Above 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 Pine Haven Home during CMS and state inspections, most recent first.
The facility did not maintain exits according to NFPA 101 standards, as exit discharges from certain nursing units were not marked to clearly indicate the direction of egress to a public way. This was observed during a recertification survey, and the Facilities Manager acknowledged the issue.
The facility's emergency preparedness plan was found lacking during a survey, as it did not document the resident populations at risk during emergencies or the services in place to address their vulnerabilities. This deficiency was identified through a record review, and the administrator acknowledged the absence of necessary documentation.
The facility's Emergency Plan, Training Program was found deficient as it did not include training or a demonstration of knowledge for responding to the most likely hazards, such as snowfall, epidemic/pandemic, and workplace violence. This was confirmed by the administrator during a survey interview.
The facility failed to maintain its fire alarm system according to NFPA 72 standards, with a trouble signal on the fire panel unaddressed and 27 smoke detectors failing sensitivity tests without re-testing. Smoke detectors were also improperly installed near ventilation ducts in various areas, violating code requirements.
The facility failed to provide emergency lighting in compliance with NFPA 101 Life Safety Code, 2012 Edition, in both Building #1 and Building #2. Observations revealed missing emergency lighting along paths of exit discharge and in various rooms, including the Physical Therapy Room and Resident Lounges. The Facilities Manager acknowledged the deficiency.
The facility's emergency preparedness plan was found lacking during a survey, as it did not include strategies for cyber-attacks, care-related emergencies, and the use of portable generators. Additionally, the plan for Pandemic/Emerging Infectious Disease had not been updated within the past year, potentially affecting all residents.
The facility was cited for failing to store food according to professional standards, as observed during a survey. Unlabeled tomato juice was found in the refrigerator, and an opened, unlabeled cranberry juice bottle was in dry storage. The Kitchen Director and Regional Food Director acknowledged the oversight, attributing it to a new employee. This deficiency violated the facility's food safety policy.
The facility failed to meet the required nursing care hours per resident day, as set by CMS, between March 23 and March 31, 2025. With an average daily census of 110, the facility's staffing levels were consistently below the required minimum, particularly in Certified Nurse Aides and Licensed Nurses. Despite efforts to recruit and retain staff, the facility struggled to maintain adequate staffing due to its remote location, leading to significant shortages in care hours on multiple days.
A stairwell door in Building #1 was found propped open with a tool, preventing it from self-closing as required by NFPA 101, Life Safety Code 2012 edition. The Facilities Manager acknowledged the issue during an interview.
The facility did not adhere to the required schedule for elevator inspection and testing in Building #1, lacking documentation for a 2024 test and a February 2025 inspection. Additionally, repairs and installations noted in a November 2023 report were not documented as completed. The Facilities Manager acknowledged the oversight.
The facility's Emergency Preparedness Program was found deficient as it lacked contact information for physicians, federal emergency preparedness officials, and the Office of the Long-Term Care Ombudsman. This issue was identified during a recertification survey and confirmed in an interview with the administrator.
During a recertification survey, the facility was found to have deficiencies in marking doors that could be confused as exits in accordance with NFPA 101, 2012 Edition. In Building #1, several doors leading to courtyards were not marked with 'No Exit' signs, and an emergency exit fence door was incorrectly marked. Similarly, in Building #2, the core area and Resident Lounge doors to the courtyard lacked the required signage. The Facilities Director acknowledged the issue during an interview.
A recertification survey revealed that the means of egress in Building #1 was not maintained as required. The smoke barrier door in the core area/West Unit did not close and latch properly, and door S4 had failed inspections in previous years without documented repairs. This violates the NFPA 80 Standard for Fire Doors and Other Opening Protectives.
A resident with moderate cognitive impairment suffered a first-degree burn after a nurse failed to check the temperature of reheated tea, as required by facility policy. The tea was placed on the bedside table, and the resident spilled it, resulting in a surface burn. The nurse admitted to the oversight, and the incident was documented by the facility.
A resident reported verbal abuse by a CNA, which was not communicated to administration until the following day and not reported to the state until two days later. The facility's policy requires immediate reporting of abuse allegations. The resident, with no cognitive impairment, felt intimidated by the CNA's behavior, which was witnessed by another CNA. The delay in reporting was due to the witness's perception of the behavior and the Administrator's initial lack of clarity on reporting responsibilities.
The facility did not maintain the kitchen fire extinguishing system as required by NFPA standards. Observations revealed that 4 out of 6 caps for the discharge nozzles of the kitchen fire suppression system were missing. The Facilities Manager acknowledged the issue and planned to discuss inspection criteria with staff.
The facility failed to provide documented education on the risks and benefits of the pneumococcal vaccine to two CNAs, as required by the Infection Control Program. This deficiency was confirmed by the Infection Control Coordinator, who admitted the lack of records for the necessary education.
The facility's emergency preparedness plan was found lacking provisions for nuclear accidents, mass casualty reception, and chemical spills, as required by New York State regulations. This deficiency was identified during a recertification survey, with no documented evidence of these provisions in the plan.
Facility Fails to Mark Exit Discharges Clearly
Penalty
Summary
The facility failed to maintain exits in accordance with the National Fire Protection Association (NFPA) 101, 2012 Edition, Sections 19.2.7 and 7.7, as observed during a recertification survey. Specifically, the exit discharges from the north and west nursing units in Building #1, and the south nursing unit in Building #2, were not marked to clearly indicate the direction of egress travel from the exit discharge to a public way. This deficiency was identified during observations conducted on March 31, 2025, at 11:00 AM. During an interview later that day at 2:21 PM, the Facilities Manager acknowledged the issue and stated that they would mark the exit discharges to clarify the direction to the public way.
Emergency Preparedness Documentation Deficiency
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the emergency plan lacked documentation regarding the resident populations at risk during an emergency event and the services in place to address their unique vulnerabilities. This deficiency was identified through a record review, which revealed no documented evidence of a description of the resident populations at risk or the services provided to address their vulnerabilities. During an interview, the facility's administrator acknowledged the absence of this documentation and indicated an intention to address the issue.
Emergency Preparedness Training Deficiency
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a Standard Life Safety Code Survey. The deficiency was identified in the Emergency Plan, Training Program, which lacked a demonstration of knowledge for responding to the most likely hazards as identified by the facility's risk assessment. Specifically, there was no documented evidence that the training program included training for and a demonstration of knowledge of emergency responses for snowfall, epidemic/pandemic, and workplace violence. This deficiency was confirmed during an interview with the facility's administrator, who acknowledged the omission and stated that these hazards were indeed the most likely to affect the facility.
Fire Alarm System Deficiencies
Penalty
Summary
The facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72 National Fire Alarm Code 2010 edition, resulting in multiple deficiencies. During the recertification survey, it was observed that a trouble signal was activated on the fire alarm panel in both Building #1 and Building #2, indicating a malfunction that had not been corrected. Interviews with the Director of Building Services and the Facilities Manager revealed that they were unaware of the trouble signal and had not taken steps to address it. Additionally, a review of the Fire Alarm Inspection Report from May 2024 showed that 27 out of 139 smoke detectors had failed the sensitivity inspection, with no documented evidence of re-testing. Further observations revealed that smoke detectors were improperly installed within 3 feet of ventilation ducts in several areas of both buildings, including resident rooms, corridors, and common areas. This installation did not comply with the NFPA 72 code requirements. The Facilities Manager acknowledged the improper placement of smoke detectors and indicated that they would contact their vendor to address the issue. However, at the time of the survey, these deficiencies remained uncorrected, demonstrating a lack of compliance with fire safety regulations.
Deficiency in Emergency Lighting Compliance
Penalty
Summary
The facility failed to provide emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8, during a recertification survey. Observations revealed that emergency lighting was missing along the path of exit discharge from the physical therapy room, and two fixtures were missing above the exit discharge door in Building #1. Additionally, emergency lighting was absent along the path of exit discharge from the North Unit and West Unit. Further observations indicated that emergency lighting, which should operate automatically without manual intervention, was not provided in the Physical Therapy Room, North Unit Resident Lounge, Activities Room, and West Unit Resident Lounge. Similarly, in Building #2, the facility did not provide the required emergency lighting along the means of egress to the public way. Observations showed that emergency lighting was missing along the path of exit discharge from the physical therapy room, and two fixtures were absent above the exit discharge door. Emergency lighting was also missing from the North Unit and West Unit. Additionally, emergency lighting that would operate automatically without manual intervention was not provided in the Resident Lounge and Personal Care Area (shower). During an interview, the Facilities Manager acknowledged the absence of emergency lighting and stated that they would add it.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the facility's emergency preparedness plan lacked documented strategies for addressing certain emergency events identified by the risk assessment. These missing strategies included provisions for cyber-attacks, care-related emergencies, and the use of portable generators. Additionally, the plan for Pandemic/Emerging Infectious Disease had not been updated within the past year. This deficiency was identified through interviews and record reviews, and it was noted that the absence of these strategies could potentially affect all residents at the facility.
Unlabeled Food Storage Deficiency
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. During an initial tour of the kitchen, a pitcher containing red liquid, identified as tomato juice, was found unlabeled in the dessert refrigerator. The Kitchen Director acknowledged that the pitcher should have been labeled with the date it was opened. Additionally, an opened, unlabeled bottle of Ocean Spray Cranberry Juice was discovered in the dry storage area. The Regional Food Director attributed this oversight to a new employee who had left the facility shortly before the survey team arrived. The facility's policy, titled 'Food from Home,' mandates safe and sanitary storage, handling, and consumption of all foods, including those brought by family and visitors. It also requires all food service workers to adhere to food safety requirements, including labeling and dating food items when opened. Interviews with the Kitchen Director and Regional Food Director confirmed that the unlabeled items were not in compliance with the facility's policy. The deficiency was cited under 10 New York Codes of Rules and Regulations 415.14(h).
Plan Of Correction
Plan of Correction: Approved April 25, 2025 No residents were affected by this deficient practice. The pitcher containing red liquid was immediately removed at the time of survey by the Food Service Director and discarded. The opened, unlabeled bottle of Ocean Spray Cranberry juice was removed at the time of survey by the Regional Food Service Director and discarded. All residents have the potential to be affected by this deficient practice. A facility wide inspection of all food storage areas, including unit nourishment kitchens and food storage areas was conducted to identify any other unlabeled or incorrectly stored food items. The policy for personal food in the work area was reviewed with no modifications needed. The Dietary staff were re-educated on the appropriate labeling and storage of food items as well as the policy on personal food in the work area. An audit tool was created for the Director of Food Service or designee to monitor the storage of food through a weekly inspection of food storage areas observing for proper food storage and to verify that there are no personal food items in the work area. Results of these weekly audits will be shared monthly with the Quality Assurance Performance Improvement committee who will determine the need for monitoring and reporting until compliance is achieved. Any deficient practice identified will be addressed with staff re-education and/or formal disciplinary action. The Food Service Director is responsible for this plan of correction.
Staffing Shortages Lead to Deficiency in Resident Care Hours
Penalty
Summary
The facility was found to have insufficient nursing staff to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Between March 23, 2025, and March 31, 2025, the facility failed to meet the minimum hours of nursing care per resident day as established by the Centers for Medicare and Medicaid Services (CMS). The facility's average daily census was 110, and the documented nursing levels equaled 3.07 hours per patient day, which was below the required 3.5 hours per day per resident. The staffing levels were consistently below the required minimum, with significant shortages in Certified Nurse Aides (CNAs) and Licensed Nurses on multiple days. The facility's staffing plan indicated efforts to maintain adequate staffing levels, but the actual staffing sheets from March 23 to March 31, 2025, showed that the facility was short of the required staffing hours on eight out of nine days. For instance, on March 23, 2025, with a census of 115 residents, the facility was short by 66.5 hours of staffing care, and on March 29, 2025, with a census of 115, the facility was short by 82.5 hours. The facility attempted to mitigate these shortages by having Licensed Practical Nurses (LPNs) work as CNAs and adopting a team approach to resident care. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility struggled to hire CNAs, attributing the difficulty to its remote location. The facility employed various strategies to recruit and retain staff, including working with recruiters, offering incentives, and providing flexible schedules. Despite these efforts, the facility continued to experience staffing shortages, impacting its ability to meet the CMS guidelines for resident care hours.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 There was no identified negative effect specified for any individual resident resulting from this deficient practice. The facility assessment has been updated to read: "The facility works diligently to maintain staffing levels for all departments that will allow for the delivery of optimal resident centered care. Staffing levels for the nursing department specifically will be based on the in-house resident acuity and clinical care needs. The Director of Nursing or Designee uses the quality measures and other clinical indicators; including but not limited to the number of medications, treatments, and/or behaviors of residents, to evaluate the resident acuity on a weekly basis." The in-house census along with resident acuity and care needs were reviewed by the Director of Nursing and compared to the staffing levels currently being scheduled. The scheduled staffing levels for the week ending (MONTH) 19, 2025 were determined to be in accordance with the staffing levels outlined in the facility assessment. All residents have the potential to be affected by this deficient practice. All resident and/or family concerns regarding staffing are addressed directly by the Administrator or Director of Nursing. The nurse unit managers and/or shift supervisors conduct unit rounds at a minimum of 3x/shift observing each patient to ensure that resident needs are met and care is being delivered according to their care plans. On a daily basis, the Director of Nursing or designee will monitor compliance with medication administration records, treatment administration records, 24-hour report and Certified Nursing Assistant's care documentation to verify that all care was delivered as scheduled. In addition, all quality measures are monitored on a weekly basis and used to identify any care deficit that may relate to inadequate staffing. Any identified care deficit is addressed with re-education of the caregiver and/or formal disciplinary action. The facility assessment was reviewed and updated to read: "The facility works diligently to maintain staffing levels for all departments that will allow for the delivery of optimal resident centered care. Staffing levels for the nursing department specifically will be based on the in-house resident acuity and clinical care needs. The Director of Nursing or Designee uses the quality measures and other clinical indicators; including but not limited to the number of medications, treatments, and/or behaviors of residents, to evaluate the resident acuity on a weekly basis." Unit Managers/Registered Nurse Supervisors were educated on the need to report insufficient staffing on their units to the Director of Nursing or Staffing Coordinator. The Staffing Coordinator was educated to report insufficient staffing to the Director of Nursing/Designee and Administrator. Additional recruitment efforts such as holding an open house for hiring, increased online job postings, in-house referral incentives were initiated to ensure sufficient staffing for all shifts. Orientation for new hires is scheduled every week (or more as needed) to increase the staffing level. A contingency staffing plan was developed to ensure coverage for any call outs and emergency staffing shortages; including incentive bonuses for staff to work additional shifts, and the use of additional nursing staffing agencies. The facility developed a weekly staffing audit tool to ensure that each shift meets the minimal required staffing levels, tracking the number of actual hours per day of nursing staff compared to the staffing levels outlined in the facility assessment. The Director of Nursing/Designee and Staffing Coordinator will review the audit weekly to ensure compliance with staffing levels. The Director of Nursing/Designee will conduct weekly staffing audits for compliance weekly for four weeks. The results of these audits will be reported to the Quality Assurance Performance Improvement committee monthly, who will determine the need for monitoring and reporting until compliance is achieved. Any trends or patterns of non-compliance will be identified, and additional training or corrective measures will be implemented as necessary. The Director of Nursing or Designee is responsible for this plan of correction.
Stairwell Door Non-Compliance with NFPA 101
Penalty
Summary
During a recertification survey, it was observed that a stairwell door in Building #1 was not compliant with the National Fire Protection Association (NFPA) 101, Life Safety Code 2012 edition. Specifically, the door was kept open using a tool inserted into the space between the door and frame, preventing it from self-closing and seating properly to the door frame as required by sections 19.2.2.2.7 and 7.2.1.8.2 of the code. This deficiency was noted during an observation at 10:36 AM, and later confirmed during an interview with the Facilities Manager, who acknowledged the issue and mentioned discussing it with the staff.
Elevator Inspection and Testing Deficiency
Penalty
Summary
The facility failed to comply with the required inspection and testing schedule for the elevator in Building #1, as mandated by the American Society of Mechanical Engineers booklet A17-1 Safety Code for Elevators and Escalators 2004 Edition Section 8.11.1.3 and Table N-1. Specifically, there was no documented evidence that the elevator was tested during 2024, nor was it inspected in February 2025, which was six months after the previous inspection in August 2024. Additionally, the report from November 2023 indicated that necessary repairs and installations, such as the hoist way door guide repair, provision of back-up power for the emergency bell, and installation of a fire extinguisher with a passing annual test in the machine room, were not documented as completed. During an interview, the Facilities Manager acknowledged the oversight and mentioned plans to contact the vendor for scheduling and documentation.
Emergency Preparedness Deficiency Due to Missing Contact Information
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the deficiency was identified in the facility's Emergency Preparedness Program, where the Communications Program lacked documented contact information for physicians, federal emergency preparedness officials, and the Office of the Long-Term Care Ombudsman. This oversight could potentially affect all residents at the facility. The deficiency was confirmed during an interview with the administrator, who acknowledged the absence of the required contact information in the emergency plan.
Deficiencies in Egress Signage
Penalty
Summary
The facility was found to have deficiencies in identifying all means of egress in accordance with the National Fire Protection Association (NFPA) 101, 2012 Edition, Section 19.2.10.1, during a recertification survey. Specifically, in Building #1, several doors that could be confused as exits were not properly marked with 'No Exit' signs. These included the dining room door to the courtyard, the North Unit Resident Lounge door to the courtyard, and the West Unit Resident Lounge door to the courtyard. Additionally, an outdoor emergency exit fence door from the main courtyard door from the North Wing was incorrectly marked with a sign that read 'Not an Exit.' These observations were made on March 31, 2025, at 11:31 AM. Similarly, in Building #2, the facility failed to mark doors that could be confused as exits with the required 'No Exit' verbiage. The core area door to the courtyard and the Resident Lounge door to the courtyard were not marked appropriately. These deficiencies were also observed on March 31, 2025, at 11:31 AM. During an interview conducted later that day at 2:37 PM, the Facilities Director acknowledged the issue and indicated that corrective actions would be taken. The deficiencies were cited under 42 Code of Federal Regulations 483.70(a)(1) and the relevant sections of the New York Codes, Rules, and Regulations.
Failure to Maintain Fire Door Assemblies
Penalty
Summary
During a recertification survey, it was found that the means of egress in Building #1 was not maintained according to the required standards. Specifically, the smoke barrier door in the core area/West Unit failed to close and latch properly. This issue was observed during an inspection, and it was noted that door S4 had failed inspections in 2022, 2023, and 2024, with no documented evidence of repairs being made. The failure to address these defects in the fire door assemblies is a violation of the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition section 5.1.5.
Failure to Check Beverage Temperature Leads to Resident Burn
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards, resulting in a first-degree burn to a resident. Specifically, a nurse reheated a resident's tea in the microwave and placed it on the bedside table without checking the temperature, as required by the facility's policy. The policy, last revised in July 2024, mandates that reheated food or beverages should not exceed 140 degrees Fahrenheit before serving. The resident, who had moderate cognitive impairment, spilled the hot tea on their chest, causing a surface burn. The incident was documented in an Incident/Accident Report, and a Nurse Practitioner noted the thermal burn resulting from the hot liquid. The resident recalled the incident as minor, despite the burn. The Director of Nursing confirmed that the responsible nurse admitted to forgetting to check the temperature and expressed remorse. The nurse was described as an excellent employee with no prior issues.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, or no later than two hours after the allegation was made. Specifically, a resident reported an incident of verbal abuse by a Certified Nurse Aide (CNA) to another CNA on February 5, 2023. However, this allegation was not communicated to the facility administration until February 6, 2023, and was not reported to the New York State Department of Health until February 8, 2023. The facility's policy mandates that any knowledge or suspicion of abuse should be reported immediately to the Shift Supervisor/Charge Nurse/Manager, who would then notify the Administrator and Director of Nursing, and subsequently report to the designated State agency within two hours. The resident involved was admitted with unspecified diagnoses and was assessed to have no cognitive impairment, being able to understand and communicate effectively. The facility's investigation revealed that the resident felt intimidated when CNA #3 yelled at them, an incident witnessed by CNA #4. Although the accused CNA did not intend to upset the resident, their approach was inappropriate as per the resident's care plan. The failure to report the incident promptly was partly due to CNA #4's perception that the accused's behavior was not abusive, as they were typically loud and gruff. Additionally, the Administrator, who was new to the position, acknowledged a lack of clarity regarding their reporting responsibilities at the time of the incident.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 Resident #115 was discharged from the facility on (MONTH) 24, 2023. Certified Nursing Aides #3 and #4 are no longer employed at the facility. All residents have the potential to be affected by this deficient practice. All staff will be re-educated on their obligation to report all instances of actual or perceived abuse immediately to the supervisor and/or administrator in order to initiate investigation and allow for reporting within two hours to the appropriate state agencies. The Abuse – Prevention and Management Policy was reviewed with no changes or modifications determined to be necessary at this time. An Incident/Event Report Checklist is currently being completed for each incident by the Administrator to ensure that any incident involving an allegation of abuse is reported within the two-hour timeframe to the appropriate individual and state agencies. A weekly audit of Incident/Event Report Checklists completed for the applicable week will be done by the Administrator or designee in order to verify that all incidents involving an allegation of abuse were reported timely and to the appropriate individual and state agencies. Results of the weekly audit will be reported to the Quality Assurance Performance Improvement committee monthly and will continue in frequency based on the determination of the committee. At a minimum, monthly audits will continue until compliance is maintained for a period of 3 consecutive months. Any identified non-compliance will be addressed through staff re-education and/or formal disciplinary action. The Administrator or Designee is responsible for this plan of correction.
Kitchen Fire Suppression System Deficiency
Penalty
Summary
The facility failed to maintain the kitchen fire extinguishing system in accordance with the National Fire Protection Association (NFPA) 17A Standard for Wet Chemical Extinguishing Systems 2009 edition section 7.2. During observations, it was noted that 4 out of 6 caps for covering the discharge nozzles servicing the kitchen fire suppression system were not in place. This deficiency was identified during a recertification survey. The Facilities Manager acknowledged the issue and mentioned discussing the criteria for the monthly quick check owners inspection of the kitchen fire suppression system with their staff, which includes ensuring that the nozzle caps are in place.
Inadequate Staff Education on Pneumococcal Vaccine
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of education provided to staff on the risks and benefits of the pneumococcal vaccine. During the recertification survey, it was found that two Certified Nursing Aides (CNAs) did not receive documented education on the pneumococcal vaccine within the past year. This deficiency was confirmed during an interview with the Infection Control Coordinator, who acknowledged the absence of records indicating that the required education was provided to the CNAs.
Plan Of Correction
Plan of Correction: Approved April 28, 2025 No residents were affected by this deficient practice. No residents have the potential to be affected by the deficient practice. The pneumococcal vaccination consent form has been updated to include a signature and date line under the options to accept or decline the vaccination beginning 4/2/25. This is attached to the Center for Disease Control's Vaccination Information Sheet for the pneumococcal vaccination. This form will be given to all staff upon hire and with each vaccination eligibility. The existing pneumococcal spreadsheet tracks all employees, vaccination education, signatures, and dates for record compliance effective 4/2/25. This worksheet will be audited monthly, and results of these audits will be shared with the Quality Assurance Performance Improvement committee who will determine the need for monitoring and reporting until compliance is achieved. Any identified deficient practice will be addressed through staff re-education and/or formal disciplinary action. The Infection Control Nurse is responsible for this plan of correction.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found to be non-compliant with Disaster and Emergency Preparedness requirements during a recertification survey. Specifically, the facility's emergency preparedness plan lacked provisions for nuclear accidents, reception of mass casualty victims, and chemical spills, as mandated by New York State regulations. This deficiency was identified through interviews, where it was revealed that there was no documented evidence of these provisions being included in the emergency preparedness plan. During an interview, the administrator acknowledged the absence of these critical components in the plan.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 No residents were affected by this deficient practice. All residents have the potential to be affected by this deficient practice. All staff will be educated on the provisions for nuclear accident, reception of mass casualty victims, and chemical spills. The Emergency Plan will be updated to include provisions for nuclear accident, reception of mass casualty victims, and chemical spill. On a quarterly basis, the facility Emergency Plan will be reviewed by the Quality Assurance Performance Improvement committee to ensure all appropriate policies and provisions are included. The Administrator or Designee is responsible for this plan of correction.
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 71 citations issued within 25 miles in the last 12 months — including the 1 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 Philmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ghent Rehabilitation & Nursing Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Livingston Hills Nursing And Rehabilitation Center | 9.9 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Barnwell | 11.7 mi | ★★★★★ | 6 | 0 |
| The Pines At Catskill Center For Nursing & Rehab | 11.8 mi | ★★★★★ | 0 | 0 |
| Greene Meadows Nursing And Rehabilitation Center | 11.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.