Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springvale Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Food items were found undated in the kitchen, including cheese, juice, warmed meat, and vegetables, despite the facility's labeling policy requiring opened and ready-to-eat foods to be dated. Staff were also observed plating and handling food without required hairnets, and one FSW with full facial hair was seen without a beard covering while working at the steam tray.
A resident with cognitive impairment and multiple medical conditions experienced changes in condition, including emesis, IV hydration, antibiotic therapy, and hospital transfer, without documented notification to the resident's representative as required by facility policy. Staff interviews confirmed the responsibility to notify and document, but no evidence of such notification was found in the medical record.
A resident with cognitive impairment reported a missing cell phone that was not protected from loss or theft, despite facility policy requiring secure storage for valuables. Staff interviews revealed inconsistent practices regarding the use of lockable drawers and documentation, and there was no evidence that the resident was offered or provided appropriate safeguards for their property.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents with significant cognitive and physical impairments did not consistently receive necessary assistance with activities of daily living, as evidenced by numerous omissions in CNA documentation for care, toileting, and dressing. Family members reported finding residents soiled or not properly dressed, and staff confirmed that documentation omissions indicate care was not provided.
Staff failed to follow infection control protocols, including an LPN not wearing a gown during wound care for a resident on enhanced barrier precautions, and home health aides not performing proper hand hygiene between assisting residents during meal service. These actions occurred despite facility policies, physician orders, and staff training on infection prevention requirements.
A call bell system on one unit repeatedly failed to provide audible alerts, requiring staff to rely solely on visual cues to identify when assistance was needed. Despite multiple maintenance interventions and an upgraded system, the issue persisted over several months, with some nursing leadership unaware of the ongoing problem.
Missing Transfer, Discharge, and Bed Hold Notifications: The facility did not complete required transfer/discharge notices or bed hold notification for one resident who was hospitalized, and the Ombudsman was not notified of that resident's transfer/discharge or of another resident's discharge to the community. The DON said nursing was responsible for informing the family about bed hold policy, and the DOSS said she was responsible for sending Ombudsman notices, but neither could provide documentation that the required notifications were made.
A resident with diagnoses including BPH, acute cystitis, and urinary retention had a Foley catheter removed, and the catheter care plan was resolved, yet multiple MDS assessments still coded the resident as having an indwelling catheter. An LPN stated the resident had not had a urinary catheter for over a year, and the MDS Coordinator said the most recent quarterly assessment was a mistake and was unsure how the annual and prior quarterly assessments were coded incorrectly.
A resident with Alzheimer's disease, impaired mobility, osteoporosis, and a history of falls had an unwitnessed fall with forehead swelling and a moderate fall risk score. Although the resident received a medical workup, ER transfer, neuro checks, and a plan to redirect to the call bell, the falls care plan was not revised to include the new post-fall risk reduction interventions, and staff stated more frequent rounding was used but not added to the care plan.
A resident with chronic respiratory failure, a tracheostomy, and dysphagia did not have an Ambu bag at the bedside despite the facility’s tracheostomy policy requiring an emergency setup at bedside. Surveyors observed the missing equipment on multiple occasions, and an RN stated they did not know where the nearest Ambu bag was. The RN unit manager and DON both acknowledged that an Ambu bag should have been in place.
Improper medication storage and labeling were found for two residents. One resident kept eye drops, a nasal spray, and an inhaler at the bedside without documented self-administration assessment or physician approval, despite facility policy requiring both. Another resident’s Humalog insulin pen was left on a med cart beyond the 28-day beyond-use date, and staff said it remained there due to oversight. The facility policies required checking expiration dates and not using outdated drugs.
Adaptive eating equipment and utensils were not consistently provided for a resident with cerebral infarction, PVD, DM2, and bilateral UE contractures who required supervision with eating. Despite care plan, OT, dietary, and MD orders for a scoop plate, rocker knife, built-up spoon, and built-up fork, the resident was observed using a regular spoon and receiving a regular knife instead of the ordered rocker knife on multiple meal observations; staff and the FSD acknowledged the mismatch with the meal ticket.
Pest control program failed to keep a resident room free of flies. Surveyors observed several flies on a resident’s pillow, bedside items, bed linens, closet door, toe, and urinal cover, and the resident said staff had been told about the flies. An LPN, RN UM, and the DOR of Housekeeping were aware of the issue, but Maintenance said it had not been reported to them, and the pest control log did not document that the room or other resident rooms were checked.
The facility did not ensure that paid feeding assistants working as Home Health Aides had completed the required NYSDOH-approved 8-hour feeding assistant training before feeding residents. Surveyors observed aides feeding residents with dementia and other conditions, including residents who needed meal assistance and one resident on aspiration precautions, while staff stated the aides were used to feed residents on the units and the SLP’s competency review was not the State-required course.
A resident with severe cognitive impairment and multiple medical conditions had a Midline IV Catheter inserted after a physician's order, but the resident's representative was not notified of this significant change. Facility staff interviews and record review confirmed that required notification and documentation did not occur, and the representative only learned of the catheter after the resident was hospitalized.
A resident with severe cognitive impairment and behavioral health diagnoses exhibited ongoing aggression, including physical altercations with peers that resulted in serious injuries. Despite repeated incidents and refusal of medications, staff did not adequately evaluate or update the behavioral care plan with new interventions, and documentation of monitoring was lacking. This failure led to unaddressed aggressive behaviors and harm to other residents.
A resident with impaired cognition and behavioral health diagnoses made an allegation of abuse, which was not reported to the state survey agency within the required two-hour timeframe. The incident was reported the following day without a documented time, and there was no evidence that the five-day investigation report was submitted. Staff could not provide confirmation of the required submissions.
A resident with multiple medical conditions alleged rough handling by a CNA. Although facility records and care plans indicated a psychiatric consult was ordered following the incident, there was no documentation that the referral was completed or that the resident was seen by psychiatry. Staff interviews confirmed the consult did not occur, and no explanation was documented for the omission.
The facility failed to ensure their assessment included an evaluation of staff needed to meet residents' needs. The assessment lacked specific staffing minimums and did not include Home Health Aides, despite their presence in the facility. The Administrator was unaware of the requirement to include these details.
Two residents were discharged from an LTC facility without documented discharge care plans or interdisciplinary team meetings. One resident had severe cognitive impairment and required maximal assistance, while the other had intact cognition but needed assistance with daily activities. Despite claims from the social worker that discharge care plans were initiated, no documentation was provided, highlighting a failure in the facility's discharge planning process.
A resident with severe cognitive impairment and a history of falls experienced multiple falls, resulting in a fracture, due to inadequate supervision and lack of timely updates to their fall risk care plan. The facility did not implement necessary interventions after each fall, and staff interviews revealed insufficient measures to prevent further incidents.
Food Storage and Staff Hygiene Standards Not Followed
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food safety. During observation of the main refrigerator, six slices of yellow cheese and a pitcher of juice were found without dates. During observation of the kitchen, a small container of warmed meat and a container of warming vegetables were seen on top of a stove without a date, and the plastic wrap only had writing indicating "Monday" rather than a date. The facility's Dating and Labeling Policy required opened products and ready-to-eat foods to be labeled with the date opened or a 72-hour use-by date, but these items were not labeled as required. Food Service Workers were also observed not following the facility's Uniform Policy during food preparation and service. Two Food Service Workers were seen without hairnets while breakfast food was being plated, and another Food Service Worker with full facial hair was observed at the steam tray without a beard covering while removing plastic wrap from food pans and handling utensils. The Director of Food Services stated staff were responsible for ensuring hairnets and beard guards were in place, but these items were missed.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition and treatment, as required by facility policy and state regulations. Specifically, a resident with a history of cerebral infarction and colon neoplasm, who was moderately cognitively impaired, experienced several changes in condition, including episodes of emesis, administration of intravenous hydration and antibiotics, and a transfer to the hospital for evaluation due to a change in mental status. Documentation in the medical record did not show that the resident's representative was informed of the initiation of intravenous hydration, antibiotic therapy, or the transfer to the hospital. Interviews with facility staff, including LPNs, the Medical Director, and the DON, confirmed that it was the responsibility of licensed nurses, nurse practitioners, and medical doctors to notify resident representatives of changes in condition and to document such notifications. However, in this case, there was no evidence in the medical record that the required notifications were made or documented for the resident's representative during these significant events.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction and schizoaffective disorder, who was moderately cognitively impaired, reported that their personal cell phone went missing while being charged during their stay. The facility's policy required that each resident be offered a locked drawer or equivalent with a key for small valuables, and that an inventory of personal belongings be maintained. However, there was no documented evidence that the resident's cell phone was protected from loss or theft at the time of the incident. The Social Work note confirmed the missing phone and communication with the resident's family, but did not indicate that appropriate safeguards were in place. Interviews with facility staff revealed inconsistent practices regarding the safeguarding of residents' valuables. The Director of Social Work stated that valuables could be kept in the Social Work Office or in a lockable dresser drawer, but was unaware if the resident had been offered such options. Nursing staff indicated that lockable drawers were available and could be provided by the Maintenance Department if needed, with keys held by either the resident or licensed nurses. The Administrator confirmed that residents' possessions were documented on an inventory checklist and that lockable drawers were available, but could not recall details about the missing cell phone. There was no evidence that the required protections for the resident's property were implemented in this case.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide and Document Required ADL Care for Dependent Residents
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 grooming and personal hygiene. For two of seven residents reviewed, documentation by certified nurse aides (CNAs) was inconsistent, with numerous omissions noted in the records for care, toileting, and dressing. One resident with diagnoses including dementia, depression, and anxiety required significant assistance with ADLs, yet CNA documentation showed 135 omissions in one month and 70 omissions the following month. The resident's family reported finding the resident soiled or wet and not dressed in their own clothing during visits. Interviews with staff confirmed that omissions in documentation indicate care was not rendered, and that all care provided or not provided should be documented with a reason. Another resident with cancer, renal insufficiency, and diabetes mellitus also required moderate to maximal assistance with personal hygiene and toileting. CNA documentation for this resident showed 35 omissions over a period of several weeks. Nursing notes documented persistent incontinence and a groin rash, and the resident's family reported having to provide incontinence care themselves, including an incident where the resident was found covered in feces. Staff interviews reiterated that all ADL care must be documented, and omissions suggest the care was not provided. The facility's policy requires that all ADL care be documented by the end of each shift, with reasons provided if care is not performed.
Failure to Adhere to Infection Control Protocols During Resident Care and Meal Service
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols. One incident involved a Licensed Practical Nurse who did not wear a gown while providing wound care to a resident on enhanced barrier precautions, despite clear policy and physician orders requiring gown and glove use for high-contact care. The resident in question had severe cognitive impairment, a pressure ulcer, and was under specific orders for enhanced barrier precautions. The nurse acknowledged awareness of the requirement but did not comply during the observed treatment. Additional deficiencies were observed during meal service, where home health aides failed to perform proper hand hygiene between assisting residents. One aide did not sanitize hands after handling various objects and before feeding a resident, while another did not perform hand hygiene after feeding one resident and before assisting another. Staff interviews confirmed knowledge of hand hygiene protocols, and management reported ongoing education and audits, but the observed lapses demonstrated non-compliance with infection control policies.
Failure to Maintain Functioning Call Bell System in Resident Areas
Penalty
Summary
The facility failed to ensure that a functioning call bell system was available in each resident's bathroom and bathing area on Unit 2 East. On multiple occasions, including during the survey, the audible portion of the call bell system was not working, meaning that when the call bell was activated, only a light illuminated outside the resident's room, but no sound was heard on the unit floor or at the centralized nurse station. Staff interviews confirmed that the sound component of the system was intermittently nonfunctional, requiring staff to visually monitor for illuminated call lights rather than being alerted by sound. Maintenance staff confirmed that the speakers at the nurse's station were not working and that the system sometimes required a computer reset to function properly. The call bell system on Unit 2 East had been upgraded to a different system than the rest of the facility several months prior, but issues persisted both before and after the upgrade. A review of maintenance records showed repeated issues with the call bell system on Unit 2 East over several months, with multiple work orders documenting malfunctions on specific dates. Despite the high priority assigned to call bell repairs, the problem recurred, and some nursing leadership were unaware of the ongoing sound issues. The expectation from some staff was to look for call bell lights and respond as soon as possible, but the lack of an audible alert compromised the intended function of the call system.
Missing Transfer, Discharge, and Bed Hold Notifications
Penalty
Summary
The facility did not ensure that required transfer and discharge notifications were completed in writing and in a language and manner understood by the resident, resident representative, and the Office of the State Long-Term Care Ombudsman for 2 of 3 residents reviewed for hospitalization and discharge. For Resident #189, who had diagnoses including Alzheimer's disease, CVA, and atrial fibrillation and had severe cognitive impairment on the admission MDS, the record showed the physician ordered transfer to the hospital, the resident's representative was notified and agreed, and the resident was sent to the hospital for further evaluation and admitted there. However, the facility did not complete a discharge notice or bed hold notification for the hospitalization, and the Ombudsman was not notified of the transfer/discharge. For Resident #191, who was admitted with diagnoses including major depressive disorder, bipolar disorder, and nicotine dependence and was cognitively intact on the admission MDS, the discharge assessment documented that return was not anticipated and the resident was discharged to the community. The Director of Nursing stated nursing was responsible for notifying the family of the bed hold policy, but could not provide documented evidence that the family was informed verbally or in writing for Resident #189. The Director of Social Services stated they were responsible for sending Transfer/Discharge Notices to the Ombudsman for all resident transfers and discharges, but could not provide documented evidence that the Ombudsman was notified of Resident #189's transfer/discharge or Resident #191's discharge, and stated it was an oversight.
Inaccurate MDS Coding for Urinary Catheter Status
Penalty
Summary
The facility did not ensure the accuracy of the Minimum Data Set for one resident reviewed for urinary catheter status. Resident #16 was admitted with diagnoses including benign prostatic hyperplasia, acute cystitis, and urinary retention. The 3/26/25 urinary incontinence care plan documented occasional bladder incontinence and included interventions to monitor for urinary tract infection symptoms and changes in continence status, and the Foley catheter/suprapubic care plan was resolved. Physician orders dated 4/11/24 directed removal of the urinary catheter, and a nursing progress note dated 4/12/24 documented that the resident's urinary catheter was removed. Despite this, the resident's MDS assessments with reference dates of 12/24/24, 3/24/25, and 6/22/25 all coded the resident as having an indwelling catheter. During interview, an LPN stated the resident had not had a urinary catheter for over a year, and the MDS Coordinator stated the most recent quarterly assessment was a mistake and was unsure how the annual and prior quarterly assessments were coded that way.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The Comprehensive Care Plan was not revised to reflect preventative interventions for Resident #64 after a fall. Resident #64 had diagnoses of Alzheimer's disease, difficulty walking, osteoporosis, and a history of falls. The 8/6/2025 MDS documented severely impaired cognition, supervision needed for transfers from sitting to standing, toileting, and walking, and one fall with injury since the prior assessment. On 8/5/2025, the resident had an unwitnessed fall and was found lying flat on the floor next to the foot end of the bed, unable to state what happened because of cognition. The resident had swelling to the right side of the forehead, an ice pack was applied, and neuro checks were completed. The nursing fall risk assessment documented a total fall risk score of 35, indicating moderate risk. The 8/5/2025 medical progress note documented that the resident sustained a fall, received ice compression and pain medication, was sent to the emergency room, x-ray was deferred, and neuro checks were ordered for 24 hours. The medical plan documented in the progress note was to redirect the resident to use the call bell. The existing falls care plan dated 4/10/2025 included interventions such as reality orientation, keeping the floor free from clutter, rehab referral, psychiatry consult, gradual dose antidepressant, anticipating ADL needs, and keeping the bed in the lowest position. New interventions effective 8/5/2025 were limited to a medical workup, and the care plan was not updated to include the new risk reduction fall interventions implemented after the fall.
Missing bedside Ambu bag for resident with tracheostomy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured when Resident #125, who had chronic respiratory failure with hypoxia, a tracheostomy, and dysphagia, did not have an Ambu bag at the bedside. The resident’s Quarterly MDS documented severe cognitive impairment and dependence on a tracheostomy and oxygen therapy, and the comprehensive care plan for Respiratory Care documented maintaining the resident’s airway. The facility’s Tracheostomy Care policy, last revised in April 2025, stated that an emergency tracheostomy setup was to be maintained at the resident’s bedside. However, during observations on 08/12/2025, 08/13/2025, and 08/14/2025, no Ambu bag was present at the bedside. During interview, an RN stated there was no Ambu bag at the bedside and did not know where the nearest one was, while the RN Unit Manager stated there used to be one at the bedside and that they were responsible for ensuring one was available. The DON also stated there should have been an Ambu bag at the bedside and that the unit manager was responsible for ensuring one was in place.
Improper Medication Storage and Expired Insulin Pen
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles for two residents reviewed for medication storage and labeling. Resident #60, who had diagnoses including acute and chronic respiratory failure, hypoxia, depression, and anxiety disorder, had intact cognition on the admission MDS and required assistance from one person with activities of daily living. The resident’s comprehensive care plan did not include self-administration of medications, and the physician orders included inhaled and PRN respiratory and eye medications. Despite this, the resident was observed on three occasions with Carboxy-methylcellulose 0.5% eye drops, Deep Sea Nasal Spray 0.65%, and a Budesonide-Formoterol inhaler on the bedside table. The resident stated they kept the medications at the bedside and took them themselves because nurses did not administer them on time. Facility staff stated that residents should not keep medications at the bedside without proper assessment and physician approval. The facility’s self-administration policy required a nurse assessment, interdisciplinary review, documentation of the resident’s capability, and physician orders for both self-administration and bedside storage. During interview, the LPN unit manager and the ADON stated that the resident needed to be assessed for capacity and have a physician’s order before keeping medications at the bedside. The medications were nevertheless observed in the resident’s room during the survey. For Resident #115, an insulin pen for Humalog 100 units/mL was observed on a medication cart with an opening date that was past the manufacturer’s recommended 28-day discard period and was found 17 days after the recommended discard date. The facility’s medication storage policy stated that discontinued, outdated, or deteriorated drugs and biologicals shall not be used and must be returned to the dispensing pharmacy or destroyed, and the medication administration/disposition policy required checking expiration or beyond-use dates before administration and recording the date opened on multi-dose containers. Staff interviews indicated the pen remained on the cart due to oversight, and the nurse manager stated it was the responsibility of the administering nurse, unit manager, and pharmacy consultant to check and audit expiration dates.
Adaptive Eating Equipment Not Provided as Ordered
Penalty
Summary
Special eating equipment and utensils were not consistently provided for Resident #17, despite multiple orders and care plan interventions requiring adaptive devices at meals. The resident was admitted with diagnoses including cerebral infarction, peripheral vascular disease, and Type 2 diabetes, and had intact cognition with impairment of both upper and lower extremities and supervision assistance needed for eating. The resident’s care plan, dietary order, OT evaluation, and medical order all documented the need for a scoop plate, rocker knife, built-up spoon, and built-up fork, with the OT noting contractures of both upper extremities that interfered with the ability to use feeding utensils. During dining observations, Resident #17 was seen eating cereal with a regular plastic spoon instead of the ordered adaptive spoon, and on two separate occasions the resident’s meal tray contained a regular knife instead of the required rocker knife. The meal tray ticket documented the adaptive utensils that were to be provided. The resident stated they needed the rocker knife because they were unable to cut turkey and other meats. A CNA stated the resident was supposed to have a weighted spoon but was using a regular spoon, and the Food Service Director stated they were unaware the resident did not receive the rocker knife even though the meal ticket required it.
Pest Control Program Failed to Keep Resident Room Free of Flies
Penalty
Summary
The facility did not maintain an effective pest control program to keep the building free of flies. During the recertification survey, Resident #8’s room was observed with several flies on multiple occasions, including on the pillow, bedside chair, call bell cord, bedside table napkin, bed sheets, closet door, the resident’s big toe, and the urinal cover. The resident stated that flies were present in the room and that staff had been informed. Staff interviews showed that the presence of flies had been known to some personnel, but the issue was not consistently communicated or documented through the facility’s pest control process. An LPN stated they had seen flies in the room and was unsure when the exterminator came. The RN Unit Manager stated the flies had been reported early the prior week to the clinical team, the Director of Housekeeping, and the Administrator. The Director of Housekeeping confirmed awareness of the flies and said the exterminator had been in the facility, but was unsure whether the room had been checked. Maintenance staff stated they were not aware of flies in the room or other rooms because it had not been reported to them, and the Administrator could not provide documented evidence in the pest control log that the room had been inspected. The pest control log reviewed covered dates from 1/27/25 to 7/28/25 and did not show that Resident #8’s room or other resident rooms were checked for flies.
Feeding Assistants Lacked Required State Training
Penalty
Summary
The facility did not ensure that paid feeding assistants working under the title Home Health Aides had successfully completed the required State-approved 8-hour feeding assistant training before feeding residents. During the recertification survey, there was no documentation that 12 of 12 reviewed Home Health Aides had the required training, even though the facility provided certificates showing completion of Home Health Aide courses from an outside agency. An email from that agency stated its Home Health Aide program did not include the separate NYSDOH-approved Feeding Assistant Training. Facility records also showed the Home Health Aide job description did not include feeding residents, despite staff statements that these aides were used for feeding and transportation. Surveyors observed Home Health Aide #4 feeding a resident with dementia, hypertension, and Alzheimer’s disease who needed assistance with meals, and later feeding another resident with Alzheimer’s disease, psychosis, and depression who had severe cognitive impairment and aspiration precautions. Home Health Aide #36 was observed feeding a resident with hypertension, type II diabetes, and dementia who had severe cognitive impairment and needed assistance with meals, and Home Health Aide #38 was observed feeding the resident with dementia, hypertension, and Alzheimer’s disease. Staff interviews confirmed that aides were feeding residents on the units, including puree, chopped, and modified diets, while the DON stated they were not aware of the required 8-hour training and the SLP stated the competencies performed were not State course certification.
Failure to Notify Resident Representative of Midline Catheter Insertion
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's representative of a significant change in the resident's physical status, specifically the insertion of a Midline Intravenous Catheter. The facility's policy required notification of the resident, attending physician, and representative in the event of a change in condition or status. The resident involved had diagnoses including dementia, end stage renal disease, and coronary artery disease, and was assessed as having severely impaired cognition and requiring moderate to maximal assistance with activities of daily living. A physician ordered the placement of a Midline Catheter, and an external intravenous contracting company inserted the catheter. However, there was no documentation in the nursing progress notes or elsewhere that the resident's representative was notified of this procedure. Interviews with facility staff revealed that the Registered Nurse Manager did not recall if the representative was notified, and the Assistant Director of Nursing confirmed that notification and documentation should have occurred. The resident's representative stated they were unaware of the catheter placement until seeing the resident in the hospital. The Nurse Practitioner also indicated an expectation that the Unit Manager would notify the representative, but there was no evidence this occurred. The lack of notification and documentation was confirmed through record review and interviews.
Failure to Evaluate and Update Care Plan Following Resident Aggression
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident with a history of dementia, anxiety disorder, and psychotic disorder remained free from abuse and that care plan interventions were evaluated for effectiveness. The resident exhibited ongoing aggressive behaviors, including agitation, yelling, refusal of medications, and physical aggression toward other residents and staff. Despite these behaviors, there was no documented evidence that the care plan was reviewed or updated with new interventions following incidents of aggression. On multiple occasions, the resident refused prescribed medications and displayed escalating behaviors, such as screaming, attempting to hit others, and pouring water on the floor. Staff documented these behaviors and attempted verbal redirection and de-escalation, but these interventions were largely unsuccessful. The care plan was only minimally updated to include medication administration and notification of the physician, but there was no evidence of a comprehensive evaluation or adjustment of interventions to address the resident's ongoing aggression. Two significant incidents occurred where the resident physically contacted other residents, resulting in injury. In one event, the resident propelled their wheelchair into another resident, and in another, the resident struck a peer, causing a fall that led to a head hematoma, wrist fracture, and hip fracture. Interviews with staff confirmed that the behavioral care plan had not been updated with new interventions after these incidents, and monitoring documentation was missing. The lack of timely and effective evaluation of care plan interventions contributed to the failure to protect residents from abuse and neglect.
Failure to Timely Report Alleged Abuse and Submit Investigation Documentation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the state survey agency within the required timeframe for one resident. Specifically, a resident with a history of bipolar disorder, paranoid schizophrenia, and schizoaffective disorder, who had moderately impaired cognition and behavioral issues, made a serious accusation of being beaten and raped. The resident called 911, prompting a response from law enforcement and paramedics, and was subsequently transferred to the hospital for evaluation. The hospital examination found no evidence of trauma, but noted a bizarre thought process and referred the resident for telepsychiatry evaluation. Despite the gravity of the allegation, the facility did not report the incident to the Department of Health within the mandated two-hour window. Documentation indicated the report was made the following day, with no specific time recorded. Additionally, there was no documented evidence that the required five-day investigation report was submitted to the Department of Health. Interviews with facility staff revealed that the Director of Nursing, who was responsible for reporting and is no longer employed at the facility, may have submitted the report, but no confirmation or documentation could be provided.
Failure to Complete Psychiatric Referral Following Abuse Allegation
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including status post fall with right elbow injury, alcoholic cirrhosis, and hypertension, made an allegation of abuse involving rough handling by a Certified Nursing Assistant. Following the incident, facility documentation—including the Accident and Incident report, nursing notes, and care plans—indicated that a referral for psychiatric consultation was made as per the physician's order and the resident's care plan, which required psychiatric consults as needed. However, there was no documented evidence that the psychiatric referral was completed or that the consultation took place after the incident. Interviews with facility staff and the psychiatric nurse practitioner confirmed that no psychiatric consult was performed for the resident following the abuse allegation, despite expectations and documented interventions requiring such a referral. The psychiatric nurse practitioner stated they had only seen the resident once prior to the incident and did not receive a referral after the event. Other staff members, including the LPN Unit Manager and DON, were unable to provide a reason for the lack of follow-through, and documentation did not clarify why the psychiatric consultation was not completed as ordered.
Deficiency in Facility Staffing Assessment
Penalty
Summary
The facility was cited for not ensuring that their facility assessment included an evaluation of the overall number of staff needed to meet each resident's needs. The Facility Assessment, last updated on October 10, 2024, included a section on staffing plans based on an average daily census of 185 residents. However, this section did not specify any actual staffing minimum numbers. During an interview, the Staffing Coordinator outlined the staffing requirements for different shifts, but these details were not reflected in the Facility Assessment. Additionally, the Administrator acknowledged the challenge of maintaining adequate staffing levels due to a state of emergency regarding the healthcare worker shortage in New York. The Administrator also mentioned the presence of Home Health Aides in the facility, but these aides were not included in the Facility Assessment or staffing assignments. The Administrator admitted to being unaware that the Facility Assessment needed to indicate minimum staffing levels or include Home Health Aides.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the practice? The facility reviewed and updated Facility Assessment to include HHA, PAR level, and Minimum PAR levels. The IDT met to review the assessment to ensure sufficient staffing for all units in the facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The staffing coordinator will maintain the daily unit staffing sheet (RN, LPN, CNA, and HHA) of all units for sufficient staffing. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? The staffing coordinator will review and update the daily unit staffing sheet to include HHAs on the unit staffing sheet. The staffing coordinator will be responsible for maintaining the daily unit staffing sheet to be presented to the Director of Nursing. A random audit of the daily staffing sheet will be conducted by the Director of Nursing times weekly x 4 weeks, then monthly x 3 months. How will the corrective action(s) be monitored to ensure the deficient practice will not recur? What quality assurance program will be put into practice? The Director of Nursing audit findings will be presented monthly and quarterly to the Quality Assurance and Improvement Committee. The facility will meet 100% compliance with such audit. All audits will be brought to QAPI monthly x 3 months. Completion Date: 1/16/25 Responsible person(s): Director of Nursing.
Failure to Initiate Discharge Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans with measurable objectives and timeframes were developed for residents' medical, nursing, and psychosocial needs, as identified in their comprehensive assessments or discharge plans. Specifically, two residents were discharged without having discharge care plans initiated upon admission. Resident #2, who had severe cognitive impairment, muscle weakness, and required maximal assistance with daily activities, was discharged without a documented discharge care plan or an interdisciplinary team meeting prior to discharge. Additionally, there were no documented interventions for the resident's incontinence and skin integrity issues. Resident #4, who had intact cognition but required assistance with daily activities, was also discharged without a documented discharge care plan or an interdisciplinary team meeting. The resident received a Notice of Medicare Non-Coverage and chose not to appeal, leading to a discharge without the necessary planning. The social worker claimed that discharge care plans were initiated, but no documentation was provided to support this claim. Interviews with the Director of Nursing and the social worker revealed discrepancies in the discharge planning process. The Director of Nursing stated that discharge care plan meetings are conducted with the interdisciplinary team, while the social worker mentioned that discharge care plans are initiated upon admission. However, the social worker was unable to provide copies of the care plans for the two residents in question, indicating a failure in the facility's discharge planning process.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for three residents reviewed for accidents. Specifically, one resident with a history of falls experienced multiple falls within a short period, resulting in an acute left femoral neck fracture. The facility did not document timely updates or interventions after each fall to prevent recurrence, and the resident's fall risk care plan was not updated with new interventions. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, and chronic pain, had severe cognitive impairment and required maximal assistance for daily activities. Despite being at high risk for falls and exhibiting poor balance, the resident's care plan lacked specific interventions to address these risks. The facility's policy required a fall risk evaluation and consistent intervention after falls, but these were not adequately implemented. Interviews with staff revealed that the resident did not have side rails due to cognitive limitations and that interventions to engage the resident outside their room were implemented only after multiple falls. The facility administrator acknowledged that a new protocol for post-fall intervention was instituted after the resident's falls, indicating a lack of effective measures in place at the time of the incidents.
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What surveyors actually found near you
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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 Croton On Hudson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New York State Veterans Home At Montrose | 0.8 mi | ★★★★★ | 4 | 0 |
| Sky View Rehabilitation & Health Care Center L L C | 1.5 mi | ★★★★★ | 6 | 0 |
| Northern Riverview Health Care, Inc | 3.3 mi | ★★★★★ | 23 | 0 |
| Helen Hayes Hospital R H C F | 3.7 mi | ★★★★★ | 0 | 0 |
| Helen Hayes Hospital T C U | 3.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.