Below 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 The Grand Rehabilitation And Nrsg At River Valley during CMS and state inspections, most recent first.
Surveyors found that treatment and medication carts were left unlocked and unattended on two units, with one cart containing Nystatin cream and another parked at a resident’s doorway while an LPN administered medications inside the room. Both involved LPNs acknowledged they knew the carts should have been locked, and the Assistant DON confirmed that nursing staff are aware of the policy requiring carts to be secured when out of the nurse’s view.
Surveyors found that staff failed to follow PPE requirements for residents on transmission-based precautions. One CNA entered a resident’s room on contact precautions without donning any PPE, despite a precaution sign on the door and facility policies requiring appropriate PPE use. Another CNA correctly donned PPE to enter a resident’s room on droplet precautions but then walked in the hallway still wearing the same mask instead of removing it upon exit. Both CNAs acknowledged their errors, and one reported that infection control training is provided but could not recall when it was last received.
The facility did not follow its own policy or regulatory requirements to provide residents with confidential quarterly statements of their personal funds held by the facility. Several residents reported they did not know their account balances and had not received quarterly statements for many months. After the former finance coordinator resigned, the Administrator assumed responsibility for disbursing resident funds, while an offsite corporate finance office was supposed to generate statements; however, no onsite staff were assigned to deliver them, and the Administrator could not verify when statements were last issued or provide documentation that any quarterly statements had been given to residents.
Surveyors identified that cold, egg-containing foods and other cold items were not consistently maintained at safe temperatures. Following resident complaints about food being overcooked, undercooked, and not arriving hot, observations showed egg salad and yogurt held well above the required 41°F or below, including an egg salad sandwich at 70°F and yogurt at 51°F. Cold items were sometimes stored under the same cover as hot items, and changes in food presentation and tray service timing contributed to elevated holding temperatures. The acting Food Service Director reported that cold food racks were kept in the walk-in refrigerator until tray assembly but acknowledged that cold food temperatures were not routinely monitored or documented.
Surveyors found multiple failures in food storage, labeling, and staff hygiene, including unlabeled foods in kitchen refrigeration areas, expired items in the walk-in refrigerator and emergency food supplies, and expired milk products in a resident’s personal refrigerator. Staff were unclear about responsibility for discarding expired items and monitoring the resident’s refrigerator, and a CNA reported that the refrigerator thermometer was missing and temperature records were not clearly maintained. Additionally, a cook prepared food with a beard net that did not cover the moustache, and a recreation staff member worked in the kitchen without a beard net, despite prior education on hair and beard net use.
The facility did not follow its own policy requiring outside dumpsters to be kept closed and free of surrounding litter. Surveyors observed multiple dumpsters left open, overflowing with cardboard and garbage, and surrounded by scattered debris including gloves, straws, spilled food, a tube feeding formula bottle, and plastic bags of trash on the ground and partially under a dumpster. The acting Food Service Director and Housekeeping Director reported that garbage and recycling are collected several times a week, that dumpster lids are routinely left open during the day, and that staff attempt to fill and close one dumpster before using the next, with the last housekeeper expected to close the lids at night.
Two residents who remained in the facility after their Medicare Part A skilled coverage ended were not provided with required Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABNs) detailing the costs of continued skilled services. Facility records showed that each resident’s Medicare Part A services were discontinued, and Notices of Medicare Non-Coverage were issued, but there was no documentation that either the residents or a representative received an SNF ABN specifying financial liability for ongoing skilled care. One resident reported not receiving any notice about the cost of skilled services after coverage ended, and the Assistant Administrator stated that the MDS Coordinator, who was responsible for issuing ABNs, was not in place at the time, resulting in the forms not being provided.
The facility did not ensure accurate completion of a PASARR Level I screen for a resident with schizophrenia, depression, and anxiety disorder. The preadmission form indicated the presence of a serious mental illness, but the required categorical determination items used to decide if a Level II evaluation was needed were left blank. Both Admissions and Social Work staff reported that they are responsible for reviewing PASARR forms for accuracy before and after admission, yet the missing categorical determinations were not identified or corrected, resulting in noncompliance with the facility’s PASARR policy and NYCRR 415.11(e).
The facility did not ensure that comprehensive care plans were reviewed and revised by the IDT in conjunction with required quarterly MDS assessments for two residents. One resident with atrial fibrillation, type 2 DM, and anemia had quarterly MDS assessments completed, including one showing intact cognition, but there was no documentation that the care plan was reviewed or updated after those assessments. Another resident with a head/scalp abscess, chronic skull osteomyelitis, and hemiplegia, and with moderately impaired cognition on a quarterly MDS, had no documented quarterly team care plan meeting during a several‑month period. The DON and Director of Social Work confirmed that quarterly care plan reviews and meetings should occur, but they did not for these residents.
A cognitively intact resident with paraplegia and multiple sclerosis, who had documented upper extremity limitations, was identified in a care plan as a smoker in a non‑smoking facility with instructions that staff secure lighters and assess smoking safety, yet later MDS assessments recorded that the resident did not use tobacco. Despite a signed agreement not to keep smoking materials in the room, the resident reported routinely storing cigarettes and a lighter in a bedside drawer and was observed smoking outside the facility gate and carrying a lighter in a fanny pack. Staff interviews showed conflicting practices and knowledge: the DON, Social Work Director, and Administrator stated that smoking materials should be locked at the front desk, while a CNA and the resident confirmed the resident kept smoking items in the room, and the receptionist reported not storing any resident cigarettes or lighters or maintaining a list of smokers. A NP stated the resident was safe to go out to smoke and could do as they wished beyond the gate, and acknowledged the resident may have smoked in their room previously, demonstrating the facility’s failure to evaluate and analyze hazards, and to monitor and adjust care plan interventions related to smoking materials.
A resident with COPD, respiratory failure, and heart failure received continuous oxygen at 4 L/min via nasal cannula without a physician’s order, despite facility policies requiring verification of orders before administering medications, including oxygen. The resident’s care plans directed staff to provide oxygen per MD orders, and observations showed the resident on oxygen from both a room concentrator and portable tanks. Record review revealed no oxygen order or MAR documentation from admission through the survey period, and interviews with an LPN, an RN, the MD, and the DON confirmed that oxygen therapy present on admission was continued without being entered into the electronic health record.
Surveyors found that MDS assessments did not accurately reflect the status of two residents. One resident with multiple comorbidities had repeated refusals of medications, IV therapy, and care, along with documented aggressive/combative behavior and behavior symptoms in nursing notes, MARs, and CNA ADL records, yet the MDS indicated no refusals or behaviors. Another resident with a chronic scalp infection and osteomyelitis had physician orders and documented treatments for a right temporal wound, but both the 5-day and quarterly MDS assessments recorded no ulcers, wounds, or skin problems. The Regional MDS Coordinator reported that errors occurred due to new staff completing MDS sections and a vacancy in the MDS Coordinator role, with corporate staff attempting to keep up with assessments.
The facility did not conduct required annual performance reviews or ensure that nurse aides completed at least twelve hours of in-service education per year. Interviews with leadership confirmed that performance evaluations were not performed, and documentation showed that two aides did not meet the annual training requirement.
A resident with severe cognitive impairment and dementia was the victim of sexual abuse by another resident. Although facility policy required prompt notification, the resident's representative was not informed of the incident until several days later, and there was no documentation of timely notification or attempts to notify. Staff interviews confirmed the delay and lack of documentation.
Two residents with cognitive impairment were not protected from abuse, as one was forcefully handled by a CNA during transport and another was subjected to inappropriate touching by a peer, with both incidents witnessed by staff and reported for investigation.
Staff failed to immediately report an observed incident of suspected abuse between two residents, both with cognitive impairment, to the State Survey Agency within the required timeframe and did not notify law enforcement, despite facility policy and state law requiring prompt reporting of such allegations.
A resident with severe cognitive impairment and a history of dementia and anxiety was the victim of a witnessed sexual abuse incident. The care plan, which previously addressed risk for abuse, was not updated to reflect the incident or to include new interventions, despite facility policy requiring care plan revisions after significant changes. Staff interviews confirmed the care plan should have been revised but was not.
A resident with arthritis, lymphedema, and peripheral neuropathy experienced multiple falls, but the facility failed to update the fall care plan. Despite documented falls, the care plan created years earlier was not revised. The DON acknowledged the oversight, noting that the ADON, DON, and RN responsible for A/I reports did not update the care plan.
Unsecured Medication and Treatment Carts Left Unattended
Penalty
Summary
The deficiency involves the facility’s failure to keep medications secure and inaccessible to unauthorized individuals, as required by its own policy and 10 NYCRR 415.18(e)(1-4). During an abbreviated survey, a treatment cart on Unit 3 East was observed at 10:20 a.m. left unlocked and unattended near a resident room, with Nystatin cream placed on top of the cart. The cart was under the responsibility of one LPN, who acknowledged in an interview that the cart had been left unlocked with the medication on top and stated that the cart should have been locked, offering no excuse for not doing so. A second incident was observed on Unit 5 East at 11:00 a.m., where a medication cart was parked at the entrance of a resident room, left unlocked and unattended while another LPN was inside the room administering medications to a resident. In an interview, this LPN admitted awareness that the cart was left unlocked and stated that it needed to be locked, noting that they normally do lock the cart. The Assistant DON later stated that nurses know they should always lock the carts and that they were likely taking a shortcut, confirming that staff were aware of the requirement that carts be locked when not in the nurse’s presence.
Failure to Adhere to PPE Requirements for Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of personal protective equipment (PPE) during an abbreviated survey. The facility’s infection control policy, last reviewed in January 2025, required the use of transmission-based precautions when more stringent measures than standard precautions were needed, and its PPE policy required appropriate barrier use based on the nature of resident interaction and likely mode of transmission, with supplies readily accessible. Despite these policies, on 3/2/2026 at 12:04 p.m., a Certified Nurse Aide (CNA #1) was observed entering the room of Resident #2, who had a contact precaution sign posted on the door, without donning any PPE prior to entry. During an interview immediately following this observation, CNA #1 stated they believed Resident #2 was on contact precautions due to “something with their head,” acknowledged they had entered the room without PPE, and admitted they should have applied PPE because the resident was on contact precautions, explaining they forgot and were rushing to answer the call bell. On 3/3/2026 at 10:37 a.m., another aide (CNA #2) was observed correctly donning PPE to enter the room of Resident #3, who was on droplet precautions. However, at 10:50 a.m., CNA #2 was observed in the hallway still wearing the mask used in the droplet precaution room. In a subsequent interview, CNA #2 acknowledged wearing the mask in the hallway and stated it should have been removed, and also reported that the facility does provide infection control training but could not recall when they were last trained, while stating they understood that PPE must be applied when residents are on precautions and removed after care is completed.
Failure to Provide Quarterly Personal Funds Statements to Residents
Penalty
Summary
The facility failed to provide required quarterly personal funds statements to multiple residents whose personal money was managed by the facility. The facility’s written policy, dated 01/2025, stated that residents were to be provided with a confidential quarterly statement of funds on deposit and activity since the previous statement. However, record review and interviews showed there was no documented evidence that six residents with personal needs accounts managed by the facility received these quarterly statements. The Administrator confirmed they were unable to provide documentation that quarterly personal funds statements had been provided. Several residents reported not receiving information about their account balances or quarterly statements. One resident stated they did not know how much money was in their account and had not received an account statement in the past year. Another resident reported not receiving quarterly statements for their personal funds account, and a third resident stated they did not know their personal fund account balance and had not received quarterly statements since approximately 06/2025. The Administrator reported they had assumed responsibility for resident banking after the former Finance Coordinator resigned in 11/2025, and that the corporate finance office, which operates offsite, was responsible for generating quarterly statements. The Administrator also stated there were no onsite staff designated to deliver the statements and that they did not know when the last quarterly statements were sent out. The facility could not produce any documentation to show that quarterly statements had been provided, in violation of 10 NYCRR 415.26(h)(5)(ii)(a-c).
Failure to Maintain Safe Cold Holding Temperatures for Egg-Containing Foods
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and drink were palatable and maintained at safe, appetizing temperatures, particularly for cold, egg-containing items. During a resident council meeting, multiple residents reported that foods were sometimes overcooked, undercooked, and did not arrive hot. In response to these complaints, surveyors observed a test tray and meal services where egg salad and yogurt were not held at appropriate cold temperatures. On one occasion, an egg salad sandwich on a test tray registered a holding temperature of 70°F, and during a lunch meal service, egg salad and yogurt were held at 58°F, both above the FDA Food Code standard of 41°F or below for cold holding of cooked eggs and egg-containing foods. Further observations showed that the last lunch tray served on one unit included an egg salad sandwich, a cold item, at 70°F and stewed tomatoes, a hot item, at 126.7°F, with both items stored under the same plate cover. The cook stated that this unit was the last to receive lunch service, that cold foods should be kept well below 70°F, and that the kitchen had recently changed the food presentation, which might have affected holding temperatures. In another observation, yogurts and pre-portioned egg salad cups held on a rack for tray assembly measured 51°F and 43°F, respectively, after being out of the walk-in refrigerator for less than ten minutes. The acting Food Service Director confirmed that the procedure was to keep the rack in the walk-in until just before tray assembly, noted that refrigerator temperature logs were within normal limits, and acknowledged that cold food temperatures were typically not obtained and tracked on the temperature log.
Failure to Maintain Safe Food Storage, Labeling, and Staff Hygiene Practices
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards and its own policies. Surveyors observed multiple unlabeled food items in the main kitchen, including a plate of unlabeled food in the walk-in refrigerator, a bag of unlabeled tortellini in the freezer, and an unlabeled pan of white smooth food on the cook’s counter that staff inconsistently identified as either pancake batter or alfredo sauce. In the walk-in refrigerator, surveyors found grape jelly, chopped lettuce, chopped tomato, hard-boiled eggs, and several gallons of whole milk that were past their labeled discard or expiration dates. In the emergency food supply, a case of honey-thick apple juice and a case of rice cereal were also found to be expired. The acting Food Service Director stated that unlabeled food should not have been stored there, that it was the evening cook’s responsibility to discard expired items, and that expired milk had been delivered and left unchecked at the door, with no one available to verify it upon delivery. The facility also did not ensure staff complied with dress code requirements for beard coverage and did not properly monitor a resident’s personal refrigerator. During kitchen observations, a cook was preparing chicken with a beard net that did not cover their moustache, and a recreation staff member was filling beverage containers without a beard net, despite prior staff education on hair and beard nets. In a resident’s room, surveyors found a personal refrigerator containing multiple individual servings and cartons of milk with dates indicating they were expired. A CNA reported that the refrigerator previously had a thermometer but did not know its current location or who was responsible for temperature records, and believed the CNA assigned each shift cleaned the refrigerator. An LPN Unit Manager stated the resident’s personal refrigerator had been “grandfathered in” and was unsure who monitored or cleaned it.
Improper Management and Disposal of Garbage and Refuse at Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in accordance with its policy and regulatory requirements. The written policy titled "Food-Related Garbage and Refuse Disposal," reviewed in January 2024, required that outside dumpsters provided by garbage pickup services be kept closed and free of surrounding litter. During an observation of the garbage area with the acting Food Service Director, only one of three dumpsters had its lid closed, while the other two were open. Litter was observed on the ground, including an unused plastic garbage bag, plastic straws, used blue and white plastic gloves, cardboard, spilled food, and a plastic bag full of garbage on the ground between the two open dumpsters. A subsequent observation of the garbage area showed all three dumpster lids open. The right dumpster was spilling over with cardboard boxes, with one box on the ground, and the middle dumpster was full of garbage and boxes, including a bag hanging over the side. Additional litter was scattered in front of the dumpsters, including an empty bottle of tube feeding formula, straws, gloves, plastic, napkins, and a plastic bag of garbage partially under the dumpster. The third dumpster was partially full, with cardboard boxes trapped under it and surrounding debris such as a milk carton and used gloves. In interviews, the acting Food Service Director and the Housekeeping Director stated that garbage and recycling were picked up multiple times per week and that dumpster lids were routinely left open during the day, with the expectation that staff would fill one dumpster and close it before using the next, and that the last housekeeper would close the lids late at night.
Failure to Provide Required SNF Advanced Beneficiary Notices After Medicare Part A Ends
Penalty
Summary
The facility failed to ensure residents were informed of items and services they could be charged for and the amounts of those charges when Medicare Part A coverage ended, as required for beneficiary notification. Record review showed that two residents, both of whom remained in the facility after their Medicare Part A skilled coverage ended, did not receive a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) outlining the cost to continue skilled services. Facility records documented that one resident was discharged from Medicare Part A services on 09/30/2025 and another on 12/04/2025, yet there was no documented evidence that either resident or the second resident’s representative received an SNF ABN specifying the financial liability for continued skilled services. The Notice of Medicare Non-Coverage for one resident, dated 09/25/2025, contained the resident’s signature acknowledging that Medicare Part A services would end on 09/30/2025, but did not include information on the cost of continued skilled services. For the other resident, the Notice of Medicare Non-Coverage dated 12/04/2025 indicated cognitive impairment and that a phone call to the resident’s representative on 12/01/2025 went unanswered, with no further documentation of SNF ABN issuance. During an interview, a resident stated they did not receive any notice from the facility about the cost of skilled services after Medicare Part A coverage ended. The Assistant Administrator reported that the MDS Coordinator was responsible for providing ABN forms, but that position was vacant when these residents’ Medicare coverage ended, and as a result, the ABN forms were not issued to them or their representative.
Failure to Complete PASARR Categorical Determinations for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the PASARR Level I preadmission screening for one resident. The facility’s policy required that all individuals applying for new admission be screened to identify serious mental illness or intellectual/developmental disability, and that the Admissions Department review the Level I screen to determine if a Level II referral was needed. For Resident #81, who was admitted with diagnoses including schizophrenia, depression, and anxiety disorder, the preadmission screen dated 03/21/2025 indicated "yes" to the presence of a serious mental illness in item 23. However, the categorical determination section (items 27 to 30), which is used to determine whether a Level II screen is indicated, was not completed as instructed. Interviews with facility staff confirmed that both the Admissions Department and Social Work were responsible for reviewing the PASARR screens for accuracy before and after admission. The Assistant Director of Social Work stated that once a resident is admitted, social work checks the screens for accuracy and that items 27 to 30 should have been completed once a serious mental illness was identified. The Director of Admissions similarly stated that admissions staff review the screens for accuracy prior to admission and that, after admission, the social worker should re-check the screen and have any errors corrected. Despite these stated processes, the categorical determinations for Resident #81 were left incomplete, resulting in a failure to follow the facility’s PASARR policy and regulatory requirements under NYCRR 415.11(e).
Failure to Complete Quarterly IDT Care Plan Reviews and Meetings
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) in conjunction with required comprehensive and quarterly Minimum Data Set (MDS) assessments, as required by facility policy and regulation. For one resident with paroxysmal atrial fibrillation, type 2 diabetes mellitus, and anemia, the quarterly MDS dated 11/18/2025 documented that the resident was cognitively intact, yet there was no documented evidence that the resident’s comprehensive care plan was reviewed or revised following the quarterly MDS assessments completed on 08/25/2025 and 11/18/2025. The facility’s policy titled “Care Plans, Comprehensive Person-Centered,” last reviewed January 2025, required that the IDT review and update the care plan at least quarterly in conjunction with the quarterly MDS, and the DON confirmed in interview that care plans should be reviewed every quarter to determine if changes and updated interventions were needed. For another resident with diagnoses including abscess of the head/scalp, chronic osteomyelitis of the skull, and hemiplegia, there was no documented evidence that a quarterly team care plan meeting was held during the period between 09/2025 and 01/2026, despite a quarterly MDS dated 01/02/2026 that documented moderately impaired cognition. The Director of Social Work stated that care plan meetings were to be held every quarter and that the MDS Coordinator typically sent a list of residents due for care plan meetings, but acknowledged that a quarterly team care plan meeting for this resident did not occur during the specified period because the facility did not have an MDS Coordinator. These findings demonstrate that the facility did not follow its own policy or regulatory requirements for timely IDT review and revision of care plans in conjunction with quarterly MDS assessments for the residents reviewed.
Failure to Control Resident Smoking Materials and Enforce Smoking Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to adequately supervise a resident who smoked and possessed smoking materials, contrary to facility policy and regulatory requirements. One resident with paraplegia and multiple sclerosis, who was cognitively intact but had functional limitations in both upper extremities, was care planned in 2022 as a smoker in a non‑smoking facility, with instructions that staff assess physical and mental ability, remove the lighter to a secure location, and instruct the resident, noting the resident chose to be non‑adherent. A 2023 contract signed by the resident documented agreement not to keep smoking materials such as lighters or matches in the room. However, the 2025 Annual MDS documented that the resident did not use tobacco, and subsequent MDS assessments continued to show cognitive intactness and upper extremity limitations without reflecting ongoing tobacco use. Surveyor observations and interviews showed that the resident continued to smoke and keep smoking materials in their possession and room, without documented evaluation of hazards, analysis of risks, or monitoring and modification of care plan interventions. The resident was observed smoking outside the facility gate and later reported routinely retrieving cigarettes and a lighter from a bedside drawer, informing staff they were going downstairs, and then smoking outside the gate. On another observation, the resident had a lighter in a fanny pack. Staff interviews revealed inconsistent understanding and implementation of the smoking policy: the DON and Social Work Director stated that resident cigarettes and lighters were to be kept in a locked drawer at the front desk, while the receptionist stated the front desk did not keep resident cigarettes or lighters and had no list of smokers, and a CNA reported that the resident kept cigarettes and a lighter in the room because they were considered responsible. The Nurse Practitioner stated the resident was physically and cognitively safe to go out on leave of absence for smoking and that once beyond the gate the resident could do whatever, acknowledging the resident had possibly smoked in their room in the past. The Administrator stated smoking materials should be kept at the front desk and not held by residents, underscoring the discrepancy between policy and practice.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
Failure to provide safe and appropriate respiratory care occurred when a resident with chronic obstructive pulmonary disease, respiratory failure, and heart failure was administered continuous oxygen therapy without a physician’s order. Facility policies required that medications, including oxygen, be administered only in accordance with physician orders and that staff verify orders prior to administration. The resident’s admission MDS documented intact cognition, assistance needs with ADLs, and shortness of breath when lying flat or on exertion. Care plans addressing cardiovascular and respiratory function directed staff to provide oxygen per medical doctor orders and to assess oxygen needs and provide oxygen as ordered. During multiple observations over several days, the resident was noted to be receiving oxygen at 4 liters per minute via nasal cannula from both an oxygen concentrator in the room and portable tanks on the wheelchair. The resident reported having been on 4–5 liters per minute of oxygen prior to admission. Record review on 1/22/2026 showed no oxygen orders in the medication administration record or physician orders from admission through that date. Nursing staff, including an LPN and an RN, stated the resident arrived on 4 liters per minute of continuous oxygen and that this therapy was simply continued without an order being entered into the electronic health record, resulting in no documentation of oxygen administration on the MAR. The physician confirmed that orders are typically entered by providers or nurses at admission and acknowledged that the resident’s oxygen administration was correct but not entered. The DON stated there should have been an order for oxygen and that its absence was an oversight.
Inaccurate MDS Coding for Refusals and Chronic Scalp Wound
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status for two residents reviewed for skin issues. For one resident with diagnoses including diabetes mellitus, heart failure, and morbid obesity, the quarterly MDS dated 09/29/2024 documented intact cognition and no behaviors, including no refusals of care, medications, or activities of daily living. However, nursing notes showed that this resident refused an IV catheter for IV infuvite on 09/23/2024 and refused milk of magnesia on 09/27/2024, stating they had not eaten in days. Additional documentation on 09/27/2024 described the resident as aggressive/combative and resisting/refusing care. The September Medication Administration Record showed refusals of Eliquis on 09/22/2024, 09/24/2024, and 09/25/2024, and CNA ADL documentation for September 2024 recorded behavior symptoms on multiple dates. Despite these documented refusals and behaviors, they were not captured on the MDS, and the Regional MDS Coordinator later acknowledged that these behaviors should have been included and that information may have been entered incorrectly by new staff. For a second resident with diagnoses including urinary abscess of the head/scalp, unspecified open wound of the head, and chronic osteomyelitis of the skull, the MDS assessments also failed to accurately reflect the resident’s condition. A physician’s note dated 11/26/2025 documented a chronic right scalp infection with greenish-brown exudate, and physician orders on 11/26/2025 and 11/27/2025 directed cleansing of the right temporal area with normal saline, application of a clean dry dressing, and topical Gentamicin Sulfate for osteomyelitis of the scalp. The Treatment Administration Record showed that the ordered scalp treatment was administered on 12/30/2025 and 12/31/2025. Despite this, both the Five-Day and Quarterly MDS assessments documented that the resident did not have other ulcers, wounds, or skin problems. The Regional MDS Coordinator stated that staff entering the MDS information made mistakes, that the MDS Coordinator position had been vacant, and that corporate staff were attempting to complete assessments while the Regional Coordinator was overseeing them but having difficulty keeping up.
Failure to Complete Annual Performance Reviews and In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that performance reviews for certified nurse aides were completed at least once every 12 months and that each aide received no less than twelve hours of in-service education per year, as required by facility policy and state regulation. During interviews, the Director of Human Resources, Director of Nursing, Administrator, and former Staff Educator all confirmed that performance evaluations for clinical staff, including nurse aides, were not conducted. Documentation reviewed for three certified nurse aides showed that performance reviews were not available for any of them. Additionally, the review of mandatory annual education packets revealed that two of the three certified nurse aides did not complete the required twelve hours of in-service education within the year. Specifically, one aide completed 7.5 hours and another completed 9 hours, with the former Staff Educator noting that the tally of education minutes was not up to date. The facility's own policy states that in-service training should be based on the outcome of annual performance reviews and must total at least twelve hours per year, but this was not followed.
Failure to Timely Notify Resident Representative After Significant Incident
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant incident involving sexual abuse. On 12/13/24, a certified nurse aide observed another resident touching the resident's left breast, and the incident was documented as having reasonable cause to believe abuse, neglect, or mistreatment may have occurred. Despite facility policy requiring that the resident and their representative be kept informed of the progress of the investigation, there was no documented evidence that the resident's family member was notified of the incident when it occurred. The accident/incident report noted a notification time but did not include a date, and review of the nurse's notes confirmed that the resident's son was not notified until 12/16/24. The resident involved had severe cognitive impairment, dementia, anxiety, and required assistance with activities of daily living. Interviews with staff, including the assistant director of nursing and the director of nursing, confirmed that the family was not notified at the time of the incident and that documentation of any attempted or successful notification prior to 12/16/24 was lacking. The director of nursing acknowledged that the family should have been notified when the incident occurred, but there was no evidence to support that this was done in a timely manner.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, as evidenced by two separate incidents involving three residents with cognitive impairments. In the first incident, a Certified Nurse Aide was observed by a Registered Nurse Supervisor forcefully pushing a resident's arm off a door jam while attempting to wheel the resident out of the dining room. The resident, who had severe cognitive impairment and was care planned as being at risk for abuse, was assessed immediately after the incident and found to have no injuries. The event was reported to the Director of Nursing, and the facility's policy required prompt investigation and reporting of abuse allegations. In the second incident, another Certified Nurse Aide witnessed a resident with moderately impaired cognition touching the breast of another resident who also had severe cognitive impairment and required assistance with activities of daily living. The facility's accident and incident report concluded there was reasonable cause to believe that abuse, neglect, or mistreatment may have occurred. The Director of Nursing, after investigation, stated they could not rule out that abuse may have occurred in this case as well.
Failure to Timely Report Suspected Abuse and Notify Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by policy and state law. Specifically, a Certified Nurse Aide observed one resident touching another resident's breast, and the incident was documented as having reasonable cause to believe that abuse, neglect, or mistreatment may have occurred. Despite this, the facility did not report the incident to the State Survey Agency until the following day, well beyond the required two-hour timeframe, and did not notify local law enforcement at any point, even though the facility could not rule out abuse. The residents involved had significant cognitive impairments and required assistance or supervision with activities of daily living. The facility's own policies required immediate reporting of suspected abuse and notification of both the State Survey Agency and law enforcement in cases of reasonable suspicion of a crime, including sexual abuse. Interviews with facility staff confirmed the delay in reporting and the failure to notify law enforcement, with the DON stating that law enforcement is only contacted if at least one resident involved is alert and oriented, which is not consistent with policy requirements.
Failure to Update Care Plan After Abuse Incident
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised in a timely manner following a significant event involving a resident. Specifically, a resident with severe cognitive impairment, dementia, anxiety, and muscle weakness was the victim of a witnessed sexual abuse incident. Although the resident's care plan, dated prior to the incident, included interventions to assess for and report abuse, there was no documented evidence that the care plan was updated to reflect the abuse incident or to include new interventions after the event occurred. Facility policy requires the interdisciplinary team to review and update the care plan when there is a significant change in a resident's condition. Despite documentation in the physician's note that the resident's son was informed and staff would increase monitoring and prevent further contact with the perpetrator, these interventions were not incorporated into the resident's care plan. Interviews with facility staff confirmed that the care plan should have been updated to document the incident and the new interventions, but this was not done.
Failure to Update Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team for a resident who experienced multiple falls. Resident #59, who had diagnoses including arthritis, lymphedema, and peripheral neuropathy, experienced falls on 2/4/23 and 2/28/23. Despite these incidents, the resident's fall care plan, initially created on 10/7/19, was not updated to reflect the new falls. The resident's Annual Minimum Data Set (MDS) dated 8/26/23 indicated intact cognition and required limited assistance for mobility and toileting. The Accident/Incident reports documented the falls, but there was no evidence of care plan revision. The Director of Nursing (DON) acknowledged that the care plans were not updated and stated that the responsibility lay with the Assistant Director of Nursing (ADON) and the DON, as well as the registered nurse (RN) who completed the A/I reports.
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What surveyors actually found near you
We read the 111 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Poughkeepsie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines At Poughkeepsie Ctr For Nursing & Rehab | 0.7 mi | ★★★★★ | 0 | 0 |
| Hudson Valley Rehabilitation & Extended Care Ctr | 2.4 mi | ★★★★★ | 37 | 0 |
| Lutheran Center At Poughkeepsie Inc | 3.6 mi | ★★★★★ | 5 | 0 |
| Taconic Rehabilitation And Nursing At Ulster | 3.8 mi | ★★★★★ | 0 | 0 |
| The Eleanor Nursing Care Center | 7.2 mi | ★★★★★ | 13 | 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.