an IDT assessment, physician order, or care plan entry authorizing self-administration. An LPN handed the resident the insulin pen and gave incorrect directions when the resident asked for guidance, while the DON could not locate documentation supporting self-administration.
A resident with a G-tube order had a continuous feed pump stop with an alarm sounding for more than 10 minutes, and staff did not respond until a surveyor located them. In a separate event, an LPN gave crushed meds to a resident who gagged and spit them out, without documented provider direction or evidence that the provider was informed of the swallowing difficulty.
Medication administration errors occurred for two residents. One resident’s Lidocaine patch was omitted when it was due, and another resident received six scheduled meds late, with the MAR showing an earlier administration time than when the LPN was actually observed giving them. The DON stated medication times had been adjusted for some residents and that nurses should follow the rights of medication administration.
Surveyors found incomplete MAR and TAR documentation for two residents, with multiple ordered meds, treatments, weekly weights, skin checks, and vital signs left unsigned or otherwise not recorded. One resident had diagnoses including PTSD, DM2, and chronic AFib, and the other had a sacral fracture, CVA, and HF with severe cognitive impairment. An LPN stated blanks generally meant the medication was not done, and the DON stated that if it was not documented, then it was not done.
Inoperable Self-Closing Device on Walk-In Freezer Door: Surveyors observed that the self-closing mechanism on the walk-in freezer’s main entry door was not working as intended and was not pulling the door closed to ensure a tight seal. The Environmental Director stated they were not aware of the issue and would address it immediately.
Persistent Odor in Hallway Near Resident Rooms
Penalty
Summary
The facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public because an unidentified unpleasant odor of varying levels was present throughout the survey. During observation on 01/22/2026 at 10:55 AM, a pungent sewer odor was noted in the hallway leading to the [NAME] Unit from the Administrator's office to the Nurse's station in front of several resident rooms. The same odor was again observed in that hallway at 1:10 PM. During interview at 1:10 PM, LPN #1 stated the odor in the hallway had been present for a while and that they were not sure where it was coming from, and they did not believe it was from any of the residents. During interview at 1:19 PM, Administrator #1 stated a resident in that hallway had a nephrostomy and that was the cause of the odor, and that it had been a persistent problem.
Failure to Timely Report Alleged Abuse and Submit Investigation Results
Penalty
Summary
The deficiency involves the facility’s failure to timely report alleged abuse incidents and to submit investigation results to the State Agency as required. Facility policy, last reviewed in January 2026, required any employee to immediately report suspected abuse, neglect, mistreatment, exploitation, or injuries of unknown origin to the Administrator and/or DON or the abuse hotline, and to report suspected crimes involving serious bodily injury, including criminal sexual abuse, immediately but no later than two hours after forming suspicion. For two residents with dementia, one with moderate cognitive impairment and one with severe cognitive impairment, an unwitnessed resident-to-resident altercation occurred at 6:15 PM and resulted in a small cut on one resident’s nose, possibly from being struck with a broken table by the other resident. This incident, which constituted resident-to-resident abuse, was not reported to the New York State Department of Health until the following afternoon at 3:53 PM, and the investigative report was not submitted until eleven days after the incident, exceeding the two-hour reporting requirement and the five-working-day timeframe for submission of investigation results. The facility also failed to report two separate allegations of staff-to-resident physical abuse to the State Agency. In one case, a resident with anxiety disorder, dementia, and severely impaired cognition for daily decision-making reportedly told a family member that an aide had hit them; a progress note documented that the DON was called for direction and the Administrator and Social Worker were emailed, and an internal investigation form recorded that the resident reported an aide was mean and struck them in the stomach, with abuse ultimately ruled out. In another case, a resident with dementia, aortic stenosis, and congestive heart failure, but intact cognition for daily decisions, reported that a nurse hit them; a facility investigative report documented that the investigation was completed with no evidence of abuse found. For both of these staff-to-resident abuse allegations, review of the iQIES system showed no submissions related to the incidents, indicating they were not reported to the New York State Department of Health. During interview, the Administrator stated that the previous DON had been responsible for submitting abuse reports, and acknowledged they were not aware that all allegations had to be reported within two hours even if unfounded, or that the complete investigation had to be submitted within five days of the allegation.
Medication administration errors exceeded the acceptable rate
Penalty
Summary
The facility did not ensure that its medication error rate remained below 5%, and the survey identified a 32.0% medication error rate during 25 medication observations involving four residents. The facility policy stated medications were to be administered accurately, safely, and in accordance with physician orders and professional standards of practice. The residents involved had diagnoses including anxiety, depression, morbid obesity, alcoholic cirrhosis of the liver, type 2 diabetes mellitus, gait abnormality, chronic kidney disease, intervertebral disc disorder, cerebral infarction sequelae, hemiplegia, and generalized muscle weakness; several were documented as usually able to understand and be understood, and one had moderate cognitive impairment. During observation, an LPN administered Humalog insulin to one resident without first checking the vial expiration date and was unaware of shortened expiration dates after opening insulin vials. The LPN only checked the vial after being asked by the surveyor and then discarded it when prompted. For another resident, the 8:00 AM Lidocaine 4% patch dose was not given because the medication was not available, and the LPN stated the physician or DON had not been notified while waiting for the medication. For a third resident, the LPN handed the resident an Insulin Aspart FlexPen and instructed the resident to self-administer 12 units even though there was no physician order for self-administration. For the fourth resident, an LPN stated that several medications due at 8:00 AM had been administered, but the MAR documented them as given at 7:00 AM and signed as given at 8:07 AM, while the surveyor observed the medications actually being administered at 9:20 AM. The LPN stated there must have been a change in the order to give the medications at 7:00 AM, but the MAR reflected the earlier time and the observed administration did not match the documented time. The DON stated residents who self-administer medications must have a physician order, an interdisciplinary assessment, and a care plan update, but no documentation could be located for the resident who was allowed to self-administer.
Unassessed Self-Administration of Insulin
Penalty
Summary
The facility did not ensure that Resident #49 was assessed by the interdisciplinary team to determine whether the resident could safely self-administer medications when clinically appropriate. Resident #49 was admitted with alcoholic cirrhosis of the liver, type 2 diabetes mellitus, and gait abnormality. The MDS dated 07/21/2025 documented that the resident usually could understand and was understood by others with intact cognition. However, the comprehensive care plan last revised 10/17/2025 did not include a focus, goal, or intervention for self-administration of medication, and there was no documented physician order authorizing self-administration or assessment by the interdisciplinary team. The MAR and physician orders documented insulin aspart FlexPen 12 units subcutaneously before meals for diabetes. During an observation on 1/20/2026 at 11:30 AM, an LPN entered the resident’s room, handed the resident the insulin pen, and told the resident to administer 12 units. The LPN provided wrong instructions when the resident looked to them for directions. During an interview later that day, the DON stated the resident was self-administering medications in preparation for discharge home and that the resident should have had a multidisciplinary assessment, a physician order to self-administer, and an updated care plan, but the DON was unable to locate documentation of any of those items.
Failure to Monitor Tube Feeding and Obtain Provider Direction for Medication Administration
Penalty
Summary
The facility did not ensure that residents received treatment and care in accordance with professional standards of practice for two residents. One resident had diagnoses including acute respiratory failure, type 2 diabetes, and COPD, was moderately cognitively impaired, and had a care plan and physician order for continuous G-tube feeding at 40 cc per hour. During an observation, the resident’s tube feed pump was found stopped with an error message and alarm sounding for more than 10 minutes, and after the call light was activated there was no response for another 10 minutes until a surveyor located staff and alerted them that the pump needed attention. Another resident had diagnoses including Wernicke’s encephalopathy, dementia, and adult failure to thrive, with severe cognitive impairment and poor appetite. Nursing documentation showed the resident had refused food, had a MOLST changed to DNR/DNI and comfort care, and later had ongoing poor intake with fluids encouraged. On a later date, an LPN documented that the resident started gagging when medications were placed in the mouth, spit them out, and then the LPN crushed the medications and reattempted administration, after which the resident gagged and brought them back up. There was no documented evidence that the LPN received instruction from the medical provider to crush the medications, and there was no documented evidence that the medical provider was informed of the resident’s gagging or swallowing difficulty at that time. Interviews with the NP and DON indicated that the facility’s usual process was to contact the medical provider when a medication was not administered, refused, or when a resident gagged or had difficulty swallowing pills, and that the provider would determine how to proceed.
Medication Administration Errors
Penalty
Summary
The facility did not ensure that residents were free from significant medication errors for two residents reviewed. Resident #36, who was admitted with anxiety, depression, and morbid obesity and was documented as usually able to understand and be understood with intact cognition, had an order for Lidocaine 4% patch due at 8:00 AM on 1/20/2026 that was omitted. During observation of the MAR at 11:20 AM, the 8:00 AM dose was highlighted as not given. An LPN stated the medication was not administered because it was not available, that pharmacy had been called the previous day, and that the physician or DON had not been notified because staff were waiting for the medication. Resident #62, who was admitted with unspecified sequelae of cerebral infarction, left-sided hemiplegia and hemiparesis, and generalized muscle weakness, had an order for six medications due at 7:00 AM on 1/21/2026. The MAR documented the medications as given at 8:07 AM by an LPN, but the nurse was observed administering the medications at 9:20 AM. During interview, the LPN stated the resident used to receive medications at 8:00 AM and believed there had been a change to 7:00 AM. The DON stated some residents’ medication times were changed to 7:00 AM and some to 8:00 AM to even out the medication pass, and that the nurse should follow policy and check the right patient, right medication, right time, right dose, and right route.
Incomplete MAR and TAR Documentation for Two Residents
Penalty
Summary
The facility did not maintain medical records in accordance with accepted professional standards and practices because medication and treatment records for two residents were not accurately documented or completed. During the recertification survey, surveyors reviewed the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for 22 residents and found missing documentation for Resident #7 and Resident #12. The missing entries included multiple medications, weekly weights, skin checks, vital signs, and topical treatments that were ordered but not documented as administered or completed. Resident #7 was admitted with diagnoses including post-traumatic stress disorder, type 2 diabetes, and chronic atrial fibrillation. The resident’s MDS dated 12/27/2025 documented that the resident was cognitively intact and could be understood and understand others. The January 2026 MAR showed numerous medications without documentation of administration, including acetaminophen, finasteride, furosemide, insulin glargine, metformin, metoprolol succinate, omeprazole, potassium chloride, Pro-Stat, sertraline, spironolactone, Stiolto Respimat, trazodone, apixaban, buspirone, ferrous sulfate, Lac-Hydrin lotion, Mucinex, Pataday, Restasis, vitamin C, Novolog, and pen needles. The TAR also lacked documentation for weekly skin checks, Eucerin lotion, and muscle rub on multiple shifts and dates. Resident #12 was admitted with diagnoses including an unspecified sacral fracture, cerebral infarction, and heart failure. The resident’s MDS documented that the resident could be understood, could understand others, and was severely cognitively impaired. The January 2026 MAR showed missing documentation for aspirin, latanoprost, metoprolol, valsartan, and Tylenol Extra Strength. The TAR also lacked documentation for weekly vital signs and a weekly skin check. During interviews, an LPN stated that blanks or missing documentation on the MAR meant the medication was not passed or was passed but not signed for, and that it generally meant it was not done. The DON stated that if it was not documented, then it was not done, and that staff should document when medications were not given or refused. A prior medication error/omission report for the same LPN documented a transcription error in which morphine sulfate was dispensed on three occasions and not signed off in the MAR.
Inoperable Self-Closing Device on Walk-In Freezer Door
Penalty
Summary
The facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition because the self-closing device on the walk-in freezer was not functioning properly as intended. During observation of the walk-in freezer, surveyors found that the self-closing mechanism on the main entry door was inoperable and was not pulling the door closed to ensure a tight seal. During an interview, the Environmental Director stated that they were not aware the device was not functioning properly and would address the issue immediately.
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 72 citations issued within 25 miles in the last 12 months — 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 Palatine Bridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Johnsville Rehabilitation And Nursing Center | 8 mi | ★★★★★ | 26 | 0 |
| Wells Nursing Home Inc | 11.3 mi | ★★★★★ | 1 | 0 |
| Fulton Center For Rehabilitation And Healthcare | 14.5 mi | ★★★★★ | 1 | 0 |
| Nathan Littauer Hospital Nursing Home | 15.8 mi | ★★★★★ | 0 | 0 |
| Alpine Rehabilitation And Nursing Center | 17 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Palatine Nursing Home.
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.