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 Sans Souci Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with impaired cognition and mobility requested pain medication from an LPN, who became upset and physically attempted to force the resident back into their room by holding their hands and shoulders, despite the resident's resistance. Multiple staff and family interviews confirmed the LPN refused to provide the requested medication and used physical force, resulting in a failure to protect the resident from abuse and neglect.
A facility failed to thoroughly investigate an alleged abuse incident involving an LPN and a resident with impaired cognition and mobility. The internal investigation did not document a review of available video surveillance footage or an interview with a roommate who witnessed the event, despite facility policy requiring comprehensive evidence review and witness interviews.
A resident with recent knee surgery and cognitive impairment did not receive prescribed pain medication in a timely manner after requesting it from an LPN. The LPN, who was behind on medication administration, did not assess the resident for pain or provide the medication as ordered, resulting in a significant delay. Interviews with staff and family confirmed the delay and lack of assessment, in violation of facility policy and physician orders.
Two residents did not consistently receive or have documented ADL care, including incontinence care, showers, personal hygiene, and meal assistance, as required by their care plans. Additionally, a notable number of residents were observed dressed in hospital gowns rather than regular clothing, without clear documentation of preference or care planning. Staff interviews revealed inconsistent practices and understanding regarding documentation of care provided.
The facility did not consistently provide enough nursing staff to meet resident needs as outlined in its Facility Assessment, with multiple shifts on the 2nd floor falling below required nurse and CNA levels. Staffing records showed several occasions where only one nurse or fewer CNAs than required were present, and some shifts had no nurse or only one CNA scheduled. Leadership interviews confirmed awareness of staffing shortages and described efforts to fill gaps, but deficiencies persisted.
A nursing shift on one unit was left uncovered, resulting in 36 residents not receiving scheduled medications, including critical drugs such as antihypertensives, insulin, anticoagulants, and antipsychotics. The absence of a nurse was not reported to facility leadership, and the missed medications were only discovered after the fact. Residents affected had complex conditions including diabetes, hypertension, and heart failure.
A resident with severe cognitive impairment and a history of pressure ulcers did not consistently receive turning and repositioning as ordered by the wound care physician and outlined in the care plan. Documentation showed multiple missed instances of this essential care, and staff interviews revealed that the electronic system only allowed shift-based, not interval-based, documentation. This resulted in the resident not receiving care in accordance with professional standards and physician instructions.
A resident with severe cognitive impairment and malnutrition experienced a significant unplanned weight loss due to inconsistent documentation of meal intake and lack of timely communication to nursing and administration about poor intake, despite facility policies requiring monitoring and reporting of nutritional status.
The facility did not submit required 5-day investigative conclusion reports to the Department of Health within the mandated timeframe following incidents involving suspected abuse and a resident elopement. In each case, either the report was delayed or there was no documentation of submission, despite staff and leadership being aware of the reporting requirements.
The facility did not thoroughly investigate multiple allegations of abuse and financial exploitation, as required by policy. In several cases, written statements were not obtained from all staff assigned to the relevant units, investigative summaries were incomplete or unsigned, and not all involved staff were interviewed. These deficiencies affected the investigation of incidents involving inappropriate touching, physical altercations, and missing property among residents.
A resident with a history of behavioral issues struck another cognitively impaired resident on the head with a therapy device after the latter entered their room by mistake. The incident was witnessed by a CNA, and although staff intervened quickly and no injury was found, the event revealed a lapse in supervision and failure to protect a resident from physical abuse.
A resident with dementia and a documented history of wandering was not identified as an elopement risk during admission assessment, despite hospital records indicating such behaviors. The resident was assigned a low elopement risk score, placed in a first-floor room without a wander guard, and later exited the facility unescorted after being buzzed out by the receptionist. Staff interviews revealed that the resident's history of wandering was not recognized during the admission process, resulting in the omission of necessary safety precautions.
A deficiency occurred when a resident with dementia and a documented history of wandering was admitted without a care plan addressing wandering or elopement risk. Although the resident's hospital and family records noted prior wandering, the facility's care plans only addressed cognitive impairment and forgetfulness, omitting interventions for wandering or elopement. The DON stated that no wandering was observed during assessment and that hospital documentation did not indicate wandering, resulting in the lack of a targeted care plan.
A resident with severe cognitive impairment and a history of wandering exited the facility unescorted after being mistaken for a visitor by the Receptionist. The individual was not identified as an elopement risk on admission, did not have a wander guard or identification band, and was not listed on the elopement risk list at the front desk. The resident was later found by emergency services after entering a neighboring home, highlighting failures in supervision, risk assessment, and communication.
Two residents in an LTC facility did not receive adequate pain management. One resident with an amputation and neuropathy was not given pain medication as ordered, and non-medication interventions were not provided. Recommendations from a Physiatrist were not reviewed. Another resident with a shoulder replacement did not receive prescribed Oxycodone due to a failure to reorder the medication, and the emergency supply was not accessed. Staff interviews revealed lapses in communication and protocol adherence.
The facility failed to provide sufficient nursing staff on the 2nd and 3rd floors, leading to delays in resident care. The Facility Assessment did not account for the higher resident capacity on these floors, resulting in staffing levels below the required 2.2 CNA hours per resident per day. Residents reported delays in receiving care, and staff confirmed frequent call-outs and high resident assignments. Despite efforts to address staffing shortages, the facility did not meet the necessary staffing levels, impacting resident well-being.
A resident with paraplegia and frequent incontinence experienced significant delays in receiving incontinence care, despite a care plan for changes every two hours. The resident waited up to 12 hours on one occasion, leading to concerns about their frequent urinary tract infections. The DON acknowledged the issue, but there was no documentation to support consistent care.
A facility failed to ensure a physician reviewed a resident's care program at each visit. A resident with a recent amputation reported persistent pain, but the Physician Assistant did not review the Nursing Pain Evaluation or Physiatrist's recommendations. Despite recommendations for increased Gabapentin and imaging, the Physician Assistant's notes lacked reference to these and did not assess pain using a numeric scale.
A medication error rate of 8% was observed in an LTC facility, exceeding the acceptable 5% threshold. An LPN administered a crushed form of enteric-coated aspirin and Depakote delayed-release tablet to a resident, contrary to the prescribed chewable form and manufacturer's instructions. The LPN acknowledged the error, and the DON highlighted the need for compliance with medication instructions.
The facility failed to maintain proper infection control practices, specifically in hand hygiene, for two residents. A CNA touched a resident's food directly, and an LPN did not wash hands between glove changes during wound care. Both staff members acknowledged their lapses, and the DON noted the need for further education on hand hygiene.
A facility failed to offer and document pneumococcal immunization for a resident with a history of Type II Diabetes Mellitus, bilateral leg absence, and end-stage renal failure. Despite facility policy requiring vaccine status confirmation and education upon admission, the resident's records were incomplete, and the vaccine was not offered. The Infection Preventionist admitted the oversight, noting the resident had been in the facility for several months.
A resident's grievance regarding missing clothing and glasses was not promptly resolved, and the facility's grievance policy lacked necessary elements. The resident, who was severely cognitively impaired, had their designated representative report the issue multiple times without resolution. The facility's grievance policy did not specify how residents were informed of the process or their right to a written decision.
A facility failed to ensure effective discharge planning for a resident with serious mental illness, issuing a Transfer/Discharge Notice without involving the resident's representative and listing a destination lacking necessary psychiatric services. The resident, with diagnoses including schizoaffective disorder, was moderately cognitively impaired and aggressive. The facility's actions were not aligned with the resident's rights, and there was inadequate documentation and involvement in the discharge process.
A resident with severe cognitive impairment and high risk for pressure ulcers developed a Stage 2 ulcer on the sacrum. The facility failed to promptly assess and notify the physician, delaying treatment. The registered nurse was not informed of the skin opening, leading to a lapse in care consistent with professional standards.
A resident with multiple mental health diagnoses did not receive individualized behavioral health care at an LTC facility. The care plan was not updated to address evolving symptoms, and Level II Preadmission Screening recommendations were not incorporated. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, contributing to the facility's inability to manage the resident's behavioral health effectively.
A resident with severe cognitive impairment and significant weight loss did not receive a required Speech Therapy evaluation for slow eating and chewing, despite a physician's order. The evaluation was not documented, and the resident continued to experience challenges during mealtimes. Staff interviews confirmed the oversight, highlighting a deficiency in providing necessary rehabilitative services.
A resident with dementia and other medical conditions was verbally threatened and had their necklace pulled by a dietary aide, as witnessed by a CNA. The facility's investigation confirmed verbal abuse occurred. The incident was reported immediately, and the dietary aide was asked to leave the building.
A resident with severe cognitive impairment and multiple diagnoses did not receive care as per their comprehensive care plan, which included the use of a foam positioning wedge and heel booties to prevent pressure injuries. Observations showed the resident's heels were not offloaded, and staff interviews revealed a lack of awareness and communication regarding the resident's care needs.
Failure to Protect Resident from Abuse and Neglect During Medication Request
Penalty
Summary
On the evening of 08/19/2025, a resident with a history of aphasia, cerebral infarction, hemiplegia, and recent right total knee arthroplasty revision was involved in an incident with an LPN. The resident, who had moderately impaired cognition but was independent with eating, bed mobility, and wheelchair use, was observed on video surveillance seated in their wheelchair in the doorway of their room. The LPN, while at the medication cart, engaged in a verbal exchange with the resident, who was requesting pain medication. The LPN turned around, moved behind the resident's wheelchair, and attempted to hold the resident's hand down and force them back into their room, despite the resident resisting and holding onto the doorway frame. The LPN continued to attempt to pull the resident into the room by holding onto their hands and shoulders, even as the resident resisted these actions. Multiple interviews corroborated the events seen on video. The resident reported that the LPN appeared upset, refused to provide pain medication, and physically pulled their wheelchair backward while holding their arms. A family member stated the resident informed them that the LPN refused to provide pain medication and put hands on the resident without permission. Certified Nurse Aide #1 heard yelling and observed the LPN wheeling the resident backward into their room, reporting the incident to the night nurse. The LPN involved stated they were running late with medication pass and were unable to provide the pain medication, and that they became scared when the resident began yelling, leading them to attempt to bring the resident back into their room. Further, another LPN and the Director of Nursing confirmed that the LPN was still passing medications late into the shift and that the resident was upset about not receiving pain medication. The second LPN observed the first LPN attempting to push the resident back into their room while yelling and intervened to stop the situation. The Director of Nursing acknowledged that the incident could have been prevented and that staff should not place their hands on a resident to force compliance, especially when the resident is upset. The facility failed to ensure the resident was free from abuse, neglect, and mistreatment during this incident.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
Surveyors found that the facility failed to thoroughly investigate an alleged incident involving possible abuse, neglect, or mistreatment of a resident. The incident involved a Licensed Practical Nurse (LPN) who was observed on video surveillance engaging in a verbal exchange with a resident, followed by the LPN forcefully pulling the resident, who was seated in a wheelchair, back into their room despite the resident's resistance. The facility's internal investigation concluded that no abuse, neglect, or mistreatment had occurred, but the investigation summary did not include a review of the video surveillance footage or documentation of an interview with the resident's roommate, who was present during the incident. The resident involved had diagnoses including aphasia, cerebral infarction, hemiplegia, and was status post revision of a right total knee arthroplasty. According to the most recent assessment, the resident was independent with eating and bed mobility, required supervision and setup assistance with transfers and toileting, and was independent with wheelchair mobility, but had moderately impaired cognition. The incident was initially reported after a Certified Nurse Aide observed the LPN speaking loudly to the resident and allegedly pulling the resident by the shoulders while maneuvering the wheelchair. The LPN reported attempting to assist the resident back into a seated position and move the wheelchair to clear the path for the medication cart. Despite the availability of video surveillance footage, the facility's investigation summary did not document a review of this footage, nor did it include an interview with the roommate who witnessed the event. Both the Director of Nursing and the Administrator acknowledged that the omission of the video review from the investigation summary was an oversight. The facility's policy requires that all investigations be thorough and complete, including reviewing all relevant evidence and interviewing witnesses, but these steps were not fully documented in this case.
Failure to Provide Timely Pain Management as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of aphasia, cerebral infarction, hemiplegia, and recent right total knee arthroplasty revision did not receive pain management as ordered. The resident had a physician's order for Oxycodone HCL 5 mg orally every 6 hours as needed for pain. On the evening in question, the resident requested pain medication from an LPN at approximately 11:54 PM due to significant knee pain. The LPN did not administer the medication, and the resident did not receive the next dose until 1:28 AM, resulting in an interval of approximately eight hours and thirty-four minutes between doses. The facility's policy required consistent pain assessment and timely administration of pain medication, which was not followed in this instance. Interviews revealed that the LPN was behind on medication administration and told the resident that the night nurse would provide the pain medication, as the LPN needed to finish their shift. The resident, their family member, and a CNA all reported that the resident's request for pain medication was refused or delayed, and the LPN did not assess the resident for pain at the time of the request. The DON confirmed that the LPN failed to follow the physician's order and facility policy by not assessing and administering the pain medication as needed.
Failure to Provide and Document Required ADL Care and Personal Grooming
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary care and assistance to maintain good nutrition, grooming, and personal care. For two residents reviewed, documentation by certified nurse assistants (CNAs) showed multiple instances where bladder and bowel incontinence care, showers, personal hygiene, and meal assistance were either not provided or not documented as provided. Specifically, one resident with severe cognitive impairment and significant physical limitations had numerous days in January and February 2024 where required ADL care was not signed off by staff, including incontinence care, showers, personal hygiene, and meal assistance. Another resident, who was cognitively intact but required maximal assistance for mobility and was dependent for toileting and transfers, also had many occasions where incontinence care and showers were not documented as provided. Observations during facility rounds revealed that a significant number of residents were dressed in hospital gowns rather than regular clothing. On two separate days, a total of 22 and 33 residents, respectively, were observed in gowns across different floors of the facility. Interviews with staff indicated that while some residents may prefer gowns or are care planned for them, not all residents dressed in gowns had such preferences or care plans. Staff confirmed that residents had access to regular clothing and that the occurrence of residents in gowns was not typical. Interviews with facility leadership revealed inconsistencies in the interpretation of blank documentation fields. The DON stated that a blank spot in CNA documentation does not necessarily mean care was not provided, but rather that the CNA may have forgotten to sign. In contrast, the Assistant DON indicated that a blank spot would mean the task was not done. Oversight of CNA documentation was described as involving reminders and checks by nursing leadership, but the documentation reviewed for the period in question showed persistent gaps in recording required care.
Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as determined by its own Facility Assessment. Record review of daily staffing sheets for January and February 2024 revealed that both nursing and certified nurse assistant (CNA) staffing levels were frequently below the minimums established by the facility for various shifts on the 2nd floor. Specific deficiencies included shifts with only one nurse or fewer CNAs than required, and several instances where no nurse or only one CNA was scheduled for a shift, contrary to the documented staffing requirements. The facility's policy stated that sufficient numbers of nursing staff would be provided in accordance with care plans and the facility assessment, but actual staffing did not consistently meet these standards. Interviews with facility leadership confirmed awareness of staffing shortages, particularly on weekends, and acknowledged that agency staff were sometimes used to fill gaps. The Director of Human Resources and nursing leadership described processes for attempting to cover shifts, such as using a staff roster and supervisors or assistant directors of nursing stepping in when needed. However, there were documented occasions when no nurse was scheduled for a unit, and leadership could not recall or confirm all such instances. These findings demonstrate that the facility did not consistently ensure adequate nursing coverage as required by regulation and its own assessment.
Significant Medication Errors Due to Unstaffed Nursing Shift
Penalty
Summary
On 2/25/2024, the facility failed to ensure that residents were free from significant medication errors when there was no nurse present on the second floor during the 7 AM to 3 PM shift. As a result, 36 out of 42 residents on the unit did not receive their scheduled medications, with 30 of these residents missing significant medications. The medications omitted included antihypertensives, retrovirals, anti-seizure drugs, antidepressants, antidiabetics, insulin, narcotics, anticoagulants, antibiotics, immunosuppressants, anti-Parkinsonism, and antipsychotics. Specific residents affected included individuals with complex medical histories such as Type 2 Diabetes Mellitus, Essential Hypertension, Cerebral Infarction, Peripheral Vascular Disease, Atrial Fibrillation, Vascular Dementia, and Chronic Kidney Disease. For example, one resident missed doses of Losartan, Clopidogrel, Paroxetine, Metoprolol, and two types of insulin; another missed Clopidogrel, Lisinopril, Glucophage, Levemir, and Novolog. Other residents missed critical medications for heart failure, diabetes, hypertension, deep vein thrombosis, and more. The absence of a nurse was not communicated to facility leadership in a timely manner. The DON was unaware of the staffing gap until after the incident, as the nursing supervisor did not report the sick call or the lack of coverage. The administrator was informed by the supervisor that everything was fine, and the scheduler was not contacted for additional staffing. The medication errors were only discovered after the fact, when the DON returned to work and was notified by the Assistant DON.
Failure to Provide and Document Required Turning and Repositioning for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, major depressive disorder, and mood disorder, who was dependent on staff for bed mobility and transfers, did not consistently receive turning and repositioning as required for pressure ulcer prevention and treatment. The resident had a stage 2 sacral pressure ulcer that resolved but later reopened, and the care plan specified repositioning at least every two hours. Certified nurse aide documentation revealed multiple instances across several months where the resident was not turned and repositioned as required, both before and after the wound reopened. The wound care physician provided specific instructions for turning and repositioning every 1-2 hours in bed and every 30 minutes while in a chair, but documentation and staff interviews confirmed that these interventions were not consistently implemented. Certified nurse aides reported that the electronic documentation system only allowed them to record turning and repositioning per shift, not every two hours, and that they did not reposition the resident while in a wheelchair. There were also several days where no documentation was present, indicating the care may not have been provided. Interviews with nursing staff and management confirmed awareness of the care requirements but also highlighted limitations in the documentation system and inconsistent adherence to the prescribed interventions. The lack of detailed, timely documentation and the failure to follow the care plan and physician orders led to the resident not receiving the necessary treatment and care for pressure ulcer prevention and management.
Failure to Monitor and Report Significant Weight Loss
Penalty
Summary
A deficiency was identified when a resident with dementia, protein-calorie malnutrition, and severe cognitive impairment experienced a significant unplanned weight loss of over fifteen percent in thirty days. The resident required maximal assistance with eating and was dependent on staff for nutrition. Documentation revealed that direct care staff did not consistently record the resident's meal intake, with numerous occasions where the amount eaten or the assistance provided was not signed off. There were multiple instances where the resident consumed only twenty-five percent or none of their meals, and there was no documented evidence that nursing or administration was informed of the resident's poor intake during this period. The facility's policy required systematic monitoring and timely management of significant weight loss, including regular documentation and communication with the physician and interdisciplinary team. Despite these requirements, the resident's declining intake and weight loss were not promptly identified or addressed due to lapses in documentation and communication. The registered dietician later confirmed the significant weight loss and noted the resident's ongoing challenges with eating, but this was only after the weight loss had already occurred and was brought to the attention of the interdisciplinary team.
Failure to Timely Submit 5-Day Investigation Reports to State Authorities
Penalty
Summary
The facility failed to ensure that the results of investigations into suspected abuse, neglect, or theft were reported to the New York State Department of Health within five working days, as required by state law and facility policy. In three separate cases involving three different residents, the facility either delayed submission or did not provide documented evidence of submitting the required 5-day investigative conclusion report. The facility's policy clearly states that all findings of investigations must be documented and reported within five business days, but this was not followed in the cited incidents. In one incident, a resident with a history of psychosis and mood disorder struck another resident on the head with a therapy device. The incident was witnessed by two certified nurse aides, and the involved residents were separated, with one being sent for psychological evaluation. However, the 5-day investigative conclusion was not submitted to the Department of Health until six days after the incident, exceeding the required timeframe. In another case, a resident with severe cognitive impairment and no wander guard exited the facility unescorted and was found in a neighboring yard before being taken to the hospital. The investigation concluded there was no evidence of abuse or neglect, but there was no documented evidence that the 5-day investigative conclusion report was submitted to the Department of Health. Interviews with facility leadership confirmed awareness of the reporting requirements, but also revealed lapses in timely submission, particularly when incidents occurred over weekends.
Failure to Thoroughly Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, exploitation, or misappropriation were thoroughly investigated for six residents. In multiple instances, the facility did not obtain written statements from all staff assigned to the relevant units during the periods of the alleged incidents. For example, after a resident reported inappropriate touching by a former roommate, the facility did not collect statements from the certified nurse aides on duty or the registered nurse involved, and the investigative summary was neither dated nor signed by the Medical Director. Similarly, in an incident where a resident was struck on the head with a therapy device by another resident, the investigative summary was unsigned and undated, and not all required staff statements were obtained. In cases involving missing property and alleged financial exploitation, the facility did not secure statements from all staff assigned to the affected units during the relevant timeframes. For three residents who reported missing credit cards and unauthorized charges, the investigation lacked comprehensive staff interviews and written statements, including from the alleged perpetrator in one case. The facility's incident reports concluded that exploitation or misappropriation by staff was inconclusive due to insufficient evidence, but the lack of thorough documentation and staff statements was evident. Throughout these events, the facility's own policy required that all allegations be thoroughly investigated, with interviews conducted with all staff members on all shifts who had contact with the residents during the periods in question. However, the documentation reviewed showed that investigative summaries were often incomplete, unsigned, or undated, and that not all relevant staff were interviewed or provided written statements. These deficiencies in the investigative process were confirmed by interviews with facility leadership, who acknowledged that some steps were missed or overlooked.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of inappropriate behaviors, including psychosis and mood disorder, struck another resident on the head with a therapy device. The incident took place in a hallway and was witnessed by a certified nurse aide, who reported that the aggressor was upset because the other resident, who had severe cognitive impairment and a history of wandering, had entered their room by mistake. The aggressor verbally expressed frustration before using a flexi-bar to hit the other resident from behind. The resident who was struck had significant cognitive impairment, exhibited wandering behaviors, and required supervision as documented in their care plan. Despite interventions such as frequent checks and redirection, the resident was able to enter another resident's room, which led to the altercation. The staff present intervened immediately after the incident, but the event still resulted in one resident physically striking another. The facility's investigation concluded that no abuse had occurred, citing the aggressor's psychiatric issues and lack of intent to harm, as well as the absence of injury to the resident who was struck. However, the incident itself demonstrated a failure to protect a resident from physical abuse, as required by regulation, and highlighted lapses in supervision and monitoring of residents with known behavioral risks.
Failure to Accurately Assess Elopement Risk on Admission
Penalty
Summary
The facility failed to ensure the accuracy of a resident's assessment upon admission, resulting in the resident not being identified as at risk for elopement. The resident, who was admitted with diagnoses including dementia, muscle weakness, and generalized anxiety disorder, had a documented history of wandering as noted in the hospital discharge records. However, the facility's admission assessment did not reflect this history, instead documenting that the resident was disoriented but had not attempted to leave prior residences and did not wander. As a result, the resident was assigned a low elopement risk score and was not provided with a wander guard. The resident was placed in a first-floor room, and subsequently exited the facility unescorted after being buzzed out by the receptionist. Interviews with facility staff revealed that the admissions process involved reviewing the resident's medical history and physicals, but the Director of Nursing who completed the assessment did not recall seeing documentation of wandering in the hospital records. The failure to accurately assess and document the resident's elopement risk led to the omission of necessary safety measures, such as the use of a wander guard and appropriate room placement.
Failure to Develop Comprehensive Care Plan for Resident with Wandering History
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing all of a resident's needs, specifically regarding wandering and elopement risk. One resident was admitted with a documented history of dementia, muscle weakness, generalized anxiety disorder, and prior incidents of wandering and aggression as reported by family and hospital records. Despite this history, the facility did not initiate a care plan for wandering or elopement risk. The resident's care plans focused on impaired cognition and forgetfulness/confusion, with interventions such as maintaining a consistent routine and providing reminders for activities, but did not address the risk of wandering or elopement. The Director of Nursing stated that the assessment on admission did not reveal wandering or exit-seeking behaviors, and that the hospital documentation reviewed did not indicate wandering, which led to the omission of a wandering or elopement care plan. However, the hospital records and family reports did document a history of wandering prior to admission. As a result, the facility did not meet the regulatory requirement to develop a comprehensive care plan that includes measurable objectives and timetables to address all identified needs, including the risk of wandering and elopement.
Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with a documented history of dementia, muscle weakness, and generalized anxiety disorder exited the facility unescorted. The resident, who had severe cognitive impairment and required supervision with daily activities, was admitted without a wander guard and was assigned a room on the first floor. The resident was able to leave the facility through the front doors after being buzzed out by the Receptionist, who did not recognize the individual as a resident and mistook them for a visitor. The facility's elopement risk assessment, completed at admission, did not identify the resident as a wander or elopement risk, despite family reports of wandering and aggressive behavior prior to admission. The resident was not included on the elopement risk list at the front desk, did not have an identification band, and was not known to the Receptionist as a new resident. The Receptionist allowed the resident to exit the building without verifying their identity, and the absence of a wander guard or other alert system contributed to the resident's ability to leave unnoticed. The resident was discovered missing during staff rounds, prompting a search of the facility. The resident was later located by emergency medical services after entering a neighboring home and was transported to the hospital for evaluation. The incident revealed gaps in the facility's supervision, risk assessment, and communication processes, which allowed the resident to exit the facility without appropriate safeguards in place.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, Resident #88 and Resident #213, as observed during the recertification and abbreviated surveys. Resident #88, who had a left above the knee amputation and neuropathy, was not administered pain medication in accordance with Physician's Orders and did not receive non-medication interventions for pain relief. Despite experiencing persistent pain, the recommendations from a Physiatrist to increase Gabapentin and conduct imaging studies were not reviewed or acted upon by the Physician Assistant. The resident's pain was not adequately assessed or documented, and the prescribed Tylenol was not administered when Oxycodone was ineffective. Resident #213, admitted with a left shoulder replacement and other conditions, did not receive Oxycodone as prescribed due to a failure to reorder the medication in a timely manner. The Narcotics Log indicated that the medication was unavailable for several doses, and there was no evidence that the emergency supply box was accessed to provide the necessary pain relief. The nursing staff did not follow the protocol for medication refills, and there was no documentation of alternative pain relief interventions being provided. Interviews with facility staff, including Licensed Practical Nurses and the Director of Nursing, revealed lapses in communication and adherence to pain management protocols. The Physician Assistant did not adequately assess or document the residents' pain levels, and there was a lack of coordination in reviewing and implementing the Physiatrist's recommendations. These deficiencies highlight significant gaps in the facility's pain management practices, impacting the residents' quality of care.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, particularly on the 2nd and 3rd floors, as identified during a recertification and abbreviated survey. The Facility Assessment did not account for the higher resident capacity and census on these floors compared to the 1st floor. The projected and actual staffing levels were below the facility's assessed needs of 2.2 Certified Nursing Assistant (CNA) hours per resident per day. This deficiency was evident in the staffing patterns and the inability to provide adequate care, as reported by residents and observed by surveyors. Specific incidents highlighted the impact of insufficient staffing. Resident #95 experienced significant delays in receiving incontinence care, waiting up to 12 hours on one occasion. The actual staffing on the 3rd floor during this period was below the required levels, contributing to the delay in care. Additionally, Resident #7 was observed with a strong odor of urine, indicating a lack of timely assistance with activities of daily living. Residents expressed concerns about staffing shortages during a Resident Council Meeting, with reports of difficulty finding staff during the night shift and delays in being assisted to bed. Interviews with staff further corroborated the staffing issues. CNAs and LPNs reported frequent call-outs and the need to cover additional shifts, often resulting in staff being responsible for a high number of residents, some of whom required two-person assistance. The facility's attempts to address staffing shortages, such as using a staffing application and offering incentives, were noted, but the staffing coordinator and nursing administration were unable to provide explanations for unfilled slots and unconfirmed staffing documentation. Despite these efforts, the facility did not meet the required staffing levels, impacting the quality of care provided to residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for Resident #95, who was dependent on staff for activities of daily living due to conditions such as paraplegia and respiratory failure. The resident, who was cognitively intact, frequently experienced bowel and bladder incontinence. Despite a grievance resolution stating the resident should be changed every two hours and as needed, there were instances where the resident waited excessively long periods to be changed. Specifically, the resident reportedly waited 12 hours on one occasion and 9 hours on another to have their soiled brief changed, which was a concern given their history of frequent urinary tract infections. Interviews and observations revealed that the resident continued to experience delays in receiving incontinence care, with one instance where the resident was not changed from 5:00 AM until 12:38 PM. The Director of Nursing acknowledged that there was no justification for such delays and confirmed the expectation for changes every two hours. However, there was no documented evidence to support that this care schedule was consistently followed. Additionally, there was a lack of documentation regarding the resident's refusals to get out of bed, which may have contributed to the care delays.
Failure to Review Resident's Pain Management Plan
Penalty
Summary
The facility failed to ensure that the physician reviewed a resident's total program of care at each visit, as required. This deficiency was identified during a recertification survey for one resident who had undergone a surgical amputation and was experiencing persistent pain. The resident reported their pain to the Physician Assistant, but no changes were made to their treatment plan. The facility's policy on pain assessment and management required a multidisciplinary team, including the physician, to reconsider approaches if pain was not adequately controlled. However, the Physician Assistant did not review the Nursing Pain Evaluation or the Physiatrist's pain management recommendations for the resident. The resident's comprehensive care plan documented chronic pain issues, including neuropathy and potential phantom pain. Despite a Physiatry Consult recommending an increase in Gabapentin and further imaging to rule out neuroma, the Physician Assistant's notes did not reference these recommendations or assess the resident's pain using a numeric scale. Interviews with facility staff revealed that the Physician Assistant was responsible for reviewing and ordering the Physiatrist's recommendations, but there was no documented evidence that this was done. The Physician Assistant admitted to not reviewing the pain scale documented by nursing unless the resident reported pain during their visit.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a recertification survey, with an observed error rate of 8%. This deficiency involved the incorrect administration of medications to one resident. Specifically, the resident was given a crushed form of enteric-coated aspirin instead of the prescribed chewable form, and a crushed form of Depakote delayed-release tablet, both of which were against the manufacturer's instructions. The facility's policy required medications to be administered safely and in accordance with prescriber's orders, which was not adhered to in this instance. The resident involved had diagnoses including seizures, schizophrenia, and hypertension, and was on a regular diet with thin liquids. The LPN responsible for the medication administration acknowledged the error, stating they were aware that Depakote should not be crushed and failed to notice the warning on the blister pack. The LPN also admitted to not checking if an alternative form of the medication was available. The Director of Nursing emphasized the importance of following medication instructions and the need to consult physicians if a medication form is not suitable for a resident.
Infection Control Deficiencies in Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, specifically in hand hygiene, for two residents during a recertification survey. One incident involved a Certified Nurse Aide who, during a lunch meal observation, placed their uncovered palm on a resident's hamburger bun while cutting it in half. The resident, who had diagnoses including hypertension, diabetes mellitus, and coronary artery disease, required tray setup for eating due to mild cognitive impairment. The aide acknowledged awareness of the rule against touching food directly but admitted to not considering it at the moment. Another incident involved a Licensed Practical Nurse who did not perform hand hygiene between glove changes during a wound care treatment for a resident with multiple sclerosis, hemiplegia, dementia, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and had a Stage 3 and Stage 4 pressure ulcer. The nurse, who was distracted due to working on another floor, admitted to not washing hands between glove changes despite knowing the protocol. The Director of Nursing acknowledged the need for more education on hand hygiene despite previous in-services and rounds.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. Specifically, for one resident reviewed, there was no documented evidence that the resident was offered, declined, or educated on the pneumococcal immunization. The facility's policy, last revised in 2017, required that residents be asked about their pneumococcal vaccine status upon admission and that this information be confirmed through medical records. If the vaccine had not been received, the resident was to be provided with information and given the opportunity to ask questions before signing a consent or declination form. The resident in question had a medical history that included Type II Diabetes Mellitus, acquired absence of both legs below the knee, and end-stage renal failure requiring dialysis. An assessment tool dated June 2024 indicated that the resident had mild cognitive impairment and was independent in self-care. However, the pneumococcal vaccine was not up to date and had not been offered by the facility. During an interview, the Infection Preventionist acknowledged that the resident's records were incomplete and that the pneumococcal vaccine status should have been obtained since the resident had been at the facility since April.
Failure to Resolve Grievance and Incomplete Grievance Policy
Penalty
Summary
The facility failed to ensure the prompt resolution of a resident's grievance and did not establish a comprehensive grievance policy. The grievance policy lacked details on how residents were informed of the grievance process and their right to receive a written decision. This deficiency was identified during a survey, where it was found that a resident's designated representative reported missing clothing and glasses, but the facility did not provide a prompt resolution. The facility's grievance policy did not specify whether residents were informed of the grievance process individually or through postings, nor did it document the right to obtain a written copy of the grievance review. The resident involved had severe cognitive impairments and a history of mental health disorders. The designated representative reported the missing items to the Director of Social Work multiple times, including during a care plan meeting, but did not receive a resolution. The Director of Social Work claimed the issue was resolved without a formal grievance investigation, and the facility's records did not show any investigation into the complaint. The administrator and social work department were unclear on how residents and families were informed of grievance outcomes, and the facility did not provide written copies of grievance reports unless requested.
Deficient Discharge Planning for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an effective discharge planning process for a resident with serious mental illness, resulting in a deficiency. The resident, who had diagnoses including schizoaffective disorder and bipolar disorder, was moderately cognitively impaired and physically aggressive. After a psychiatric hospitalization, the facility issued a Transfer/Discharge Notice without involving the resident's Designated Representative, listing a destination that lacked the necessary specialized psychiatric services. The Ombudsman and the Designated Representative were involved in care plan meetings and discovered that the facility listed on the Transfer/Discharge Notice did not have the required psychiatric unit. Despite the facility's claim that the resident's behaviors were unmanageable, the Transfer/Discharge Notice lacked adequate documentation and did not include contact information for advocacy agencies. The facility's Social Work Department and Administrator failed to properly involve the resident and their representative in the discharge planning process. Interviews with the Director of Social Work and the Administrator revealed that the facility had issued several Transfer/Discharge Notices without proper documentation or involvement of the resident's representative. The facility's actions were not aligned with the resident's rights, and there was no evidence that the discharge care plan was reviewed or revised in light of the developments, including the issuance and rescission of the Transfer/Discharge Notice.
Failure to Timely Address Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. Specifically, a resident was found with a skin opening on the sacrum, but a registered nurse did not assess the area or notify the physician until the following day. The facility's policy required that any change in a resident's condition, including skin alterations, be documented and that the physician be notified. However, this protocol was not followed, leading to a delay in the assessment and treatment of the pressure ulcer. The resident involved had severe cognitive impairment and was at high risk for developing pressure ulcers. Despite being incontinent and having a care plan in place to prevent skin breakdown, the resident developed a Stage 2 pressure ulcer on the sacrum. The issue was not addressed promptly, as the registered nurse on duty was not informed of the skin opening, and the physician was not notified until the following day. This oversight resulted in a delay in the implementation of appropriate interventions and modifications to the resident's care plan.
Failure to Provide Individualized Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident with multiple mental health diagnoses received individualized behavioral health care and services. The resident, diagnosed with schizoaffective disorder, bipolar disorder, catatonia, and major depressive disorder, had a care plan that was not reviewed or revised to address their symptoms effectively. Despite documented mood symptoms and behavioral issues, such as physical aggression and noncompliance, the care plan remained unchanged since its initiation, lacking necessary updates to address the resident's evolving needs. The resident's behavioral health care plan did not incorporate the recommendations from a Level II Preadmission Screening, which included psychiatric care, ongoing consultations, and therapeutic interventions. The facility's documentation showed a lack of individualized non-pharmacological interventions to manage the resident's behavior. Additionally, there was no evidence of a psychology referral or intervention following the resident's psychiatric hospitalization, indicating a gap in the continuity of care. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's behavioral health needs and the Level II recommendations. The Physician Assistant and Certified Nursing Assistant were not informed of the necessary interventions, and the Director of Social Work admitted to not referring the resident for further evaluation after behavioral changes. This lack of coordination and failure to update the care plan contributed to the facility's inability to manage the resident's behavioral health needs effectively.
Failure to Provide Required Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide necessary rehabilitative services for a resident who was experiencing significant weight loss. The resident, who had severe cognitive impairment and required assistance with eating, had a physician's order for a Speech Therapy evaluation due to slow eating and chewing. Despite this order being placed on 7/17/2024, the evaluation was not completed. The resident's medical record lacked documentation of the speech therapy evaluation, which was confirmed by the Occupational Therapist and the Speech Therapist. The Speech Therapist acknowledged being informed of the order on 8/2/2024 but did not document the screening they conducted. Observations during mealtimes revealed that the resident was served meals in soup bowls and required assistance with feeding. Interviews with the Clinical Nutrition Manager and the Director of Rehabilitation Department highlighted the resident's risk for weight loss due to slow eating and the expectation that evaluations should occur within 72 hours of an order. The failure to conduct and document the speech therapy evaluation as ordered contributed to the deficiency identified during the survey.
Resident Abuse Incident Involving Dietary Aide
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a dietary aide and a resident. On the specified date, a dietary aide was witnessed by a certified nurse aide verbally threatening a resident and pulling on the resident's beaded necklace. The resident's written statement corroborated the account, indicating that a staff member entered their room, held them by the shirt and chest area, and verbally threatened them. The facility's investigation concluded that verbal abuse had occurred. The resident involved had a medical history that included osteoarthritis of the right shoulder, depression, and dementia, with moderately impaired cognition and no behavioral symptoms. The resident required supervision for various activities of daily living. The incident was immediately reported by the certified nurse aide to the charge nurse, and the facility's investigation was initiated promptly. The dietary aide involved was asked to leave the building, and the police were notified. At the time of the onsite visit, the resident was no longer at the facility.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including Multiple Sclerosis and severe cognitive impairment, had a care plan that required the use of a foam positioning wedge to maintain a side-lying position and elevate heels off the bed surface to prevent pressure injuries. Additionally, a physician order mandated the application of bilateral heel booties at all times for prophylaxis. However, observations on a specific day revealed that the resident's heels were resting on the mattress without heel booties, and the foam positioning wedge was not used as directed. Interviews with staff indicated a lack of communication and awareness regarding the resident's care needs. A Certified Nursing Assistant, who was new to the unit, was unaware of the requirement to use a foam positioning wedge and heel booties. A Licensed Practical Nurse acknowledged the resident's risk for pressure ulcers and the necessity of heel booties or offloading pillows but admitted that the booties were not applied that day. The deficiency was identified under 10 NYCRR 415.11(c)(1), highlighting the facility's failure to adhere to the care plan and physician orders, potentially compromising the resident's care.
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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 Yonkers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudson Hill Center For Rehabilitation & Nursing | 0.4 mi | ★★★★★ | 9 | 0 |
| Yonkers Gardens Center For Nursing And Rehab | 1 mi | ★★★★★ | 33 | 0 |
| Adira At Riverside Rehabilitation And Nursing | 1.9 mi | ★★★★★ | 6 | 0 |
| Elizabeth Seton Children's Center | 2 mi | ★★★★★ | 0 | 0 |
| Park Gardens Rehabilitation & Nursing Center L L C | 2.5 mi | ★★★★★ | 6 | 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.