Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Ten Broeck Commons during CMS and state inspections, most recent first.
Food items were found unlabeled, undated, and expired in kitchen refrigeration and dry storage, and a resident kept eight cups of almond milk at bedside without dates. Staff were also observed in the kitchen without hair or beard restraints and one Dietary Supervisor wore gloves while touching a cart handle and then serving utensils without changing gloves.
The facility did not maintain required infection control records related to legionella and water management. The annual water sampling report was missing, the annual facility assessment and required components were not provided, and the Maintenance Director could not produce a current legionella lab report, Water Management Plan, or the DOH environmental assessment form. The Water Management policy also lacked control locations, control limits, and prevention measures, while a water log showed chlorine was added and water sampling was still pending.
A resident with DM, cardiomyopathy, and an immunodeficiency condition was observed in a wheelchair wearing socks with the resident's name clearly visible to others. The resident had moderately impaired cognition and needed staff assistance with lower-body dressing and footwear. Staff interviews confirmed that sock labels should have been placed on the inside or back so names were not visible.
A resident with dementia was observed wandering into other residents’ rooms and lying in their beds, but the behavior care plan only addressed potential aggression and did not include the wandering behavior or related interventions. Another resident with Alzheimer’s disease had an activities care plan that had not been updated to reflect current participation, including spouse visits, one-to-one visits, music, fidgets, socials, worship service, and other preferred activities. Staff confirmed the care plans were not current with the residents’ observed needs and routines.
A resident with cerebral infarction, DM2, and hemiplegia had an order and care plan for gel boots to be worn at all times, but was repeatedly observed in a Geri chair wearing only socks, with heels pressing against the footrest. The resident had documented heel redness/tenderness, and staff gave conflicting statements about whether the boots were needed only in bed or at all times.
Improper disposal of garbage and refuse was observed when the recycle dumpster was left open and cardboard boxes were spilling over the top, with debris such as cardboard, used gloves, plastic packing material, and plastic drink lids on the ground around it. The FSD stated the dumpster lid was likely never closed because it was too high to reach, and the D of M later confirmed the dumpster should be closed per facility policy.
A resident with severe cognitive impairment and a history of dementia, dependent on staff for all transfers, was transferred alone by a CNA using a mechanical lift, contrary to the care plan requiring two-person assistance. The resident sustained a right spiral hip fracture requiring surgery. The CNA admitted to acting alone despite being trained and aware of the policy, and there were no staffing shortages at the time.
Food Storage, Labeling, and Staff Hygiene Lapses
Penalty
Summary
Food was not stored and prepared in accordance with professional standards for food service safety. During kitchen observations, multiple racks in the walk-in refrigerator and tray line refrigerator contained unlabeled and undated single-serving puddings, desserts, prunes, salads, and drinks. The refrigerator also contained a large carton of potato salad with a use-by date of 12/02/2025, a pan of ground macaroni salad dated 12/20/2025, and the cook’s refrigerator contained thawed deli-cut ham dated 12/30/2025. In the dry storage room, staff observed portioned powdered rice dated 01/14/2025, clam base and ham base with no expiration dates, and an opened jug of soy sauce that required refrigeration. The Food Service Director stated items on the tray line were not labeled or dated because they were intended for same-day use, and that disposal of expired food was everyone’s responsibility. Additional observations showed an opened and undated prune juice in the Catskill unit pantry refrigerator and four medical ice packs in the freezer, which the RN Unit Manager stated should not have been there. In Resident #160’s room, eight Styrofoam cups of almond milk were found at the bedside, marked only with a black letter A and no date; the resident stated the cups were saved from meals and would be smelled or tasted to decide if they were safe to drink. Staff also observed dietary employees not wearing hair or beard restraints while in the kitchen, including while cutting raw meat and preparing sandwiches, and a Dietary Supervisor wearing gloves while touching a cart handle and then touching serving utensils without changing gloves between tasks. The Food Service Director stated staff with facial hair had been educated on beard restraints and later provided an in-service on hygiene.
Missing Legionella Water Monitoring Records
Penalty
Summary
The facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. During review of facility records, the annual water sampling report for 2025 was missing, and the annual facility assessment for legionella and required components were also missing and not provided at the time of survey. A water temperature log documented that chlorine was added, and a vendor service report dated 11/2025 had a sticker indicating the water report was due 12/2024. A legionella lab report was available only for 11/27/2024, and when requested, the Maintenance Director was unable to provide a 2025 legionella lab report, a Water Management Plan, or the annual facility assessment/Department of Health form for Environmental Assessment of Water Systems in Healthcare Settings. The facility’s Water Management policy and procedure did not document control locations, control limits, or prevention measures. In interview, the Maintenance Director stated that chlorine was added to the water to prevent legionella and that water sampling was scheduled for the following week.
Visible Name Labels on Resident Socks
Penalty
Summary
The facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of quality of life for Resident #43. The resident had diagnoses including Diabetes Mellitus, cardiomyopathy, and an immunodeficiency condition. The admission MDS documented moderately impaired cognition, that the resident could usually understand others and could make himself understood, and that he was dependent on staff for lower body dressing and donning footwear. The care plan documented the resident was dependent on staff daily for activities of daily living and required substantial to maximal assistance with putting on and taking off footwear, as well as partial to moderate assistance with lower-body dressing. During observations, Resident #43 was in the hallway seated in a wheelchair and wearing socks with the resident's name clearly visible on the outside of the socks to other residents, staff, and visitors. This was observed on two occasions. Staff interviews confirmed that resident socks should have been labeled on the inside and not visible to others. A CNA stated the socks were labeled on the outside near the toe area, an LPN stated socks should have been labeled on the inside so names were not visible, and the Director of Environmental Services and Maintenance stated socks should be labeled on the back rather than on the toe area where labels may be visible.
Care plans not updated for wandering behavior and current activity participation
Penalty
Summary
The comprehensive care plan was not revised to reflect changes in two residents’ conditions and care needs. The facility’s care planning policy stated that the comprehensive care plan includes measurable objectives and timetables to meet the resident’s medical, nursing, mental, and psychological needs, and that assessments are ongoing with care plans revised as information and condition change. During the recertification survey, surveyors found that the care plans for Resident #71 and Resident #139 did not match their current behaviors and activities. Resident #71 was admitted with diagnoses including dementia, depression, and falls. The admission MDS documented severely impaired cognition, no behaviors including wandering, dependence on staff for transfers, and ambulation not attempted due to medical condition and fall history. The behavior care plan, created on 01/06/2026 with an initiation date of 10/29/2025, addressed potential physical aggression related to anger, dementia, depression, and poor impulse control, with interventions focused on medication administration, monitoring, and de-escalation. However, the care plan did not document the resident’s wandering, entering other residents’ rooms, or lying in other residents’ beds. Surveyors observed Resident #71 lying in another resident’s bed on one occasion and in another resident’s room and bed on another occasion, and staff stated that the resident often goes into other residents’ rooms. Resident #139 was admitted with diagnoses including Alzheimer’s disease, major depressive disorder, and anemia. The annual MDS documented severely impaired cognition, no behaviors, moderate assistance with eating, and dependence for all other ADLs. The activities care plan, last revised years earlier, described the resident’s humor, dependence on staff, and a goal to participate in activities of capability and interest such as movie day, with interventions to provide activities of capability and interest and a monthly calendar. Survey observations showed the resident sitting in common areas while a spouse visited, with an activity ending without active participation, and later resting with music playing. Staff stated the resident’s spouse visited daily and that the resident also engaged in one-to-one visits, watched the lucynt table, used fidgets, attended socials and worship service, enjoyed music, chronicles, manipulatives, and hand massages, but the care plan had not been revised to reflect these current activities.
Failure to Use Ordered Heel Off-Loading Boots
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with diagnoses including cerebral infarction, type 2 diabetes mellitus, and hemiplegia. The resident’s quarterly MDS documented intact cognition, substantial to max assist with all ADLs, and use of pressure relieving devices for both chair and bed. A Braden Scale assessment showed a score of 16, indicating risk for pressure injuries, and the care plan documented that the resident wore gel boots at all times. The physician ordered gel boots to both feet at all times, and an LPN documented tenderness to the right heel and blanchable redness to the right heel and left lateral foot, with gel boots applied. However, during multiple observations the resident was seated in a Geri chair wearing socks only, without the gel boots, and the heels were pressing against the footrest. The resident stated staff had not been putting the off-loading boots on. An LPN stated the resident should have been wearing the boots to offload the heels, a CNA believed the boots were only needed in bed, and the wound nurse and DON stated the resident should have been wearing the gel boots at all times.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Proper disposal of garbage and refuse was not ensured. During the recertification survey, the facility’s recycle dumpster was observed left open, with cardboard boxes spilling over the top and debris on the ground around the dumpster, including pieces of cardboard box, used gloves, plastic packing material, and plastic drink lids. The facility policy titled Disposal of Refuse stated that outside dumpsters or compactors provided by waste management services are to be kept closed and free of surrounding debris. During interview, the Food Service Director stated garbage and recycle are picked up once weekly and said they did not think the recycle dumpster lid is ever closed because it is too high for anyone to reach. On follow-up observation, the recycle dumpster lid remained open. The Director of Maintenance later stated the dumpster door should be closed per facility policy and suggested kitchen staff may not have closed it because it was cold and they did not want to stay outside.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident, who required a two-person assist for transfers using a mechanical lift as specified in their care plan, was transferred from a chair to bed by a single Certified Nurse Aide (CNA) without assistance. The CNA admitted to performing the transfer alone, despite being aware of the resident's care plan and having received training and signed acknowledgment regarding the requirement for two-person assistance during mechanical lift transfers. Facility policies and the resident's Kardex clearly documented the need for two staff members for such transfers. Following the unassisted transfer, the resident was later found with flaccidity and deformity to the right hip and leg. Assessment by nursing staff and subsequent hospital evaluation revealed a periprosthetic right spiral hip fracture with an unstable prosthesis, necessitating surgical intervention. The resident was unable to communicate due to severe dementia, and the injury was identified during routine morning care by another CNA, who promptly reported the abnormality to nursing staff. Interviews with facility staff confirmed that there were no staffing shortages at the time of the incident, and other CNAs were available to assist. The CNA responsible for the transfer acknowledged knowledge of the care plan requirements but chose to proceed alone. The facility's investigation and staff interviews corroborated that the CNA had received appropriate orientation and training regarding safe transfer procedures and the necessity of following the resident's individualized care plan.
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Illustrative
What surveyors actually found near you
We read the 91 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Katrine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northeast Ctr For Rehabilitation And Brain Injury | 1.3 mi | ★★★★★ | 0 | 0 |
| Ferncliff Nursing Home Co Inc | 5.2 mi | ★★★★★ | 1 | 0 |
| Golden Hill Nursing And Rehabilitation Center | 5.7 mi | ★★★★★ | 3 | 0 |
| The Baptist Home At Brookmeade | 7.5 mi | ★★★★★ | 0 | 0 |
| Renaissance Rehabilitation And Nursing Care Center | 11.8 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.