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 The Grand Rehabilitation And Nrsg At Guilderland during CMS and state inspections, most recent first.
A facility failed to prevent significant medication errors for five residents, including missed psychiatric and antibiotic doses, leading to hospitalizations and untreated conditions. Issues included delayed pharmacy deliveries, staff shortages, and documentation inconsistencies.
The facility failed to meet the required staffing levels from late February to early March 2025, impacting resident care. Residents reported insufficient care, such as missed showers, due to staffing shortages. A nurse highlighted the difficulty of managing multiple units with low staff numbers. Despite these issues, the administration did not recognize significant understaffing, although the facility did not meet the mandated care hours per resident per day.
Two residents reported being treated without dignity and respect in the facility. One resident experienced rough handling and neglect from CNAs, while another, who was partially paralyzed, had their call light turned off without receiving assistance. The RN Regional Clinical Director confirmed that staff were expected to treat residents with dignity and respect.
The facility failed to maintain a clean and comfortable environment, with observations of strong odors, dust build-up, stained ceiling tiles, and soiled floors across three resident units. Chewing gum was found under dining tables, and window blinds were dusty. The administrator acknowledged these issues and planned to address them with the housekeeping and maintenance departments.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical and psychosocial needs. Examples include a lack of care plans for a urinary tract infection, fungal skin rash, pressure ulcer, and gastrostomy tube. Staff interviews revealed challenges in completing care plans, with RNs and LPNs facing difficulties in updating them, and the DON sometimes stepping in to assist.
The facility failed to update comprehensive care plans for several residents, leading to outdated or incorrect information regarding medical conditions, interventions, and goals. For example, a resident's care plan did not reflect a diagnosed urinary tract infection, and another resident's discharge plan was not updated to reflect their long-term care status. Staff interviews revealed challenges in managing care plans due to workload and oversight.
The facility failed to provide appropriate care and monitoring for several residents, including a newly admitted diabetic resident whose blood sugar was not checked as required, a resident with inadequate personal care leading to skin issues, and residents whose vital signs were not consistently monitored or documented. These deficiencies indicate a lack of adherence to care plans and monitoring protocols.
The facility failed to ensure proper physician review and medication management for two residents. One resident received a topical medication without clear instructions, leading to incorrect self-administration. Another resident's high potassium level was not evaluated promptly, despite being reported. Staff interviews revealed confusion over responsibility for monitoring lab results, contributing to the deficiencies.
The facility's governing body failed to ensure proper implementation of policies, resulting in significant medication errors and compromised resident care. Several residents did not receive prescribed medications, leading to hospitalization and incomplete treatments. Interviews revealed communication and documentation breakdowns, with staff unaware of the extent of the issues until the survey.
A facility failed to maintain accurate medical records, with incomplete narcotic count books and repeated or missing vital signs for two residents. Narcotic count records lacked signatures, and vital signs were duplicated or missing for a resident with respiratory issues. Another resident's wound care documentation was inaccurate, as confirmed by staff and the resident. Interviews revealed that staff sometimes signed records days after their shifts, contrary to policy.
The facility failed to implement enhanced barrier precautions for three residents with indwelling medical devices, as observed during a survey. A resident with a hemodialysis catheter, another with a urinary catheter and wound, and a third with a gastrostomy tube did not have the necessary precautions in place. Staff interviews revealed inconsistencies in understanding and implementing these precautions, leading to a deficiency in infection control practices.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and lack of timely follow-up by staff. One resident missed multiple doses of an antipsychotic for schizophrenia, while another did not receive a medication for hyperkalemia for several days. Documentation and staff interviews confirmed the medications were not available and that expected procedures for handling such situations were not consistently followed.
A resident was found with a topical steroid cream in their room without an assessment or physician order for self-administration. The resident, who was cognitively intact, misunderstood the prescription label and applied the cream incorrectly. The facility failed to conduct a required evaluation of the resident's ability to self-administer medications, leading to the resident using the medication without proper guidance.
The facility did not ensure residents were aware of the grievance process, as grievance forms were not readily available, and residents could not file grievances anonymously. During a Resident Council meeting, all residents reported they were unaware of the grievance process and feared retaliation. Staff interviews revealed a lack of awareness about grievance forms and procedures.
A facility failed to report an alleged abuse incident involving two residents, where one resident entered another's room and engaged in a non-malicious altercation. Despite the facility's policy requiring immediate reporting of such incidents, the event was not reported to the New York State Department of Health, as it was deemed playful and not malicious.
The facility failed to provide proper written notification of hospital transfers to the Ombudsman and representatives for two residents. One resident was transferred multiple times without notifying the Ombudsman, while another was sent to the hospital after a fall without notifying the resident, representative, or Ombudsman. Staff interviews confirmed the oversight.
The facility failed to provide written notice of its bed hold policy to two residents or their representatives upon hospital transfer, as required by their policy. Despite multiple hospitalizations for medical reasons, there was no documentation that the policy was communicated. Staff interviews confirmed the lapse in procedure.
A facility failed to conduct a proper PASARR screening for a resident with schizophrenia, resulting in the omission of a necessary Level II referral. The resident, admitted with serious mental health diagnoses, was not identified as having a serious mental illness on the PASARR form. The Director of Social Work, who was not screen certified, relied on the Regional Admissions Coordinator for assistance if inaccuracies were found, but this process was not followed, leading to the deficiency.
A resident with a stage 3 pressure ulcer on the left heel did not receive wound care as ordered by the provider. The facility failed to document and administer the prescribed treatment consistently, and a care plan was not developed until weeks after the wound was first assessed. Staff interviews revealed a lack of adherence to treatment orders, contributing to the deficiency in care.
The facility failed to provide necessary respiratory care for three residents, including inadequate nebulizer maintenance and improper oxygen administration. A resident's nebulizer was found unplugged with undated tubing, and another resident's oxygen flow rate was set incorrectly, contrary to physician orders. Staff interviews revealed inconsistent procedures for respiratory care, contributing to the deficiencies.
The facility failed to provide appropriate dialysis care for two residents, with deficiencies in communication and documentation. One resident's care plan lacked necessary interventions, and multiple instances of incomplete dialysis communication forms were noted. Another resident's dialysis binder was missing essential documentation, and staff interviews revealed lapses in expected procedures. These issues were identified during a survey and were not previously addressed in Quality Assurance meetings.
The facility failed to ensure that nurses and CNAs had the necessary competencies and skills, as evidenced by incomplete education records and insufficient training. Education records for several staff members were incomplete, and RN #2 lacked proficiency in care plan updates and handwashing protocols. Interviews revealed issues with the training program, high staff turnover, and gaps in orientation paperwork.
The facility's medication error rate exceeded 5%, reaching 6.87%, during a survey. Two residents were involved in errors: one received an incorrect dosage of Tylenol due to distractions, and another received crushed medication without an order. The LPN involved noted unclear orders, and the administrator acknowledged missing documentation for medication issues.
The facility failed to store drugs and biologicals according to professional standards, with undated medications and misplaced insulin pens observed. Narcotic logbooks lacked consistent signatures from two licensed nurses, indicating improper narcotic count procedures. Staff interviews revealed a lack of adherence to medication labeling and storage policies.
A resident with dysphagia and malnutrition was not provided the prescribed therapeutic diet during a meal observation. The resident was served whole chicken instead of ground meat as ordered. Staff interviews revealed a failure to adhere to dietary orders, with the Director of Food Service acknowledging the mistake and the Regional Director of Nursing noting that staff should have verified meal accuracy.
The facility failed to adhere to food safety protocols, with pureed vegetables improperly cooled, a malfunctioning dishwashing machine, and lack of proper sanitizing solution testing. Additionally, two food thermometers were out of calibration, and there was no evidence of staff training on thermometer calibration.
The facility did not properly dispose of garbage and refuse, as the dumpster lid was propped open with a broom handle, exposing kitchen and housekeeping waste. An administrator confirmed that the dumpster should be kept closed.
A resident with multiple chronic conditions did not receive ordered laboratory tests on three separate occasions, and the provider was not notified of the missed tests. Orders were entered and confirmed, but the labs were not completed as scheduled, and results were delayed until after repeated reordering. Staff interviews confirmed ongoing issues with lab order processing and communication lapses.
A resident with multiple chronic conditions had abnormal lab results, including elevated potassium, that were not promptly communicated to the ordering provider. Staff interviews revealed confusion about responsibility for monitoring and notifying providers of lab results, and documentation did not show that the provider was informed or that any new orders were made in response to the abnormal findings.
A resident with diabetes, depression, and bladder cancer received a 30-day discharge notice, but the facility failed to notify the Ombudsman in a timely manner, delaying the notification by nearly a month. The Director of Social Work admitted the oversight and confirmed that the facility's policy for same-day notification was not followed.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting five residents. Resident #47 was not administered their psychiatric medication, Clozapine, for 12 days, leading to psychiatric decompensation and a request for hospitalization. The medication was not delivered to the facility until 12/06/2024, despite being ordered on 11/25/2024. Documentation inconsistencies were noted, as the medication was recorded as given on certain days when it was not available in the facility. Resident #12, diagnosed with a urinary tract infection, was prescribed intravenous Ampicillin due to refusal of oral antibiotics. However, the resident missed 10 out of 20 scheduled doses due to pharmacy delivery delays and staff shortages. This led to a change in medication to Levaquin for better compliance, but the resident still missed doses. Resident #23, also with a urinary tract infection, missed four doses of Augmentin due to unavailability, resulting in the development of pneumonia and the need for intravenous antibiotics. Resident #77, with high potassium levels, did not receive the prescribed medication, sodium zirconium cyclosilicate, until four days after it was ordered, leading to further elevated potassium levels. Resident #327, with pneumonia, did not receive prescribed Azithromycin due to the inability to establish intravenous access, resulting in a hospital transfer for treatment. Interviews with facility staff revealed awareness of medication availability issues and a lack of proper documentation and communication regarding missed doses.
Staffing Deficiency in Nursing Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as required by New York State Public Health Law and Regulations. From February 22, 2025, to March 6, 2025, the facility did not meet the minimum staffing levels necessary to provide adequate care. Specifically, the facility was unable to maintain the required 3.5 hours of care per resident per day, with at least 2.2 hours provided by certified nurse aides and 1.1 hours by licensed nurses. The staffing sheets revealed that on multiple days, the number of licensed nurses and certified nurse aides scheduled was insufficient to meet the required care hours based on the facility census. Residents and staff reported the impact of the staffing shortages. During a resident council meeting, residents expressed concerns about the lack of staff, and one resident reported receiving fewer showers than scheduled due to staffing issues. A registered nurse also noted the challenges of working with low staffing numbers, indicating that they had to manage care plans for multiple units, which was difficult. The nurse also mentioned the lack of effective staff appreciation and incentives for picking up additional shifts. Despite these observations, the facility's administration did not acknowledge significant understaffing. The administrator and director of nursing both stated that they had not been informed of any tasks that could not be completed due to staffing shortages. However, the documented staffing levels and resident and staff feedback clearly indicated that the facility did not meet the required staffing standards, compromising the care and well-being of the residents.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the experiences of two residents. Resident #39, who was cognitively intact and diagnosed with congestive heart failure, hypertension, and Parkinson's disease, reported having to wait for personal care for up to two hours. The resident described some Certified Nurse Aides as rough, stating they were pushed and shoved during care. Additionally, an aide ignored the resident's request for help, leaving a nightgown on the side of the bed and exiting the room. Resident #61, also cognitively intact and diagnosed with spinal fusion, diabetes mellitus, and hypertension, reported that staff would turn off their call light without providing assistance. The resident, who was partially paralyzed and dependent on staff for all care, stated that staff would speak harshly and tell them to wait. Despite having a call bell device, the resident's needs were not fully addressed, as staff would only inquire about water needs. The Registered Nurse Regional Clinical Director confirmed that staff were expected to treat residents with dignity and respect, and should not turn off call lights without assisting residents.
Deficient Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services across three resident units, leading to unsanitary and uncomfortable living conditions. Observations revealed strong urine and fecal odors in various corridors and rooms, indicating inadequate cleaning and ventilation. Trash was found on the floor in one room, and unwashed body odor was detected near another. Additionally, the ventilation grid by the emergency exit was heavily soiled with dust, and stained ceiling tiles were present in multiple areas, including corridors and utility rooms. Further observations highlighted a significant build-up of dirt and dust on floors, particularly where corridor door frames meet the floor and next to walls in the Rehabilitation room. Nurse stations across all wings were also soiled with dirt build-up. Chewing gum was found under dining tables, and window blinds in several rooms were caked with dust. The lobby furniture was worn, and there were multiple instances of chipped paint and damaged wall guards throughout the facility. These conditions were acknowledged by the facility's administrator, who indicated plans to address the issues with the housekeeping and maintenance departments.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for eight residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For instance, a resident diagnosed with a urinary tract infection did not have a care plan for antibiotic treatment, despite being prescribed oral and later intravenous antibiotics due to refusal to take oral medication. Another resident with a fungal skin rash did not have a care plan for the use of Lotrisone Cream, which was administered without specific instructions on where to apply it. Additionally, the facility did not include cultural information and interventions in the care plan of a resident, and another resident's care plan for antibiotics was initiated only after the completion of antibiotic therapy. A resident with a pressure ulcer did not have a care plan addressing its presence or interventions, and another resident with dentures lacked a comprehensive care plan. Furthermore, a resident with a gastrostomy tube did not have a care plan to address its presence and use, highlighting a significant oversight in care planning. Interviews with facility staff revealed challenges in completing care plans, with registered nurses sometimes responsible for multiple units and licensed practical nurses unable to update care plans themselves. The Director of Nursing occasionally had to update care plans, but there was no assurance that care plans were completed promptly. The Regional Director of Clinical Services expressed an expectation for care plans to be initiated for specific medical needs, such as a gastrostomy tube, indicating a gap between expectations and practice.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in response to changes in residents' conditions and needs. Specifically, for eight residents, care plans were not updated to reflect current medical conditions, interventions, and goals. For instance, Resident #20's care plan was not revised to remove a medication that was no longer prescribed. Resident #23's care plan for bladder incontinence did not include a diagnosed urinary tract infection, despite documentation of the infection and a new antibiotic prescription. Resident #28's discharge planning care plan was outdated, still reflecting community discharge goals despite the resident's long-term care status. Similarly, Resident #84's care plan for impaired skin integrity was not resolved even after the wound was documented as healed. Additionally, the care plans for Residents #47, #51, and #328 included medications that were no longer prescribed, indicating a lack of timely updates to reflect current medication regimens. Interviews with facility staff revealed systemic issues in care plan management. Registered Nurse #1 expressed difficulty in managing care plans due to workload, and the Director of Nursing acknowledged the oversight in updating care plans. The Regional Director of Nursing emphasized the expectation for care plans to accurately reflect residents' needs, including falls, wounds, behaviors, medications, and new concerns. The facility's policy required care plans to be revised with any significant change in condition, which was not adhered to in these cases.
Failure to Provide Appropriate Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for five residents. Resident #6, who was newly admitted with diabetes, did not have their blood sugar checked as required by discharge paperwork until the following day, despite being insulin-dependent. The Director of Nursing acknowledged that assessments, including vital signs and finger sticks, should be completed during the shift of admission, but this was not done in a timely manner. Resident #14's care was inadequate as their bed clothes were not changed effectively, and the mattress was found covered with dead skin. This indicates a failure to adhere to the resident's comprehensive care plan, which required supervision and assistance for personal care and maintaining skin integrity. Similarly, Resident #20 did not receive proper foot care, resulting in elongated toenails and blisters. The resident had informed staff about their condition, but there was no documented evidence of a care plan addressing foot care. For Residents #23 and #77, the facility failed to monitor vital signs as ordered, and there was a lack of documentation regarding the residents' conditions. Resident #23 had orders for daily vital signs and monitoring for changes in condition, but there were repeated instances of missing or duplicated vital sign entries without notifying the medical provider. Resident #77 also had orders for daily vital signs, but there were multiple occasions where vital signs were not documented, and the medical provider was not informed. These deficiencies highlight a systemic issue in the facility's ability to monitor and document resident conditions effectively.
Deficiencies in Physician Review and Medication Management
Penalty
Summary
The facility failed to ensure that the physician reviewed the residents' total program of care, including medications and treatments, at each visit for two residents. For one resident, a topical medication was prescribed without clear instructions on where it should be applied or the duration of use. The resident, who was a registered nurse, applied the medication incorrectly to their face instead of under the breast as intended, due to a lack of clear instructions and a formal assessment for self-administration. The physician was unaware of the fungal infection under the breast and had prescribed the medication for a facial rash. Another resident with chronic kidney disease and other conditions had a high potassium level reported, which was not evaluated by a provider in a timely manner. The laboratory results indicating the high potassium level were accessible to the provider, but there was no documentation that the provider was notified of the critical results. The high potassium level was not addressed until several days later, despite the provider being in the facility and having access to the results. Interviews with staff revealed a lack of clarity regarding the responsibility for monitoring and acting on laboratory results. Registered nurses believed that providers should monitor test results themselves, while the facility's administration indicated that nurses should notify providers of critical results. This lack of communication and responsibility led to delays in addressing the residents' medical needs, contributing to the deficiencies noted in the survey.
Medication Errors and Quality of Care Deficiencies
Penalty
Summary
The facility's governing body failed to ensure that residents received appropriate quality of care, as evidenced by significant medication errors and compromised resident care. The facility was cited for deficiencies under F760 and F684, indicating that established policies regarding the management and operation of the facility were not implemented effectively. This resulted in multiple residents not receiving their prescribed medications, which placed them at risk for serious harm. Several residents experienced medication errors, including a resident who did not receive prescribed psychiatric medication for 12 days, leading to decompensation and hospitalization. Other residents received only partial doses of their prescribed antibiotics, and one resident did not receive medication to lower potassium levels until four days after it was prescribed. Additionally, there were failures in monitoring vital signs and providing personal care assistance, further compromising resident care. Interviews with facility staff revealed a lack of communication and documentation regarding medication availability and administration. The Director of Nursing and the Administrator were unaware of the extent of the medication issues until the survey, indicating a breakdown in the facility's quality assurance processes. The Medical Director acknowledged communication breakdowns and was only notified of significant problems, highlighting systemic issues in the facility's operations.
Inaccurate and Incomplete Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards, as evidenced by incomplete and inaccurate documentation across three units. Narcotic count record books for Units A, B, and C were found to have numerous missing signatures from both on-coming and off-going nurses, indicating a lack of proper documentation during narcotic counts. Interviews with nursing staff revealed that some nurses were signing the narcotic count book days after their shifts, contrary to the facility's policy that requires signatures at the time of the count. Resident #23's medical records showed repeated and missing vital signs, suggesting inaccuracies in documentation. The Treatment Administration Record for January, February, and March 2025 documented identical vital signs on multiple days, which is highly unusual and was acknowledged as such by the nursing staff and a nurse practitioner. Additionally, there were several days with no vital signs recorded at all, further indicating incomplete documentation. For Resident #53, wound care documentation was found to be inaccurate. Despite a wound assessment note indicating that a wound on the left buttocks was healed, the March 2025 Treatment Administration Record documented that dressing was completed. Interviews with the resident and nursing staff confirmed that there were no open areas requiring a dressing, highlighting discrepancies in the documentation of care provided. The Regional Clinical Director emphasized that staff should not document care that was not provided, underscoring the importance of accurate medical records.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for three residents with indwelling medical devices, as observed during a recertification survey. Specifically, Residents #110, #115, and #231 did not have enhanced barrier precautions implemented, which are necessary to prevent the spread of multi-drug resistant organisms. Resident #110, who had a hemodialysis catheter, did not have signage or setup for enhanced barrier precautions in their room, and there was no documented physician's order for such precautions. Similarly, Resident #115, with an indwelling urinary catheter and a wound on the right lateral ankle, and Resident #231, with a gastrostomy tube, also lacked signage, setup, and documented orders for enhanced barrier precautions. Interviews with facility staff revealed inconsistencies in understanding and implementing enhanced barrier precautions. Registered Nurse #2 incorrectly stated that indwelling medical devices like urinary catheters and gastrostomy tubes did not require enhanced barrier precautions, while Licensed Practical Nurse #7 and Registered Nurse #1 indicated that such precautions should be initiated for residents with wounds or external medical devices. The Regional Clinical Director also expected residents with indwelling medical devices and wounds to be placed on enhanced barrier precautions, highlighting a discrepancy between policy expectations and actual practice.
Failure to Ensure Timely Availability and Administration of Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring the timely availability and administration of prescribed medications. For one resident with schizophrenia, chronic obstructive pulmonary disease, and type 2 diabetes, there was a physician's order for Clozapine to begin on a specific date. However, the medication was not available for administration on multiple days, with documentation indicating delays in pharmacy delivery and the medication not being dispensed until nearly two weeks after the initial order. The Medication Administration Record and pharmacy reports confirmed missed doses and late delivery, with staff documenting the issue but not ensuring the medication was on hand as ordered. Another resident with chronic kidney disease, cerebral infarction, and chronic obstructive pulmonary disease had a high potassium level identified by laboratory testing. The provider ordered Lokelma to address the hyperkalemia, but the medication was not available in the facility for several days after the order. Nursing notes indicated the pharmacy could not deliver the medication until the following afternoon, and there was no documentation that the provider was notified of the ongoing unavailability or that the medication was administered on the days following the order. The Medication Administration Record and nursing notes lacked evidence of timely administration or provider notification regarding the missed doses. Interviews with facility staff, including the DON and Administrator, revealed awareness of ongoing issues with pharmacy deliveries, particularly with an out-of-state pharmacy, and a lack of consistent documentation and reporting of missed medications. Staff described expected procedures for handling unavailable medications, but there was no evidence these procedures were consistently followed in the cases reviewed. The deficiency was identified through record review and staff interviews during the recertification and abbreviated survey.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Resident #23, who was cognitively intact and had a history of chronic obstructive pulmonary disease, congestive heart failure, and type 2 diabetes, was observed with a topical steroid cream in their room without an assessment or physician order for self-administration. The facility's policy required an evaluation of the resident's mental and physical abilities to self-administer medications, which was not conducted for Resident #23. During an observation, Resident #23, a former registered nurse, was found using antifungal powder and a tube of cream for a rash under their breast and on their face. The resident stated that the nurse left the cream for them to apply themselves, although the prescription label indicated it was to be applied under the breast. The resident misunderstood the label and applied the cream to their face, unaware it was intended for the breast. The physician's progress note indicated the cream was prescribed for a rash on the face, but the resident was not formally assessed for self-administration. Interviews with the physician and facility staff revealed discrepancies in the instructions for the cream's application. The physician stated the cream was intended for the nurse to apply, not the resident, and was unaware of the prescription instructions to apply it under the breast. The facility's Registered Nurse Regional Clinical Director confirmed that a self-administration form should have been completed, and a physician's order was necessary to leave medications at the bedside. The lack of assessment and clear instructions led to the resident self-administering the medication incorrectly.
Residents Unaware of Grievance Process and Forms Unavailable
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, as evidenced by the lack of readily available grievance forms and the absence of an option to file grievances anonymously. During a Resident Council meeting, all 12 residents present reported they were unaware of the process to file a grievance and did not know who the Grievance Officer was. Some residents expressed fear of retaliation if they made a complaint. The facility's policy, dated November 2016, stated that grievances could be made orally or in writing without fear of retaliation, and a designated Grievance Officer was responsible for investigating grievances. Interviews with staff revealed a lack of awareness and availability of grievance forms. The Activity's Director was unaware of the existence of grievance forms, while the Director of Social Work, who served as the Grievance Officer, had forms in their office but was unsure if they were available on the units. The Director of Social Work also reported an open-door policy for informal complaints but was uncertain about the possibility of filing grievances anonymously. The Regional Clinical Director of Nursing acknowledged the process for addressing complaints, involving the Social Worker, Administrator, and Director of Nursing, but corrective actions were only taken after the survey raised concerns.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged violation involving abuse within the required timeframe. Specifically, an incident occurred where a resident reported that another resident entered their room, knocked off their hat, and tapped them on the cheek. This incident was documented in an Incident Report, but the facility did not report it to the New York State Department of Health as required by regulations. The facility's policy mandates that all reports of resident abuse, neglect, exploitation, and other related incidents be promptly reported to the appropriate authorities. The residents involved had distinct medical conditions. One resident was admitted with Alzheimer's disease and was severely cognitively impaired, while the other had alcoholic cirrhosis of the liver, acute kidney failure, and hypotension, but was cognitively intact. The facility's investigation concluded that the incident was playful and not malicious, leading to the decision not to report it. However, this decision was contrary to the facility's policy and state regulations, which require immediate reporting of such incidents, regardless of intent.
Failure to Notify Ombudsman and Representatives of Resident Transfers
Penalty
Summary
The facility failed to ensure proper written notification of transfer or discharge was sent to the resident, the resident's representative, and the Office of State Long-Term Care Ombudsman for two residents reviewed for hospitalization. For Resident #112, the facility did not provide written notification to the Ombudsman for three out of four hospital admissions. The resident, who was cognitively intact, was transferred to the hospital on multiple occasions for reasons including missed dialysis, pain control, unresponsiveness, and critical lab values. Interviews with facility staff revealed that the required notifications were not documented as sent to the Ombudsman. For Resident #123, the facility did not provide written notification of the transfer to the hospital to the resident, the resident's representative, or the Ombudsman. The resident, who had mild cognitive impairments and required substantial assistance with daily activities, was sent to the hospital after a fall. The Director of Social Work admitted that discharge notifications were not sent for hospital transfers, and the Administrator acknowledged the oversight. The facility's policy required such notifications, but they were not followed in these instances.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives upon transfer to a hospital, as required by their policy. This deficiency was identified during a recertification survey for two residents who were hospitalized. Resident #112, who was cognitively intact and had multiple health conditions including metabolic encephalopathy, type 2 diabetes, and end-stage renal disease, was transferred to the hospital on several occasions for various medical reasons. However, there was no documented evidence that the bed hold policy was communicated in writing to the resident or their representative during these transfers. Similarly, Resident #123, who had acute kidney failure, absolute glaucoma, and type 2 diabetes, was transferred to the hospital following a fall. The facility's social work and nursing staff acknowledged that the bed hold policy should have been provided at the time of transfer, but there was no documentation to support that this occurred. Interviews with facility staff, including the social worker and the administrator, confirmed that the bed hold policy was not reviewed or documented as having been provided to the residents or their representatives, indicating a lapse in following the facility's established procedures.
Failure to Conduct Proper PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident was properly screened for a mental disorder or intellectual disability prior to admission, as required by the Preadmission Screening and Resident Review (PASARR) process. Specifically, the PASARR form for a resident with a diagnosis of schizophrenia incorrectly documented that the resident did not have a serious mental illness, and a Level II referral was not made. The facility's policy required the admissions coordinator to obtain and review the PASARR for all new residents and to ensure a Level II screen was completed when necessary. However, this process was not followed for the resident in question. The resident, who was admitted with diagnoses of schizophrenia, generalized anxiety disorder, and major depression disorder, was later hospitalized for bacterial pneumonia and transitioned to a psychiatric unit due to suicidal ideation. Despite the resident's history of schizophrenia and multiple inpatient hospitalizations, there was no documented evidence of a Level II referral. The Director of Social Work, who was not screen certified, stated that they would check the resident's diagnoses for the need for a Level II referral and would contact the Regional Admissions Coordinator if a screen was found to be inaccurate. This oversight in the screening process led to the deficiency identified during the recertification survey.
Failure to Follow Wound Care Orders for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. Specifically, the wound care treatment ordered by the provider for a resident with a pressure ulcer on the left heel was not followed. The treatment administration record did not document the wound care provider's treatment orders as prescribed, and there were inconsistencies in the administration of the treatment. The ordered foam dressing was not included in the treatment administration record, and there were days when the treatment was not administered as required. The resident, who was admitted with diagnoses including urinary tract infection, acute kidney failure, and age-related physical disability, had a stage 3 pressure ulcer on the left heel. The wound care provider's orders specified cleansing the wound and applying specific dressings on designated days, but these instructions were not consistently documented or followed. Additionally, a care plan to address the pressure ulcer was not developed and implemented until several weeks after the wound was first assessed, delaying necessary interventions to promote healing and prevent infection. Interviews with facility staff revealed a lack of adherence to the prescribed wound care regimen. Licensed Practical Nurse #8 acknowledged that wound care should be performed according to physician orders and noted that blanks on the treatment record indicated missed treatments. The Registered Nurse Regional Clinical Director stated that if a nurse could not complete a treatment during their shift, they should notify the provider and ensure a handoff to the next shift. These lapses in following treatment orders and developing a timely care plan contributed to the deficiency in care for the resident's pressure ulcer.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. For two residents, the facility did not ensure proper documentation and maintenance of nebulizer equipment. Specifically, Resident #23's nebulizer was found unplugged with undated tubing, and there was no record of nebulizer maintenance in the Treatment Administration Record. Similarly, Resident #231's nebulizer tubing was not dated, and there was no documentation of maintenance, despite the resident receiving nebulizer treatments. Additionally, the facility did not adhere to physician orders for oxygen administration for Resident #51. The resident's oxygen concentrator was observed set at 4 liters per minute, but during another observation, the portable oxygen flow rate was set at 2 liters per minute, contrary to the physician's order of 4 liters per minute to maintain oxygen saturation above 88%. This discrepancy indicates a failure to follow the prescribed oxygen administration protocol. Interviews with staff revealed a lack of consistent procedures for nebulizer maintenance and oxygen administration. Licensed Practical Nurse #5 admitted to inadequate labeling and maintenance of nebulizer tubing, while the Regional Director of Nursing acknowledged that licensed staff were responsible for ensuring proper respiratory care but did not consistently document or follow through with the necessary procedures. These lapses contributed to the deficiencies observed during the survey.
Deficiencies in Dialysis Care Documentation and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents, Resident #11 and Resident #110, as identified during a recertification and abbreviated survey. For Resident #11, the facility did not ensure ongoing communication and collaboration with the dialysis facility, nor did it conduct ongoing assessments in January and February 2025. The care plan for Resident #11 lacked interventions for assessing and monitoring the resident before and after dialysis. Additionally, multiple instances were noted where the dialysis treatment communication forms were incomplete, missing vital signs, and lacked signatures from the nursing staff. Resident #110 also experienced deficiencies in dialysis care. The facility did not consistently complete, review, and log dialysis communication sheets between February 18, 2025, and February 26, 2025. Observations revealed that Resident #110's dialysis binder contained only an incomplete sheet dated February 18, 2025, and the sheets for subsequent dates were missing. Interviews with the resident and staff indicated that the dialysis book had been lost, and there were no progress notes documenting the resident's condition before or after dialysis on specific dates. Interviews with nursing staff and the Regional Registered Nurse Clinical Director highlighted expectations for completing dialysis communication sheets and maintaining communication with the dialysis center. However, these expectations were not met, as evidenced by the incomplete documentation and lack of communication logs. The facility's administrator acknowledged that issues regarding dialysis documentation were not previously discussed in Quality Assurance meetings, and these deficiencies were identified through the survey process.
Inadequate Staff Training and Competency in LTC Facility
Penalty
Summary
The facility failed to ensure that licensed nurses and Certified Nurse Aides (CNAs) possessed the necessary competencies and skills to meet the needs of residents, as evidenced by incomplete education records and insufficient training. Specifically, the education records for CNAs #3 and #4, Licensed Practical Nurses (LPNs) #11 and #12, and Registered Nurse (RN) #4 were found to be incomplete. Additionally, RN #2 lacked the knowledge required to perform assigned tasks, as they were not proficient in updating care plans and were unaware of proper handwashing protocols. The facility's assessment outlined specific training and competency requirements for staff, including mandatory annual training and orientation topics such as infection control, resident rights, and person-centered care. However, the records showed that these requirements were not consistently met. For instance, CNA #3's file lacked evidence of annual education after a year of employment, and CNA #4's orientation checklist and competency evaluations were unsigned. Similarly, LPNs #11 and #12 did not have documentation of annual education, and RN #4's file was missing signatures and evidence of completed education. Interviews with staff revealed further issues with the facility's training program. RN #2 reported that the orientation was insufficient and that staff turnover was high, leading to a workforce of mostly new and inadequately trained individuals. LPN #13, the facility educator, acknowledged gaps in orientation paperwork and stated that competencies were reviewed annually, with additional training provided as needed. The Regional Director of Nursing and the facility Administrator were both new to their positions and expressed intentions to improve training processes, but were not fully aware of the existing deficiencies.
Medication Error Rate Exceeds 5% During Survey
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.87% during a recertification survey. This deficiency was identified through observations and interviews involving two residents. Resident #47, who has a history of metabolic encephalopathy, type 2 diabetes, and breast cancer, was involved in a medication error when an LPN attempted to administer an incorrect dosage of Tylenol. The LPN acknowledged the error, attributing it to distractions at the medication cart. Resident #67, with diagnoses including diabetes, stroke, and hyperlipidemia, was also involved in a medication error. The LPN administered Tylenol Extra Strength without a specified milligram dosage on the order and crushed the medication without a documented order to do so. The LPN admitted to knowing the correct dosage but noted that several orders were unclear and required clarification. The facility's administrator acknowledged the lack of documentation for missing medications and the absence of specific reports on medication issues.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional standards of practice, as observed during a recertification survey. On Unit A cart 2, multiple stock medications were not dated, and two bottles of resident-specific eye drops lacked opening dates. Additionally, a bottle of insulin was found without a label indicating resident ownership or the date it was opened, and a bottle of Valproic Liquid was not stored in a biohazard bag as required. On Unit B cart 2, a stock medication was not dated, and on Unit C cart 1, an insulin pen for a resident was misplaced and should have been in a different cart. The survey also revealed inconsistencies in the narcotic count logbooks across multiple units. Five out of six narcotic logbooks lacked consistent signatures from two licensed nurses, as required by law, to document a two-person narcotic count between shifts. Specific instances of missing signatures were noted on various dates for Units A, B, and C, indicating a failure to adhere to proper procedures for narcotic counts. Interviews with nursing staff revealed a lack of awareness and adherence to medication labeling and storage policies. Registered Nurse #2 and Licensed Practical Nurse #9 were unable to explain why medications were not labeled with dates or why narcotic sheets were not consistently signed. The Regional Director of Nursing confirmed that stock medications and insulin should be dated when opened, and narcotic counts should be conducted with two licensed nurses signing the log sheet. The Administrator acknowledged that these issues were not previously addressed in Quality Assurance meetings and were only identified through the survey process.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as prescribed by a physician for a resident with a history of cerebral infarction, dysphagia, and malnutrition. During a lunch observation, the resident was served whole portions of chicken parmesan instead of the prescribed ground meat. The resident's meal ticket indicated a regular, chopped diet with ground meats, but the meal did not comply with these specifications. The resident, who was significantly cognitively compromised, was observed attempting to cut the meat with a fork, and their roommate noted that meals usually consisted of pureed foods. Interviews with facility staff revealed a lack of adherence to dietary orders. The Director of Food Service acknowledged the error, stating that the meat should have been ground as per the speech therapy's determination. The responsibility for ensuring meal accuracy was attributed to the staff member who delivered the tray. Additionally, the Regional Director of Nursing indicated that nurses and Certified Nurse Aides should have verified the trays before serving them to residents, highlighting a lapse in the facility's protocol for meal distribution.
Food Safety Protocols Not Followed
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the main kitchen, pureed vegetables stored in the walk-in refrigerator were found to be at 52 degrees Fahrenheit, despite being prepared the previous day. This indicates improper cooling practices, as the facility's training documentation required foods to be cooled to 41 degrees Fahrenheit within six hours. Additionally, the automatic dishwashing machine was not functioning correctly, with a final rinse temperature of 150 degrees Fahrenheit, below the required 180 degrees Fahrenheit, and the water pressure gauge was not operational. Further deficiencies were noted in the facility's lack of a test kit for checking the concentration of the sanitizing solution used for food contact equipment, which should be between 150 and 400 parts per million. Moreover, two out of four food temperature thermometers were found to be out of calibration, reading 27 and 25 degrees Fahrenheit in a standard ice-bath test. There was no documented evidence that dietary staff had been trained on how to adjust or calibrate these thermometers. These deficiencies were identified during a recertification survey, highlighting significant lapses in food safety protocols.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a recertification survey. Specifically, the lid of the garbage dumpster was found propped open with a broom handle, allowing kitchen and housekeeping waste to be exposed. This condition was noted during an observation, and it was confirmed through an interview with an administrator who acknowledged that the dumpster should be kept closed.
Failure to Provide Timely Laboratory Services as Ordered
Penalty
Summary
The facility failed to provide timely laboratory services as ordered for a resident with chronic kidney disease, cerebral infarction, and chronic obstructive pulmonary disease. The provider initially ordered laboratory tests, including a complete blood count, procalcitonin, and B-type natriuretic peptide, to be completed on a specified date. However, these tests were not completed as ordered, and there was no documentation that the provider was notified of the missed tests. The provider subsequently reordered the same laboratory tests on two additional occasions, but the tests were again not completed in a timely manner, and the provider was not informed of the delays. Documentation shows that the laboratory orders were entered and signed by the providers and confirmed by nursing staff, but there were repeated failures in ensuring the laboratory draws were performed as scheduled. The laboratory results were not available in the resident's chart for the dates ordered, and there was no evidence in the nursing notes that the provider was notified about the uncompleted tests. It was only after the third order that the laboratory specimens were collected and resulted several days later. Interviews with facility staff revealed that there were known issues with laboratory orders not being completed on the day they were ordered, and that communication lapses occurred regarding unsigned or unconfirmed orders. Staff also indicated that routine labs were only drawn on certain days unless marked as stat, which may have contributed to the delays. The deficiency was identified through record review and staff interviews, confirming that the facility did not ensure timely laboratory services to meet the needs of the resident.
Failure to Promptly Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering nurse practitioner or on-call provider of abnormal laboratory results for one resident. Specifically, a resident with chronic kidney disease, cerebral infarction, and chronic obstructive pulmonary disease had a basic metabolic profile collected, which revealed several critical or abnormal values, including a high potassium level. There was no documented evidence in the nursing notes that the provider was notified of these abnormal results when they were reported. Interviews with staff revealed confusion regarding responsibility for monitoring and communicating laboratory results, with some staff believing it was the provider's responsibility to check the results directly in the electronic medical record, while others stated that nurses should notify the provider. The resident's medical record showed that abnormal laboratory results, including a high potassium level, were present on multiple occasions, but there was no documentation of provider notification or new orders addressing these findings. Interviews with the nurse practitioner and other staff indicated ongoing issues with laboratory orders not being completed as requested and a lack of clarity about who was responsible for following up on abnormal results. The deficiency was identified through record review and staff interviews, which confirmed the lack of timely provider notification for abnormal laboratory findings.
Failure to Timely Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility did not ensure timely notification to the Office of the State Long-Term Care Ombudsman regarding the discharge of a resident. Specifically, Resident #52, who was admitted with diagnoses of diabetes mellitus type 2, depression, and bladder cancer, received a 30-day discharge termination notice on 11/7/2023. However, the Ombudsman was not notified until 12/4/2023, which is a delay of nearly a month. The facility's policy, dated 3/2018, mandates that the Ombudsman should be notified at the time of the discharge notice, but this was not adhered to in this case. During an interview, the Director of Social Work acknowledged that it was the Social Work Department's responsibility to send out discharge notification letters and admitted that the delay in notifying the Ombudsman was an oversight. The Director also confirmed that the facility had a policy in place for same-day notification, which was not followed in this instance. This deficiency was identified during a record review of facility-initiated discharges from 9/1/2023 to 1/30/2024, where it was found that only one 30-day notice of discharge was issued, and it was not properly communicated to the Ombudsman in a timely manner.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 179 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Altamont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Our Lady Of Mercy Life Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Kingsway Arms Nursing Center Inc | 5.7 mi | ★★★★★ | 0 | 0 |
| Schenectady Center For Rehabilitation And Nursing | 6.4 mi | ★★★★★ | 27 | 0 |
| Daughters Of Sarah Nursing Center | 6.8 mi | ★★★★★ | 1 | 0 |
| Teresian House Nursing Home Co Inc | 6.8 mi | ★★★★★ | 0 | 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.