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 Sapphire Nursing At Wappingers during CMS and state inspections, most recent first.
Medications were not available for a resident on admission, and ordered doses of Buprenorphine/Naloxone, pregabalin, clonazepam, valacyclovir, and topiramate were missed before pharmacy delivery. The MAR and nursing notes did not show documented administration, rationale, pharmacy contact, MD notification, monitoring, or alternate interventions while the meds were unavailable. The resident had Parkinson’s disease, herpes infection, major depressive disorder, bipolar disorder, opioid dependence, and intact cognition.
The facility lacked dietitian oversight of meals obtained from an outside food vendor while the kitchen was under renovation. Meals were delivered in bulk from a local restaurant, then plated and texture-modified by facility staff for residents with chopped and pureed diets. The RD was not involved in vendor communications or meal preparation planning, and the vendor did not receive individual diet orders or prepare separate therapeutic meals.
Food was plated and served with hot items falling below safe temperatures while meals were delayed and held on sterno setups. One cook was plating trays alone, a sterno burner went out during service, and multiple foods measured below 135 F, including a test tray with Salisbury steak, potatoes, and vegetables at 110 F, 118 F, and 100 F. Staff and residents reported that meals often arrived cold or lukewarm, and the FSD stated the kitchen was under renovation and meals were being catered and modified on-site.
Multiple incidents occurred where a resident with dementia and a history of wandering engaged in physical altercations with two other residents, resulting in injuries. Despite known behavioral risks, no behavior care plan was in place for the resident prior to these events, and required documentation and interventions were lacking.
A resident did not receive multiple doses of prescribed Enoxaparin Sodium and Diazepam, with omissions noted on the MAR and no documentation or physician notification provided. The resident experienced a change in mental status and was transferred to the hospital. Staff interviews confirmed a lack of documentation and communication regarding the missed medications.
A resident with multiple medical conditions reported shoulder pain after being repositioned by staff, with an x-ray revealing a displaced scapular fracture. Despite the resident's report and subsequent hospital transfer, the facility did not complete or document an official investigation or incident report, resulting in a deficiency for failure to respond appropriately to an alleged violation.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to lapses in safeguarding measures.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
A resident with multiple medical conditions reported shoulder pain after being repositioned by staff, with an x-ray showing a displaced scapular fracture. The facility did not provide an incident report or conduct a documented investigation into the allegation, despite the resident and family raising concerns and the hospital noting the injury.
A resident with severe cognitive impairment and aggressive behaviors entered another resident's room and physically assaulted them, despite the facility's policy against abuse. The assaulted resident, who had intact cognition, reported the incident and showed a bruise from the altercation. The facility's failure to prevent this incident highlights a deficiency in ensuring resident safety.
The facility failed to provide appropriate care for several residents, including missed wound dressing changes, lack of follow-up appointments, and failure to provide prescribed compression stockings. A resident with a vascular wound did not receive daily dressing changes, while another resident did not have necessary post-hospitalization follow-up appointments scheduled. Additionally, a resident did not receive prescribed compression stockings, and a urology appointment was not scheduled, highlighting lapses in care and communication among staff.
The facility failed to provide sufficient nursing staff, resulting in unmet resident needs such as missed showers and unanswered call lights. Interviews revealed that staffing was scheduled on a day-to-day basis, leading to inadequate coverage, especially on weekends. The new staffing coordinator found no existing staffing plan, and staff reported working alone and without sufficient support.
The facility did not conduct annual performance reviews for five certified nurse aides, as required. Interviews with the ADON and DON confirmed the absence of reviews since February 2023, and complaints from residents and visitors were noted. A CNA reported never receiving a performance review despite long-term employment.
The facility's kitchen failed to maintain sanitary conditions, with issues such as undated food, improper dishwasher temperatures, and personal food stored with residents' meals. Staff did not wear beard covers while serving meals, and food items were improperly stored together. These deficiencies highlight a lack of adherence to professional food safety standards.
The facility failed to maintain infection control practices, as staff did not change gloves between tasks and did not wear gowns during procedures for residents on Enhanced Barrier Precautions. A CNA used the same hand to feed two residents without hand hygiene, and a wound care nurse's badge contacted a resident's wound drape. Additionally, there was no documentation of oxygen tubing changes for a resident, and staff expressed confusion about new precautions.
The facility failed to ensure residents' dignity during dining by applying clothing protectors without permission and having staff stand while feeding residents. A resident expressed discomfort with the practice of applying clothing protectors without consent, and another resident, unable to raise their head, wished to see the person feeding them. Staff acknowledged these practices, citing routine and workload as reasons.
A resident reported missing clothing, but the facility failed to document or resolve the grievance in a timely manner. Despite the facility's policy requiring prompt investigation, the social worker was unaware of the issue, and no grievance form was completed. The administrator acknowledged that an investigation should have been documented.
A facility failed to send required documentation during a hospital transfer for a resident with a history of cerebral vascular accident, dysphagia, and seizures. The resident, who had moderately impaired cognition, was transferred at the family's request, but there was no evidence of a transfer summary or necessary information being sent. The Assistant DON confirmed the absence of documentation after reviewing the electronic medical record.
A facility failed to provide a resident or their representative with written notice of the Bed Hold policy upon transfer to a hospital. The resident, with diagnoses including cerebral vascular accident and moderately impaired cognition, was not informed of the policy when discharged to the hospital. Staff interviews revealed that notices were not sent unless residents were private pay, contrary to the Administrator's acknowledgment of the requirement.
A resident with Type II Diabetes Mellitus and Major Depressive Disorder, who required moderate assistance for toileting, was not provided timely care after requesting help due to diarrhea. Despite the resident's care plan specifying toileting every 2-4 hours, staff failed to assist promptly, leading to the resident feeling humiliated. Interviews revealed that the nurse on duty did not provide necessary care, resulting in a deficiency under 10 NYCRR 415.12(a)(3).
A facility failed to provide a tailored activity program for a resident with severe cognitive impairment and multiple diagnoses, including diabetes and anxiety disorder. The resident did not receive an admission activity assessment, and their care plan was not updated after coming off isolation precautions. Observations showed the resident alone in their room, with minimal documented activity engagement.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed Lidocaine patches and document pain assessments. One resident did not receive patches due to supply issues, and staff failed to notify the physician or offer alternatives. Another resident received Tylenol without documented pain assessments, affecting their sleep. Staff interviews revealed a lack of communication and awareness regarding these issues.
The facility failed to post daily nurse staffing information in an accessible location for residents and visitors, placing it behind a coded door. The information was not updated to reflect staffing changes, leading to discrepancies between posted and actual staffing. Staff interviews revealed a lack of training and clarity on responsibilities for updating the information.
The facility's assessment inaccurately documented CNAs as having competencies in tasks beyond their scope, such as medication administration and tracheostomy care. The Administrator initially claimed the assessment was accurate, but later acknowledged the inaccuracies, confirmed by the DON.
The facility did not implement an antibiotic stewardship program with protocols and monitoring systems. During a survey, it was found that infection and antibiotic tracking reports for February and March 2024 were missing. The Infection Control Practitioner acknowledged being behind in reviews, with the last one in January 2024. The Administrator was unaware of the delay, showing a lack of oversight.
The facility did not ensure a safe, sanitary, and comfortable environment, as evidenced by a strong urine odor in a shared room and a damaged curtain in another room. Interviews revealed that the odor was due to a resident's incontinence and non-compliance with care, while the curtain issue was due to a lack of replacements. The facility's cleaning policy was not effectively implemented.
A resident with a Do Not Resuscitate (DNR) order and instructions to be sent to the hospital if necessary was not sent to the hospital despite requests and was improperly administered CPR when found unresponsive. Staff interviews confirmed the error and misunderstanding of the resident's advance directives, leading to a deficiency.
Medications Not Available and Missed Doses Without Documented Notification or Follow-Up
Penalty
Summary
Necessary medications were not available to be administered as ordered for one resident on admission, and there was no documented evidence of timely pharmacy contact, physician notification, follow-up, or monitoring related to the missed doses. The resident had diagnoses including Parkinson’s disease without dyskinesia, herpes viral infection of the urogenital system, major depressive disorder, bipolar disorder, and opioid dependence, and the 11/06/2025 MDS documented intact cognition. The physician’s orders dated 10/31/2025 included Buprenorphine/Naloxone, Pregabalin, Clonazepam, Valacyclovir HCL, and Topiramate, but pharmacy delivery records showed several of these medications were not delivered until after the resident had already missed scheduled doses. The MAR did not reflect administration of scheduled doses on 11/01/2025 and 11/02/2025, and for Buprenorphine/Naloxone, Valacyclovir HCL, and Clonazepam, the 09:00 AM dose on 11/03/2025 was also not documented as given before delivery later that day. Topiramate was also not delivered until 11/03/2025, and the MAR did not reflect administration for scheduled doses on 11/01/2025 and 11/02/2025. Nursing progress notes did not identify a documented rationale for the missed doses, physician notification, follow-up, monitoring, or substitution of other medications during the period the medications were unavailable. Additional review found Pregabalin and Ropinirole were not delivered until 11/07/2025, and the MAR did not reflect documented administration for scheduled doses prior to delivery. Nursing notes from the relevant period did not identify physician notification, follow-up, monitoring, or alternate interventions related to the missed doses. The facility’s policy required reconciliation of medications at admission and ensuring residents received all ordered medications, but the record did not show documentation that the pharmacy was contacted or that the physician was made aware of the delays in medication availability.
Lack of Dietitian Oversight for Vendor-Provided Meals
Penalty
Summary
The facility did not ensure that a dietitian or other clinically qualified professional was sufficiently involved in the food and nutrition service while the kitchen was under renovation and resident meals were being obtained from an outside vendor. The report states that the renovation began in 2025 and that the outside vendor arrangement began on 02/02/2026, but the facility did not provide a contract with the food vendor. Meals were delivered in bulk from a local restaurant, and facility staff altered the food at the facility, including texture modification for chopped and pureed diets, after delivery. During observations on 03/30/2026 and 04/01/2026, surveyors saw meals from the outside vendor being plated for resident service while the kitchen was under renovation. Food items such as Salisbury steak, vegetables, and potatoes were removed from bulk containers and modified at the facility for residents requiring altered textures. Meal trays were assembled with corresponding meal tickets, but the food was prepared in bulk and modified at the facility without evidence that the outside vendor prepared meals according to specific diets. The Food Service Director stated that the vendor did not receive individual resident diet orders and that food preparation was limited to reheating or modifying items after delivery. Interviews with the Administrator, Registered Dietitian, Food Service Director, and restaurant owner showed that the Registered Dietitian was not involved in communications with the vendor and had not provided input regarding meal preparation, therapeutic diet requirements, or nutritional needs. The Administrator stated that meals were ordered for the resident population and modified after delivery based on meal tickets, while the restaurant owner stated meals were prepared in the same manner as regular business operations and no separate meals were prepared for therapeutic diets. The report states there was no dietitian oversight of meals obtained from the outside vendor, cited under 10 NYCRR 415.12(c).
Food Held and Served Below Safe Temperatures During Meal Service
Penalty
Summary
The facility did not ensure food was procured, distributed, and served under sanitary conditions and at safe temperatures. During lunch meal service, the surveyor observed one staff member plating resident meals in the basement kitchen while food was held in metal pans on sterno setups. A sterno burner went out during plating and had to be relit by the Food Service Director. Meals were being plated on disposable foam plates with plastic lid coverings, and meal service was delayed beyond the scheduled delivery times to the units. Food temperatures were measured while plating was in progress and were already below acceptable hot-holding levels for several items. Initial temperatures taken by the Food Service Director showed several foods at 130 F, including mixed vegetables, pureed chicken, pureed vegetables, ground meat, and ground vegetables. As plating continued, temperatures declined further, with Salisbury steak at 120 F, mixed vegetables at 118 F, pureed chicken at 122 F, pureed vegetables at 118 F, mashed potatoes at 120 F, and ground vegetables at 110 F. At the end of meal service, a test tray showed Salisbury steak at 110 F, baked potato at 118 F, and vegetables at 100 F. The Food Service Director stated the kitchen had been under construction since late November 2025 and meals were being obtained from outside vendors. The director stated lunch was catered daily and dinner on some days, and that meals were altered at the facility to meet resident diet needs, including chopped and pureed textures. The director also stated meal preparation started late because one cook arrived late and another left early, and that the facility had no equipment available to maintain food temperatures other than sterno setups until a hot holding box was obtained later. Residents and staff reported that meals often arrived cold or lukewarm, and one resident stated the food was always cold and that no other choices were offered when meals were not eaten.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Behavior Care Planning
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving resident-to-resident altercations. One resident with a known history of wandering and dementia entered another resident's room, leading to a physical altercation where the second resident became agitated, grabbed the wandering resident, and both ended up on the floor. The wandering resident kicked the other in self-defense. Despite the known behavioral history and high risk for elopement, there was no behavior care plan in place for the wandering resident prior to the incident. Another incident involved the same wandering resident being observed holding their roommate by the collar in the doorway of their room. This resident had a documented history of previous altercations, yet no behavior care plan had been initiated to address or mitigate these risks. Staff interviews confirmed that the resident was known to wander and could become physically aggressive if not handled appropriately, but interventions to prevent such incidents were not documented or implemented before the altercations occurred. Additionally, a third resident, who was at risk for abuse due to immobility and cognitive impairment, was involved in a physical altercation with the wandering resident, resulting in scratches and visible injuries. The facility's own policies required thorough investigation and care plan updates for residents at risk of victimization or with aggressive behaviors, but these were not in place prior to the incidents. Documentation gaps were also noted, such as missing nursing progress notes regarding the altercation and lack of behavior care planning for the involved residents.
Failure to Administer and Document Physician-Ordered Medications
Penalty
Summary
A deficiency occurred when a resident did not receive physician-ordered medications, including Enoxaparin Sodium and Diazepam, over several days. The Medication Administration Record (MAR) showed multiple omissions for both medications, with no documented nursing notes explaining the reasons for non-administration. There was also no evidence that the physician was notified about the missed doses or that any rationale for withholding the medications was recorded. The facility's policy required timely and accurate medication administration and documentation, which was not followed in this instance. The resident involved had a medical history including trauma subdural hematoma, alcohol abuse, and major depressive disorder. The resident required varying levels of assistance with activities of daily living and was noted to have changes in mental status, including being unresponsive and having dilated pupils, prior to being transferred to the hospital. The MAR and nursing progress notes did not contain explanations for the missed doses of Enoxaparin Sodium or Diazepam, nor was there documentation of medication refusals or physician notification as required by facility protocol. Interviews with facility staff, including the Nurse Practitioner and Director of Nursing, confirmed that there was no documentation to explain the medication omissions. The staff interviewed were unable to recall the specific circumstances surrounding the missed doses, and attempts to contact the nurses responsible at the time were unsuccessful. The lack of documentation and communication regarding the missed medications constituted a significant medication error as identified by the surveyors.
Failure to Investigate and Document Alleged Injury During Resident Repositioning
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury for one resident. The resident, who had diagnoses including Parkinson's Disease, functional quadriplegia, and acute kidney failure, was cognitively intact and dependent on staff for bed mobility and transfers. The resident complained of right shoulder pain, and an in-house x-ray revealed a displaced scapular fracture and osteopenia. The resident was subsequently transferred to the hospital, where the hospital's history and physical documented that the resident reported hearing a pop in their right shoulder while being repositioned by staff. Despite this, the facility did not provide any incident or accident report related to the event when requested by surveyors. Interviews and record reviews revealed that the facility did not complete an official investigation into the incident. The administrator acknowledged that while the resident's complaint was discussed and aides were questioned, no formal investigation or documentation was completed. The family representative also reported the incident to the DON, who stated an internal investigation would be conducted, but no formal complaint was filed and no documentation was produced. The lack of a thorough investigation and absence of required incident reporting led to the deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Investigate Alleged Injury During Resident Repositioning
Penalty
Summary
Surveyors found that the facility failed to thoroughly investigate an allegation of injury for one resident. The resident, who had diagnoses including Parkinson's Disease, functional quadriplegia, and acute kidney failure, was cognitively intact and dependent on staff for bed mobility and transfers. The resident complained of right shoulder pain, and an x-ray revealed a displaced scapular fracture and osteopenia. The hospital history and physical documented that the resident reported hearing a pop in their right shoulder while being repositioned by staff. Despite this, the facility did not provide any incident or accident report when requested by surveyors, and the administrator confirmed there were no such reports on file for the relevant period. Further review and interviews revealed that the facility did not conduct or document a formal investigation into the incident. The administrator stated that although the resident's family reported concerns to the DON and were told an internal investigation would be completed, there was no official investigation or documentation found. Staff interviews indicated that aides denied being rough with the resident, and the administrator believed the resident was at their baseline with no increased pain. The lack of a documented investigation and incident report constituted a failure to respond appropriately to an alleged violation.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. One resident, known for being physically and verbally abusive, entered another resident's room and physically assaulted them by throwing items on the floor, attempting to take their walker, and punching them on the arm. The assaulted resident reported the incident and showed a fading bruise on their arm, indicating physical contact. The facility's policy prohibits any form of abuse, yet this incident occurred, highlighting a lapse in ensuring resident safety. The resident who was assaulted had a history of intact cognition and was independent in most activities, requiring moderate assistance for toileting. They were occasionally incontinent of urine but continent of bowels. The incident was documented in their behavior care plan, which noted the unsolicited physical contact and aimed to prevent further victimization by separating them from the aggressor. Despite these measures, the incident occurred, suggesting a failure in implementing effective preventive strategies. The aggressor resident had severe cognitive impairment, with a history of neurocognitive disorder with Lewy bodies and dementia. Their care plan documented severe cognitive deficits, poor impulse control, and aggressive behaviors. The facility's failure to adequately supervise and manage the resident's behaviors led to the altercation. The incident was investigated, and the aggressor was temporarily removed for evaluation, but the initial failure to prevent the altercation constitutes a deficiency in resident protection.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders and professional standards for several residents. Resident #14, who had a vascular wound, did not receive daily dressing changes as ordered. Observations revealed that the dressing was not changed for several days, and staff interviews indicated a lack of awareness and adherence to the treatment schedule. The resident expressed concerns during a council meeting about the infrequency of dressing changes, which was corroborated by the treatment administration records showing multiple missed dressing changes. Resident #54 did not have necessary post-hospitalization follow-up appointments scheduled, despite discharge instructions indicating the need for consultations with specialists. The resident expressed confusion about the lack of follow-up care, and staff interviews revealed a misunderstanding of the importance of these appointments, with one staff member incorrectly assuming they were for billing purposes only. This oversight resulted in the resident not receiving timely evaluations by a gastroenterologist, neurologist, and maxillofacial surgeon. Resident #56 did not receive prescribed compression stockings and a follow-up urology appointment was not scheduled. The resident's records showed that the stockings were not applied on numerous occasions, and staff interviews highlighted a lack of awareness and communication regarding the resident's needs. Despite the resident's acknowledgment of the benefits of the stockings, they were not provided, and the urology consult was overlooked, indicating a failure in executing the care plan and following discharge instructions.
Inadequate Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by the review of staffing schedules and interviews conducted during the recertification and abbreviated surveys. The facility's policy on staffing, dated 11/2/18, stated that sufficient numbers of nursing staff with appropriate skills and competency were necessary to provide care in accordance with resident care plans. However, the facility-wide assessment did not specify a staff-to-resident ratio or the number of staff required per unit. Interviews revealed that during February and March 2024, residents did not receive showers due to staffing shortages, and on weekends, there was sometimes only one certified nurse aide for the entire building. Interviews with staff indicated that the previous staffing coordinator scheduled nursing staff on a day-to-day basis rather than monthly, leading to inadequate staffing. The new staffing coordinator, who started on 3/18/24, reported not receiving any documentation or old schedules, and the staffing book was blank. The Director of Nursing acknowledged that the facility did not have a staffing plan in place due to conflicts with the previous coordinator. Staff reported instances of working alone, insufficient certified nurse aides, and the absence of registered nurses, leading to unmet resident needs such as toileting assistance and unanswered call lights.
Lack of Performance Reviews for Certified Nurse Aides
Penalty
Summary
The facility failed to ensure that certified nurse aide performance reviews were conducted at least once every 12 months for five staff members. This deficiency was identified during a recertification survey, which revealed no documented evidence of performance reviews for Staff #8, 9, 16, 17, and 18. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that performance reviews had not been conducted since the Assistant Director of Nursing's employment began in February 2023. The Director of Nursing acknowledged that staff performance was not being monitored, and there had been complaints from residents and visitors about the staff. Additionally, Staff #8, a certified nurse aide, reported never having received a performance review despite working at the facility for several years.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen area, as observed during a recertification survey. Several deficiencies were noted, including undated and unlabeled food items, such as sausage patties, stored in the freezer. The dishwasher was not reaching the appropriate final rinse water temperature, which should range from 120-150 degrees, but was only reaching 110 degrees. Additionally, staff were storing personal food in the same refrigerators used for residents' meals, and the exhaust wall fan was covered with dust and grease debris, which was blowing onto a rack where clean dishes were stored. Further observations revealed that staff were not adhering to proper hygiene practices, as a dietary aide was not wearing a beard cover while serving meals to residents. This issue was compounded by the fact that the Food Service Director was also observed without a beard cover during a follow-up visit. Additionally, tuna fish and lettuce were improperly stored on the same shelf in the refrigerator, contrary to the facility's policy that requires uncooked and raw animal products to be stored separately from ready-to-eat foods. These findings indicate a lack of adherence to professional standards for food storage, preparation, and service.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, leading to deficiencies in preventing the transmission of communicable diseases among residents. Staff members were observed not changing gloves after touching a resident or assistive devices and before handling food trays. Specifically, a Certified Nurse Assistant (CNA) was seen using the same hand to feed two residents without performing hand hygiene. Additionally, staff did not wear gowns during procedures for residents on Enhanced Barrier Precautions, which are intended to reduce the spread of multi-drug resistant organisms. This included a wound care nurse who did not wear a gown during a dressing change, resulting in their identification badge coming into contact with a resident's wound drape. Furthermore, there was a lack of documentation regarding the change of oxygen tubing for a resident, which is a critical component of infection control. The facility's policy for Enhanced Barrier Precautions was not consistently followed, as evidenced by staff not wearing gowns during treatments for residents on these precautions. Interviews with staff revealed confusion and forgetfulness regarding the new infection control measures, indicating a need for better training and adherence to protocols. These lapses in infection control practices were observed during a recertification survey, highlighting the facility's failure to implement its infection prevention and control program effectively.
Violation of Resident Dignity During Dining
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence during dining, as observed during a recertification survey. Specifically, clothing protectors were applied to six residents without obtaining their permission, contrary to the facility's policy that requires staff to ask residents if they would like to wear a clothing protector. Staff #14 admitted to routinely placing clothing protectors on all residents without asking, as it was a standard practice. Resident #54 expressed discomfort with this practice, indicating a preference to be asked before a clothing protector is applied. Additionally, staff were observed standing over two residents while feeding them, which is against the facility's policy that requires staff to be seated while assisting residents with meals. Staff #13 and Staff #8 both acknowledged standing while feeding residents, citing personal preference and workload as reasons. Resident #56, who is dependent on staff for eating due to quadriplegia and a neck collar, expressed a desire to see the person feeding them, which was not possible due to the staff's standing position. Staff #7 confirmed that aides were trained to ask for permission before applying clothing protectors and to sit while feeding residents, but noted that sometimes chairs were unavailable.
Failure to Resolve Resident Grievance Timely
Penalty
Summary
The facility failed to ensure timely resolution of grievances for a resident who reported missing clothing. The resident, who was cognitively intact and had continuous behaviors, reported the missing clothing to the social worker, but there was no documented evidence of a grievance being completed in March 2024. The facility's policy required a prompt and thorough investigation of all grievances, but this was not adhered to in this case. During interviews, the social worker stated that missing clothes were documented on a missing personal and misappropriation of property form, not a grievance form, and was unaware of the resident's missing clothing despite a progress note indicating otherwise. The administrator confirmed that an investigation should have been documented and a form completed if the property was not quickly located. The lack of documentation and follow-up on the resident's grievance led to the deficiency.
Failure to Provide Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that required documentation was sent to the receiving provider during a hospital transfer for a resident. The deficiency was identified during a recertification survey, where it was found that there was no documented evidence of a transfer summary being completed or sent when the resident was transferred to the hospital. The resident, who had a history of cerebral vascular accident, dysphagia, and seizures, was noted to have moderately impaired cognition. A nursing progress note indicated that the family requested the transfer to the hospital, but there was no evidence that necessary documentation, including contact information, advance directive information, special instructions, medications, and comprehensive care plan goals, was sent with the resident. The Assistant Director of Nursing confirmed the absence of the transfer documentation after reviewing the electronic medical record.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its Bed Hold policy to a resident or their representative upon transfer to a hospital, as required by regulations. Specifically, Resident #54, who had diagnoses of cerebral vascular accident, dysphagia, and seizures, was not given written notice of the bed hold policy when they were discharged to the hospital. The resident had moderately impaired cognition, as documented in the 5 Day Minimum Data Set. The nursing progress notes indicated that the resident was sent to the hospital at the family's request and returned six days later. However, there was no documented evidence that the bed hold policy was communicated in writing to the resident or their representative. During interviews, the Social Worker admitted that notices were not sent unless residents were private pay, and the Administrator acknowledged that notices should be given upon hospital discharge.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure that necessary assistance and care were provided for a resident to carry out activities of daily living, specifically toileting. The resident, who was cognitively intact and required moderate staff assistance for walking and toilet use, was not toileted in a timely manner after using the call bell to request assistance due to diarrhea. The resident's care plan included interventions to toilet every 2-4 hours and as needed, and to educate the resident on the toileting plan. However, when the resident called for assistance, the certified nursing assistant on the unit was not allowed to care for them, and the resident was told to wait for assistance from another unit. The resident expressed frustration and embarrassment over the situation, stating they felt humiliated for having a bowel movement in bed. Interviews with staff revealed that the nurse on duty did not provide the necessary care, despite being aware of the resident's urgent need. The Licensed Practical Nurse Unit Manager expressed surprise that the nurse did not assist the resident, acknowledging that the resident had a legitimate concern. The Director of Nursing confirmed that the nurse should have been responsible for providing care in this situation. The failure to provide timely toileting assistance resulted in a deficiency under 10 NYCRR 415.12(a)(3).
Failure to Provide Individualized Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the individual needs and preferences of a resident, identified as Resident #50, during a recertification survey. Resident #50, who was admitted with diagnoses including diabetes, end-stage renal disease, and anxiety disorder, did not have an admission activity assessment completed. This assessment was necessary to evaluate and provide meaningful activities for the resident. The resident's care plan, dated December 7, 2023, indicated that they were on contact isolation for Clostridium difficile and required in-room activities. However, there was no documented evidence in the electronic medical record of an activities admission assessment or a quarterly activities assessment for March 2024. Observations on April 9 and April 11, 2024, revealed that the resident was sitting alone in their room, and the activities attendance sheets showed that the resident was only seen once in March 2024 for a one-on-one visit, with no attendance at other activities. During an interview, the Activity Director acknowledged that the resident should have been assessed for activities upon admission and that the care plan should have been updated when the resident was no longer on precautions. The Activity Director admitted that the original assessment, if completed, would have triggered a review, highlighting a lapse in the facility's process for ensuring residents' activity needs are met.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide consistent pain management for two residents, leading to deficiencies in care. Resident #56, who was admitted with quadriplegia and other conditions, did not receive Lidocaine patches as ordered on multiple occasions due to supply issues. Despite the resident's reports of pain, there was no documented evidence of pain monitoring or alternative pain management being offered. Interviews with staff revealed a lack of communication and awareness regarding the unavailability of the patches, and the physician was not notified of the issue. Resident #43, diagnosed with type 2 diabetes, schizophrenia, and dysphagia, also experienced inadequate pain management. Although the resident received Tylenol as ordered, there was no documentation of pain assessment to evaluate the effectiveness of the medication. The resident reported pain affecting their sleep, but staff did not document pain levels as it was not included in the order. The Assistant Director of Nursing acknowledged the lack of documentation and stated that pain scales should be recorded to assess the intervention's effectiveness.
Inaccessible and Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was consistently posted in an accessible location for residents and visitors. The information was placed in the lobby area, which required a code to access, making it inaccessible to residents without staff assistance. Additionally, the posted information was not updated to reflect staffing changes throughout the day, and specific units were not included in the postings. This led to discrepancies between the posted information and the actual staffing sheets, which documented different numbers of registered nurses responsible for resident care on various days. Interviews with staff revealed a lack of clarity and training regarding the responsibility for updating the daily nurse staffing information. The receptionist, who was tasked with posting the information, admitted that the sheets were often inaccurate and outdated. The Staffing Coordinator, who previously served as the receptionist, also indicated a lack of training and stated that the Nursing Supervisor was supposed to fill out the staffing information for shifts other than the day shift. However, the Nursing Supervisor did not fulfill this responsibility, as confirmed by the Director of Nursing, who acknowledged that the receptionist should not be responsible for updating the staffing information due to their lack of awareness of staffing updates.
Inaccurate Facility Assessment for CNA Competencies
Penalty
Summary
The facility failed to ensure that the Facility Assessment was reviewed, accurate, and updated as necessary, leading to a deficiency. The Facility Profile, last reviewed on 3/20/24, inaccurately documented that certified nurse aides (CNAs) had training and competencies in tasks beyond their scope of practice, such as glucometers, medication administration, gastronomy tube placement, ventilation/tracheostomy, aseptic dressings, electrocardiograms, and pleural catheters. During interviews, the Administrator initially stated that the Facility Assessment was accurate, but later acknowledged inaccuracies in the duties assigned to CNAs and registered nurses/licensed practical nurses. The Director of Nursing also confirmed that CNAs were not able to perform the duties as indicated in the assessment.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that included protocols and a system to monitor antibiotic use, as required by regulations. During a recertification survey conducted from April 8 to April 17, 2024, it was found that the facility could not provide infection and antibiotic tracking reports for February and March 2024. The Infection Control Practitioner admitted during an interview on April 15, 2024, that the facility was behind in reviewing and tracking antibiotic stewardship, with the last review conducted in January 2024. Additionally, the Administrator was unaware of the delay in infection control tracking and antibiotic stewardship, indicating a lack of oversight and communication within the facility.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable home-like environment for its residents, as evidenced by a strong urine odor in a shared room and a damaged window curtain in another room. During the recertification survey, it was observed that the shared room of two residents had a persistent strong urine odor. One of the residents expressed uncertainty about any actions being taken to address the odor, while the other resident mentioned having informed the staff about the issue a long time ago. Interviews with staff revealed that the odor was attributed to one resident's incontinence and non-compliance with care, as well as their habit of washing and hanging clothes in the room. The mattress was identified as a source of the odor, and it was noted that the resident was not sending all their dirty clothing to the laundry. Additionally, the window curtain in another resident's room was found to be ripped and hanging off the rod. The maintenance worker stated that these were the only curtains available, and the facility was in the process of transitioning to blinds. The facility's policy on cleaning and disinfecting rooms, revised in 2019, requires regular disinfection and monthly spot checks to ensure cleanliness and orderliness of curtains and window treatments. However, the observations and interviews during the survey indicated that these policies were not effectively implemented, leading to the deficiencies noted.
Failure to Honor Advance Directives and Improper Administration of CPR
Penalty
Summary
The facility failed to adhere to the advance directives of a resident, leading to a significant deficiency. The resident, who had been admitted with acute sepsis, acute hyperkalemia, and altered mental status, had a documented Do Not Resuscitate (DNR) order and instructions to be sent to the hospital if necessary. Despite these directives, the resident was not sent to the hospital when they expressed a desire to go, and cardiopulmonary resuscitation (CPR) was improperly administered when the resident was found unresponsive. This was contrary to the Medical Orders for Life Sustaining Treatment (MOLST) and the facility's policy on advance directives. Interviews with staff and other residents revealed that the resident had been requesting to go to the hospital due to not feeling well, but these requests were ignored. The Director of Nursing confirmed that the resident should have been sent to the hospital as per their MOLST. Additionally, the staff involved acknowledged the error in performing CPR on a resident with a DNR order. The incident was further compounded by a misunderstanding of the resident's advance directives, which were supposed to be indicated by a red dot on the door and a bracelet, but were not properly followed, leading to the deficiency.
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 165 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 Wappingers Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Taconic Rehabilitation And Nursing At Hopewell | 4.5 mi | ★★★★★ | 15 | 0 |
| Fishkill Center For Rehabilitation And Nursing | 6.3 mi | ★★★★★ | 3 | 0 |
| The Pines At Poughkeepsie Ctr For Nursing & Rehab | 6.6 mi | ★★★★★ | 0 | 0 |
| Taconic Rehabilitation And Nursing At Beacon | 6.6 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nrsg At River Valley | 7.3 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.