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 Sullivan County Adult Care Center during CMS and state inspections, most recent first.
A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident with a table, and used profanities toward the resident. The RN supervisor and DON did not initiate an immediate abuse investigation, did not complete a resident assessment or incident documentation, did not notify the provider, and did not remove the accused CNA from access to the resident. The resident had dementia with moderately impaired cognition and a care plan noting potential for abuse related to resistance of care, verbal aggression, and physical aggression.
Failure to Protect Resident From Alleged Abuse: A CNA reported that another CNA used profanities toward a resident, forcibly grabbed and pushed the resident in a wheelchair, and blocked the resident with a table. The resident had dementia and moderately impaired cognition, and the care plan identified a potential for abuse and verbal or physical aggression. Although the allegation was reported to supervisory staff, the accused CNA remained assigned to the resident, and there was no documented resident assessment, MD notification, psych consult, incident report, or abuse investigation.
Failure to Timely Report Alleged Abuse: A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident’s movement with a dining table, and used profanities toward the resident. The allegation was reported to an LPN and RN supervisor, but the facility did not notify DOH within the required timeframe; the resident had dementia and moderately impaired cognition.
A resident with dementia, depression, and anemia had care plans for psychosocial well-being, risk of victimization/aggression, and behavior that were not reviewed or revised after allegations of verbal and physical abuse by a CNA. Staff described the CNA yelling profanities, pushing the resident back into a wheelchair, and later blocking the wheelchair with a table. The QI nurse acknowledged the plans were not updated to reflect the incident, and an RN stated they were unaware of the allegations until later staff education.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
Three residents experienced actual harm when the facility failed to follow care plans, ensure safe transfers, and adequately investigate injuries of unknown origin. One resident, dependent on a two-person transfer, was transferred by a single CNA who did not check the Kardex, resulting in a fall and head laceration. Another resident, severely cognitively impaired and recently post–eye surgery, was later found with a right hip bruise, unable to stand, and was diagnosed with a displaced femoral neck fracture, with no documented cause, no staff statements, no investigation, and no report to the state health department. A third resident with dementia and limited mobility developed a large bruised and swollen left leg, later found to have tibia and fibula fractures, while the facility’s incident report attributed the injury to contact with a Hoyer lift without supporting statements or clear evidence.
Two residents with severe cognitive impairment and mobility limitations each developed large bruises and subsequent fractures of unknown origin (one hip fracture and one tibia/fibula fracture). In both cases, staff noted pain and functional decline, completed internal incident reports, and involved medical providers, but did not conduct or document thorough investigations into how the injuries occurred. Required statements and supporting information were missing, one incident was attributed to bumping a Hoyer without documented evidence, and reports to the state health department were not made immediately as required for alleged abuse, neglect, or injuries of unknown origin resulting in serious bodily injury.
Two residents experienced significant bruising and subsequent fractures of unknown origin, and the facility did not conduct thorough investigations as required by its incident policy. One resident, with severe cognitive impairment and recent eye surgery, was later found with a right hip bruise and an acute displaced femoral neck fracture, with no documented look‑back, staff statements, or clear circumstances of injury, and no report initially made to the state health department. Another resident with dementia and total dependence for transfers developed a large, painful bruise on the left lower leg that was later diagnosed as tibia and fibula fractures; the initial incident report attributed the injury to bumping a Hoyer lift without supporting statements or clear evidence, and the DON reported not knowing how this conclusion was reached or why they were not informed promptly.
A resident with severe cognitive impairment and a history of self-injurious behavior experienced a traumatic finger amputation after repeatedly chewing on nonfood items. Despite physician orders for frequent safety checks and facility policies requiring documentation, staff were unable to provide records showing that hourly or 15-minute safety checks were completed as ordered. Interviews confirmed that while procedures for monitoring existed, no documentation could be found to demonstrate that the required supervision was provided.
A resident with multiple chronic conditions died, and the death certificate was not signed within the required timeframe due to a lack of timely communication between nursing staff and the Medical Director. The delay caused additional stress for the family and postponed funeral arrangements, as the funeral home could not proceed without the signed certificate.
A resident with dementia and impaired cognition was allegedly picked up, dropped, and carried by a staff member in front of multiple witnesses. Although the incident was reported to two RNs and the DON, no investigation was initiated and the event was not reported to the administrator, contrary to facility policy requiring immediate action for suspected abuse.
A resident with dementia and mood disturbance was given an intramuscular injection of Lorazepam solution that had been prescribed for another resident. The DON administered the medication after it was prepared by the Nurse Educator, who did not verify the prescription details and assumed it was a stock medication. Facility policy prohibits sharing medications between residents, and there was no documentation that the injectable Lorazepam was dispensed for this resident.
The facility did not provide nursing staff with training or competencies to address the behavioral health needs of residents with psychiatric or mood disorders beyond dementia care. A resident with multiple psychiatric diagnoses did not have access to appropriately trained staff, and staff interviews confirmed the absence of behavioral health training and protocols for managing such conditions.
A facility failed to ensure safety for two residents, leading to harm. One resident fell from a mechanical lift due to a dead battery and improper handling by CNAs, resulting in a head injury. Another resident, with a swallowing disorder, was given a non-compliant snack, causing choking and respiratory arrest. Both incidents required hospital transfers.
The facility failed to store food according to professional standards, with items in freezers and refrigerators found unlabeled, undated, and expired. Essential equipment, such as freezer doors, was not in safe operating condition, causing ice formation. Damaged flooring near the dishwasher also indicated maintenance issues.
The facility was found to have insufficient nursing staff, particularly during night shifts, leading to unmet resident needs. Staffing schedules showed frequent shortages, with only one CNA often covering Unit 1. Staff interviews revealed overwhelming workloads and frequent callouts, with the RN Supervisor having to assist with care. Despite efforts to improve staffing, the facility struggled to maintain adequate levels, impacting resident care.
The facility did not ensure food and drink were served at safe and appetizing temperatures. A resident reported receiving cold food due to delays in tray delivery, and another resident confirmed similar issues. During a Resident Counsel Group meeting, several residents noted that food was often cold and unappetizing. A test tray showed food temperatures below acceptable levels, although the Food Services Director stated they were acceptable when leaving the kitchen.
A facility failed to maintain a safe and homelike environment when a ceiling leak caused by a faulty air conditioner led to a large hole and water pooling in a resident's room. Despite being notified, maintenance did not address the issue promptly, and residents were not moved immediately, posing a safety risk. Communication lapses among staff contributed to the delay in resolving the problem.
A facility failed to report an alleged misappropriation of a resident's gold necklace to the NY State Department of Health. The resident, who was moderately cognitively impaired, reported the necklace missing after two staff members took it for cleaning. Despite a police investigation, the facility did not report the incident, as it was considered a missing item.
A resident with Alzheimer's was temporarily moved due to repairs but was not returned to their original room promptly, despite expressing dissatisfaction with the temporary room. The facility failed to document discussions or follow up on the resident's preferences, leading to distress and confusion.
A resident with chronic health conditions was administered oxygen therapy without a physician's order, contrary to the facility's policy. Observations and records showed the resident consistently received 2 liters of oxygen via nasal cannula, but there was no documented order or care plan. Nursing staff confirmed the requirement for a physician order, which was not obtained.
A resident admitted on hospice care did not have a physician's order documented until months later. Despite being on hospice since admission, the necessary order was not entered into the facility's electronic records. Staff interviews confirmed the oversight, highlighting a deficiency in ensuring proper documentation of hospice services.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident and failed to implement immediate protective actions after a CNA reported observing another CNA forcibly grab the resident, push the resident into a wheelchair, and use a dining room table as a barrier to keep the resident from getting out of the wheelchair. The reporting CNA also stated they heard repeated profanities directed at the resident. The resident had diagnoses including dementia, depression, and anemia, and the admission MDS documented moderately impaired cognition. The resident’s psychosocial care plan identified a potential for abuse related to resistance of care, verbal aggression, and physical aggression. After the allegation was reported to an LPN and an RN supervisor, the RN supervisor did not initiate an immediate investigation at the time of discovery. The resident was not assessed for physical injury or psychosocial harm, no incident report or abuse investigation was documented, and the medical provider was not notified. The resident’s representative was not contacted until later, and there was no documented psychiatric consultation. The staff member accused of abuse was not removed from access to the resident or other residents, and the resident continued to be assigned to that staff member on subsequent shifts. Statements obtained from staff reflected conflicting accounts of the interaction in the dining/dayroom area of the locked memory care unit. One CNA reported seeing the resident being pushed and blocked in by a table, while the accused CNA stated the resident was yelling, cursing, and being redirected, and denied pinning the resident against a wall or blocking the resident with a table. The RN supervisor acknowledged that no accident and incident report, investigative summary, body assessment, resident assessment, or abuse investigation was completed on the day the allegation was reported, and that the accused CNA remained on the unit. The DON and administrator also stated the allegation was not reported as abuse because it was not believed abuse had occurred.
Failure to Protect Resident From Alleged Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA reported observing another CNA forcibly grab the resident, push the resident against a wheelchair, use a dining room table as a barrier to keep the resident from getting out of the wheelchair, and repeatedly use profanities toward the resident. The resident had diagnoses including dementia, depression, and anemia, and the admission MDS documented moderately impaired cognition. The resident’s care plan identified a potential for abuse and verbal or physical aggression, and the behavior care plan documented the resident could become verbally aggressive when frustrated or confused. The allegation was reported to supervisory staff on the day it occurred, and staff statements were obtained. However, the resident remained routinely assigned to the accused CNA after the allegation and until the onsite visit when the CNA was reassigned. The report states there was no documented resident assessment, physician notification, psychiatric or psychology consult, accident and incident report, investigation summary, law enforcement notification, care plan review or update, or abuse investigation related to the allegation. Interviews showed conflicting accounts of the event, but multiple staff acknowledged the allegation was reported and that the accused CNA was not removed from the unit. The DON stated the allegation should have been investigated and the accused CNA should have been removed from assignments pending the investigation. The Administrator stated the alleged incident should have been investigated and an accident and incident report should have been initiated. The Medical Director stated arguing in front of residents can cause psychological harm and residents should be evaluated if that occurs.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported to the New York State Department of Health within the required timeframe. Certified Nurse Aide #1 reported observing Certified Nurse Aide #2 forcibly grab the resident, force the resident into a wheelchair, place a dining room table in front of the resident to prevent movement, and repeatedly use profanities toward the resident. The allegation was reported to an LPN and an RN supervisor on 05/11/2026, but the facility did not report the allegation to the Department of Health until 05/21/2026. The resident involved was admitted with diagnoses including dementia, depression, and anemia, and the admission MDS dated 04/11/2026 documented moderately impaired cognition. During interviews, Certified Nurse Aide #1 stated the resident was yelling profanities near the nurses' station and asking to be toileted while pants were down, and that Certified Nurse Aide #2 yelled profanities back, aggressively pushed the resident into the wheelchair, and later positioned the wheelchair and dining room table to prevent the resident from getting out. The RN supervisor stated the allegation was reported to the DON on 05/11/2026, while the DON stated the allegation was not reported because it was not believed that abuse had occurred.
Care Plan Not Updated After Abuse Allegations
Penalty
Summary
The facility failed to ensure Resident #1’s comprehensive care plan was reviewed and revised after a significant change in condition and as needed to reflect current needs. Resident #1 was admitted with diagnoses including dementia, depression, and anemia, and the admission MDS documented moderately impaired cognition. The facility’s policy stated comprehensive care plans shall be reviewed and updated with significant changes in condition and when desired outcomes are not achieved, and that care plans shall be current, accurate, and reflective of the resident’s present condition. Following allegations of verbal and physical abuse of Resident #1 by Certified Nurse Aide #2, the resident’s psychosocial well-being, risk to be victimized/aggressor, and behavior care plans were not reviewed or revised. The care plan for risk to be victimized or aggressor, last revised on 04/09/2026, documented the resident was at risk related to impaired judgment and confusion and included interventions such as encouraging positive outlets, keeping the resident within viewing distance, monitoring mood or behavior changes triggered by environmental factors, and monitoring well-being without environmental restrictions. The psychosocial well-being care plan, also last revised on 04/09/2026, documented potential for abuse related to resistance to care, verbal aggression, and physical aggression, with interventions including allowing the resident to express fear or anxiety, developing a trusting therapeutic relationship, encouraging reporting of abuse, and following facility reporting protocol. The behavior care plan, last revised on 04/24/2026, documented the resident had the potential to be verbally aggressive when frustrated or confused related to difficulty understanding situations, unmet needs, or communication breakdowns, with interventions to analyze triggers and de-escalation factors. During interview, CNA #1 stated CNA #2 yelled profanities back at the resident, aggressively pushed the resident back into a wheelchair, and later positioned the wheelchair against a wall with a dining table in front of the resident, preventing the resident from getting out. The Infection Control/Quality Assurance Nurse acknowledged the care plans were not reviewed or revised after the allegations and stated they should have been updated to reflect the incident and resident-specific interventions. RN #3 stated they were not aware of the allegations until staff received education regarding abuse and reporting requirements.
Missing Mandatory Orientation and Training for Agency CNA
Penalty
Summary
Certified Nurse Aide #1 was assigned resident care duties on 05/11/2026 as agency staff, but the facility could not provide documentation showing completion of required orientation and mandatory training before the aide worked independently. The missing documentation included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, Trauma Informed Care, Communication Training, and other required orientation and in-service training elements. During the survey, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff and that training modules, sign-off documentation, and post-tests are maintained in employee files. However, the facility was unable to locate records verifying that Certified Nurse Aide #1 completed the required training. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or any of the listed training topics before being assigned to provide resident care on Units 2 and 3. The Administrator also stated that all staff are required to complete mandatory orientation and in-service training prior to working independently and that documentation should have been maintained in the employee file.
Failure to Prevent Falls and Investigate Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to prevent accidents for three residents. For the first resident, who had traumatic subdural hemorrhage, dementia with mood disturbance, muscle weakness, and was care planned as dependent on two-person assistance for transfers, a CNA attempted a stand-pivot transfer alone. The resident fell, struck their head on the bedside table and garbage can, and sustained a forehead laceration requiring sutures and hospital evaluation. The CNA later stated they were not aware the resident required a two-person assist because they did not check the Kardex, despite the Kardex being accurate at the time and the resident’s care plan clearly indicating a two-person transfer requirement. For the second resident, who was severely cognitively impaired and had recently undergone eye surgery, staff discovered a bruise on the right hip and noted that the resident, who had previously been able to stand and ambulate for surgery, could no longer stand and complained of pain. An Accident and Incident report documented a purple bruise on the right hip and that the resident was unable to describe what happened. The x-ray later showed a displaced acute fracture of the right femoral neck. There was no documentation of how the injury occurred, no staff statements, and no facility investigation to determine the cause of the injury. The incident was not reported to the New York State Department of Health, and the Medical Director stated they had no idea what caused the incident and would have expected a more thorough investigation and look-back of staff who provided care. For the third resident, who had Alzheimer’s disease, severe cognitive impairment, used a wheelchair for mobility, and required assistance for transfers and bed mobility, staff identified a large purple bruise with swelling on the left lower leg. The resident showed mild discomfort on palpation and later complained of pain when the area was touched. The Accident and Incident report, completed by the Infection Control Nurse, concluded that the bruise resulted from bumping the Hoyer lift during transfer, but there were no supporting staff statements in the report. The DON later stated they did not know how the Infection Control Nurse reached that conclusion and that they were not made aware earlier. Subsequent evaluation in the emergency department revealed a fracture of the left tibia and fibula of unknown origin. Across these three cases, the facility did not ensure adherence to care plans, did not adequately investigate injuries of unknown origin, and did not ensure that the resident environment and transfer processes were free of accident hazards, resulting in actual harm to the residents.
Failure to Timely Report and Investigate Injuries of Unknown Origin Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to immediately report and investigate injuries of unknown origin that resulted in fractures for two residents, as required by 10 NYCRR 415.4(b)(2). For the first resident, who was severely cognitively impaired and had osteoporosis and other diagnoses including muscle weakness and glaucoma, staff documented that the resident returned from eye surgery with instructions not to ambulate without assistance and with an alarm placed on the bed. On a subsequent day, an Accident and Incident report noted a light to dark purple bruise, approximately the size of a 50‑cent piece, on the resident’s right hip. The resident was unable to describe what happened, reported pain, and could not stand as they normally could. The resident was sent to the hospital, and imaging later showed a displaced acute traumatic fracture of the right femoral neck. There was no indication in the record of how the injury occurred, no documented facility investigation into the cause, and no report submitted to the New York State Department of Health within the required timeframe. The same resident’s incident documentation showed that the facility’s internal policy required the Nurse Supervisor/Charge Nurse or department supervisor to complete an incident/accident report and submit it to the Director of Nursing within 24 hours, and for the Director of Nursing to ensure the Administrator received a copy. The incident report for this resident included a brief description of the bruise and immediate actions such as notifying the provider, DON, and family, and sending the resident to the emergency department. However, the report lacked statements from staff or others, and there was no documented investigation into the circumstances surrounding the injury, despite the x‑ray impression describing a displaced acute traumatic fracture of the right femoral neck. During interview, the Medical Director stated they had no idea what caused the incident, would have expected more investigation and a look‑back of staff who provided care, and acknowledged the possibility of a fall or a fracture related to osteoporosis, but there was still no documented determination of cause or timely reporting to the Department of Health. For the second resident, who was severely cognitively impaired, incontinent, used a wheelchair for mobility, and required assistance for transfers and bed mobility, staff identified a large purple bruise with mild swelling on the left lower leg. The resident showed mild discomfort on palpation and later complained of pain, saying "Ow, ow, that hurts," according to a CNA. The Infection Control Nurse completed an accident/incident report describing the bruise and mild discomfort, and documented that a root cause analysis determined the bruise was from bumping the Hoyer during transfer, yet there were no supporting statements in the report. A nurse practitioner assessed the bruise as a contusion and planned monitoring. The Medical Director later ordered an x‑ray, which was not completed at the facility, and the resident was eventually sent to the emergency department, where a fracture of the left tibia and fibula was diagnosed. The DON later stated they did not know how the Infection Control Nurse concluded the bruise was from bumping the Hoyer and did not know why they were not made aware earlier. The injury of unknown origin was reported to the Infection Control Nurse on one date, but the DON did not submit a report to the New York State Department of Health until several days later, outside the required immediate reporting timeframe for alleged abuse, neglect, or injuries of unknown origin resulting in serious bodily injury.
Failure to Thoroughly Investigate Injuries of Unknown Origin for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate accidents and injuries of unknown origin for two residents, in accordance with its own "Accidents and Incidents - Investigating and Reporting" policy and 10 NYCRR 415.4(b)(3). The policy requires that incident/accident reports include the date and time of the event, the nature of the injury, the circumstances surrounding the incident, and the location, and that the Nurse Supervisor/Charge Nurse or department director complete and submit the report to the DON within 24 hours, with the Administrator also receiving a copy. For both residents, the facility did not identify how the injuries occurred, did not complete a comprehensive investigation, and in one case did not report the incident to the New York State Department of Health. For the first resident, who had diagnoses including muscle weakness, insomnia, and bilateral glaucoma and was documented as severely cognitively impaired, staff noted a bruise on the right hip after the resident’s return from an eye surgery hospitalization. Prior to this, the resident required supervision or touching assistance for most ADLs, was independent in rolling, and needed only setup or cleanup help for chair-to-bed transfers. After returning from eye surgery, documentation indicated the resident had an eye patch, was to remain NPO after midnight for surgery, was not to ambulate without assistance, and had a bed alarm in place. On the date of the incident, a CNA called the nurse after finding a light to dark purple bruise, about the size of a 50‑cent piece, on the resident’s right hip; the resident was unable to describe what happened and complained of pain and inability to stand, despite previously being able to ambulate for surgery. The incident report for this first resident documented that an x‑ray was ordered, the provider, DON, and family were notified, and the resident was sent to the ED per family request. The subsequent x‑ray showed a displaced acute traumatic fracture of the right femoral neck, with no aggressive osseous lesion or erosions. The incident report contained a later note referencing the resident’s limited medical history, long‑standing tobacco use, and osteoporosis, and concluded that there was no evidence of abuse, neglect, or mistreatment, and that the resident had recently been at the hospital alone for eye surgery. However, there were no staff statements on the report, no documented look‑back of staff who provided care, no explanation of how the injury occurred, and no facility investigation or report to the New York State Department of Health. The Medical Director stated they would have expected more investigation, including a look‑back of staff, and acknowledged they had no idea what caused the incident. For the second resident, who had Alzheimer’s disease, intermittent explosive disorder, generalized anxiety disorder, severe cognitive impairment, incontinence, wheelchair mobility, and dependence on staff for transfers and bed mobility, staff discovered a large purple bruise with mild swelling on the left lower leg. The resident laughed when asked what occurred, but a CNA reported that the resident had been complaining of pain from the time the bruise was found, saying "Ow, ow, that hurts," despite not being very vocal generally. The initial Accident/Incident report, completed by the Infection Control Nurse, described mild discomfort on palpation, mild swelling without redness or warmth, and a pain level of 2 with facial grimacing. The resident was seen by a Nurse Practitioner with no further orders at that time, and the report’s root cause analysis concluded the bruise was from bumping the Hoyer during transfer, yet there were no supporting staff statements documented. Subsequent documentation showed that the Medical Director later ordered an x‑ray of the left lower extremity, and when the x‑ray could not be completed, the resident was sent to the ED, where a fracture of the left tibia and fibula was diagnosed. The CNA who found the bruise stated they did not know how it happened, that the resident was transferred with a Hoyer, that many residents on the unit required Hoyer transfers, and that no one knew how such a large, swollen, green and purple bruise that wrapped around the leg had gone unnoticed earlier. The DON stated they did not know how the Infection Control Nurse concluded the bruise was from bumping the Hoyer, given the absence of statements in the Accident/Incident report, and also stated they did not know why they were not made aware earlier. An injury of unknown origin was reported to the Infection Control Nurse on the date the bruise was found, and the DON submitted a report to the New York State Department of Health several days later, but the facility did not complete a thorough investigation into the circumstances of the injury as required by policy.
Failure to Document and Implement Required Safety Checks for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that adequate supervision and safety monitoring interventions were consistently implemented and documented for a resident with severe cognitive impairment and a history of self-injurious behavior. The resident, diagnosed with Alzheimer's Disease and other conditions, had a care plan addressing behaviors such as chewing on nonfood items and placing fingers in their mouth. Despite these known risks, the resident was observed biting their left middle finger, resulting in traumatic amputation and subsequent hospitalization. Upon return from the hospital, physician orders were issued for hourly safety checks, later changed to 15-minute safety checks. However, there was no documented evidence that these safety checks were completed as ordered. Multiple interviews with staff, including LPNs, CNAs, and the DON, confirmed that while procedures for documenting safety checks existed—primarily using paper forms—no records could be produced to show that the required monitoring was performed for this resident during the relevant period. The facility's own policy required prompt, accurate, and legible documentation of 15-minute safety checks for residents at risk, yet review of accountability forms and care guides revealed no such documentation. The absence of these records indicated that the facility did not follow its own protocols or physician orders for monitoring, resulting in a lack of evidence that adequate supervision was provided to prevent further self-injurious behavior.
Delay in Death Certificate Signature Due to Communication Breakdown
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled their responsibility for timely implementation of resident care policies following the death of a resident. Specifically, after a resident with diagnoses including dementia, repeated falls, chronic kidney disease stage 3, and basal cell carcinoma died, the death certificate was not signed within the required 72-hour timeframe as mandated by State Public Health Law 4041. Documentation showed that the resident was found without respirations and an apical pulse, and post-mortem care was provided. The family and funeral home were notified, but the funeral home was unable to proceed with arrangements due to the unsigned death certificate, resulting in a delay of services. Interviews with the resident's representative and the funeral director confirmed that the delay in signing the death certificate caused additional stress and postponed the resident's services. The Medical Director stated that they were not informed in a timely manner to sign the certificate, as the nurse who documented the resident's expiration did not follow up with a phone call. The facility's investigation found no documentation that the Medical Director was contacted to sign the certificate, leading to the late signature. This breakdown in communication between nursing staff and the Medical Director resulted in the deficiency.
Failure to Investigate and Report Alleged Abuse Incident
Penalty
Summary
The facility failed to initiate and complete a thorough investigation into an alleged incident of abuse involving a resident with moderately impaired cognition and diagnoses including unspecified dementia and mood disturbance. On the date of the incident, three staff members witnessed a domestic aide approach the resident from behind, pick them up in a bear hug, drop them on the floor, and then carry them to their room. These staff members reported the incident to two different registered nurses and the Director of Nursing. However, there was no evidence that the nursing staff reported the allegation to the facility administrator or that an investigation was conducted, as required by the facility's abuse policy. Interviews revealed that the Director of Nursing did not initiate an investigation, stating that the incident was not described to them in terms that raised suspicion of abuse. The Director of Nursing relied on the information provided by the registered nurses and did not pursue further inquiry. The facility's abuse policy mandates immediate documentation, reporting, and investigation of any suspected mistreatment or abuse, including notification of the administrator and completion of incident reports. These procedures were not followed in this case, resulting in a failure to respond appropriately to the alleged violation.
Medication Administration Error: Injectable Lorazepam Given to Wrong Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including unspecified dementia, mood disturbance, and non-Alzheimer's dementia, who had moderately impaired cognition, was administered an intramuscular injection of Lorazepam solution 1 MG that had been prescribed for another resident. The facility's policy on medication administration explicitly prohibits sharing medications between residents and requires that the right medication be given to the right resident, at the right time, by the right route, and in the right dose. The resident was only prescribed Lorazepam oral tablets, not the injectable form, and there was no documentation that the injectable Lorazepam had been dispensed by the pharmacy for this resident. During the incident, the DON stated that the resident was experiencing escalating behavior and was evaluated by a psychiatrist who ordered an immediate intramuscular injection of Lorazepam. The Nurse Educator retrieved the medication from another unit, did not verify the name on the medication bag, and assumed it was a stock medication. The Nurse Educator prepared the medication, which was then administered by the DON. It was later discovered that the Lorazepam solution used was not a house stock medication but had been prescribed for another resident. Both the Nurse Educator and DON confirmed that Lorazepam solution was not stocked as an emergency medication in the facility.
Lack of Behavioral Health Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and training to meet the behavioral health needs of residents with psychiatric or mood disorders, as identified in the facility assessment. Record review and staff interviews revealed that staff education on behavioral health was limited to dementia care, with no documented evidence of training for other psychiatric conditions such as schizophrenia, bipolar disorder, depression, or PTSD. The general orientation materials referenced behavioral health and trauma-informed care, but only in the context of dementia or PTSD, and did not address care for residents with other mental health diagnoses listed in the facility assessment. A resident with multiple psychiatric diagnoses, including moderate cognitive impairment and elevated depression, was identified as not having access to appropriately trained staff. Interviews with nursing staff and the staff education nurse confirmed the absence of behavioral health training and protocols for managing residents with psychiatric or behavioral health issues. Staff reported feeling unprepared and unsafe when dealing with behavioral incidents, and the administrator acknowledged that training had focused solely on dementia care rather than broader behavioral health needs.
Failure to Ensure Resident Safety and Adherence to Dietary Guidelines
Penalty
Summary
The facility failed to ensure a safe environment for Resident #219, who was being transferred via a mechanical lift by two certified nurse aides. During the transfer, the battery of the mechanical lift died, and instead of using the emergency lower button, the aides unhooked the straps, causing the resident to fall and sustain a hematoma to the back of the head. This incident required the resident to be transferred to the emergency room for further evaluation. The resident had a history of falls and was at risk due to conditions such as dementia and chronic pain syndrome. In another incident, Resident #95, who had severe cognitive impairment and a swallowing disorder, was given a peanut butter and jelly sandwich by a certified nurse aide without checking the resident's prescribed diet. The resident's diet was supposed to be pureed with thin liquids, but the aide provided a regular sandwich, leading to a choking incident. The resident became unresponsive, necessitating a Code Blue and transfer to the hospital for respiratory arrest associated with feeding. Both incidents highlight the facility's failure to adhere to safety protocols and dietary guidelines, resulting in harm to the residents. The mechanical lift incident was attributed to user error and a lack of battery checks, while the choking incident was due to the aide's failure to verify the resident's dietary restrictions.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food safety practice, as observed during a recertification survey. Specifically, food items in the walk-in freezers and refrigerators were found unlabeled, undated, and without expiration dates. Expired foods were also stored in the refrigerators and dry storage room. Observations included a bag of frozen chicken breast without an expiration date, opened boxes of beef patties and beef chuck without dates, and undated bags of mozzarella cheese and leftover baked ziti. Additionally, the facility's policy on food receiving and storage, which requires all foods to be covered, labeled, and dated, was not adhered to. Furthermore, essential equipment was not in safe operating condition, as evidenced by the improper sealing of freezer doors, leading to ice formation on the ceiling and walls inside the freezers. The Food Services Director confirmed that the door seals for freezers #6 and #7 had not been closing properly for over a year, and reports about the situation were sent to QAPI meetings monthly. Additionally, damaged tile flooring next to the dishwashing machine created an uneven and wobbly surface, further indicating a lack of maintenance in the facility's food service area.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents during the Recertification and Abbreviated surveys. The staffing schedule review revealed that on multiple occasions, the facility did not provide adequate staffing, particularly during the night shifts. For instance, on Unit 1, there were 17 out of 28 night shifts where only one Certified Nursing Assistant (CNA) was scheduled, despite the unit's census and needs. This staffing shortage was evident on 9/27/2024, when a strong smell of feces was noted on Unit 1, and many residents were left unattended with their breakfast trays at their bedside. Interviews with staff highlighted the challenges faced due to inadequate staffing. A CNA reported being overwhelmed with the workload, as they were often responsible for 20 residents during the night shift. The Registered Nurse (RN) Supervisor also noted that staffing issues were frequent, with callouts being a significant problem. The RN Supervisor had to assist with resident care due to the shortage of CNAs, and there were instances where agency staff did not fulfill their scheduled shifts, further exacerbating the staffing issues. The facility's staffing coordinator and administrator acknowledged the staffing challenges, particularly during the night and evening shifts. Despite efforts to improve staffing through job fairs, bonuses, and flexible hours, the facility continued to struggle with maintaining adequate staffing levels. The administrator confirmed that the facility's staffing par levels were aligned with state requirements, but the actual staffing often fell short due to callouts and scheduling errors.
Deficiency in Serving Palatable and Safe Temperature Food
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature during the Recertification survey conducted from 9/22/24 to 9/27/24. The facility's policy, revised in August 2023 and edited in December 2023, requires food and nutrition services staff to ensure meals are served at appropriate temperatures. However, observations and interviews revealed that food was served out of temperature. A resident reported that their food was cold by the time it was delivered to their room, as it took the Certified Nurse Aide half an hour to bring the tray after serving the dining room residents. Another resident also stated that their food was cold upon delivery. During a Resident Counsel Group meeting, several residents expressed that the food was often cold and unappetizing. A test tray temperature check with the Food Service Director showed the chicken at 130°F, vegetables at 105°F, pasta at 106°F, and milk at 48°F, indicating that the food was not maintained at safe temperatures. The Food Services Director claimed the food and milk were at acceptable temperatures when they left the kitchen.
Failure to Maintain Safe and Homelike Environment Due to Ceiling Leak
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for residents, as evidenced by a large hole in the ceiling of a room on Unit 2, where two residents were residing. The hole was caused by a leaking air conditioner unit from above, which led to water pooling and dripping into the room. This issue was first observed on 9/21/24, but the maintenance department was not informed until 9/23/24, resulting in a delay in addressing the problem. The residents were not moved immediately, despite the potential safety hazard posed by the water leakage and the risk of further ceiling collapse. Interviews with staff revealed a breakdown in communication and response to the maintenance issue. The Director of Maintenance was unaware of the problem until 9/23/24, although the maintenance assistant had been notified verbally and through a work log on 9/21/24. The Director of Nursing and the Registered Nurse Unit Manager were also not informed in a timely manner, leading to a delay in relocating the residents for their safety. The maintenance assistant attempted to mitigate the issue by turning off the air conditioners and placing a basin to collect water, but the ceiling was not repaired until 9/23/24, and the residents were only moved after the situation was reassessed on 9/22/24.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of a resident's property to the New York State Department of Health, as required by regulations. This deficiency was identified during a recertification and complaint survey. The incident involved a resident diagnosed with Parkinson's disease and cerebral infarction, who was moderately cognitively impaired. The resident and their representative reported that the resident's gold necklace went missing after two unidentified male staff members took it for cleaning. Although the police were called and a larceny investigation was initiated, there was no documented evidence that the facility reported the allegation to the state health department. The facility's administrator stated that the incident was not reported because it was considered a missing item, not a reportable event.
Failure to Honor Resident's Room Preference
Penalty
Summary
The facility failed to honor a resident's right to make choices about significant aspects of their life, specifically regarding room changes. Resident #110, who has Alzheimer's disease, depression, and glaucoma, was temporarily moved from their room due to ceiling repairs. Despite the repairs being completed, the resident was not moved back to their original room as per their preference until several days later. During this period, the resident expressed dissatisfaction with the temporary room, citing it was cold and unclean, and repeatedly attempted to return to their original room. The facility's policy on room changes emphasizes minimizing negative impacts and maintaining residents' rights and dignity. However, the staff did not document any conversation with the resident about the room change, and the social worker did not follow up with the resident to assess their needs or preferences. The Director of Nursing acknowledged the lack of documentation and follow-up, which contributed to the resident's distress and confusion during the room change process.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received it in accordance with professional standards of practice. Specifically, Resident #105, who had diagnoses including dependence on renal dialysis, chronic systolic heart failure, and atrial fibrillation, was administered oxygen without a physician's order. The resident's Quarterly Minimum Data Set did not document the use of oxygen therapy, and the facility's Oxygen Administration Policy required verification of a physician order for such procedures. Observations and record reviews revealed that Resident #105 was consistently on 2 liters of oxygen via nasal cannula from 9/22/24 to 9/27/24, without a documented physician order or care plan. Nursing progress notes indicated the application of oxygen when the resident's oxygen saturation was low, but there was no documentation in the electronic health record or medication and treatment administration records. Interviews with nursing staff confirmed that a physician order should have been obtained, but it was not, leading to the deficiency.
Lack of Physician's Order for Hospice Care
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including medications and treatments, at each required visit. Specifically, a resident admitted to the facility on hospice care did not have a physician's order for hospice services documented until several months after admission. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, depression, and psychotic disorder, was admitted on hospice care, but the necessary physician's order was not entered into the facility's electronic medical records until months later. Interviews with facility staff, including a Registered Nurse Manager and the Director of Nursing, confirmed that the resident was on hospice care since admission, and there should have been a physician's order for hospice services. The Medical Director acknowledged that while physicians and nurse practitioners are responsible for managing residents' care, they cannot verify every single order due to the facility's size. This oversight resulted in a deficiency related to the lack of a documented physician's order for hospice care for the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 38 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Achieve Rehab And Nursing Facility | 2.2 mi | ★★★★★ | 10 | 0 |
| Roscoe Regional Rehab & Residential H C F | 15.1 mi | ★★★★★ | 28 | 0 |
| Mountainside Residential Care Center | 24.5 mi | ★★★★★ | 0 | 0 |
| Highland Rehabilitation And Nursing Center | 28 mi | ★★★★★ | 3 | 0 |
| St Josephs Place | 28.8 mi | ★★★★★ | 3 | 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.