Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Valley View Center For Nursing Care And Rehab during CMS and state inspections, most recent first.
The facility failed to develop and implement comprehensive behavior care plans for two residents with severe cognitive impairment and documented behavioral symptoms. One resident with Alzheimer’s disease and mobility issues had repeated episodes of wandering, resistance to care, confusion, agitation, and aggression documented by CNAs and nurses, yet no behavior care plan or ADL care plan notation of resistance to care was present in the EMR. Another resident with encephalopathy and severe cognitive impairment had multiple documented episodes of wandering, verbal and physical aggression, socially disruptive behavior, and resistance to care, and was identified as an elopement risk with an elopement care plan in place, but no behavior care plan was initiated. A unit manager stated that behavior care plans should be triggered by combative or aggressive behaviors and acknowledged that such plans were not created or updated for these residents despite the documented behaviors.
A resident with Alzheimer’s disease, severe cognitive impairment, delusions, and documented wandering behavior was assessed as high risk for elopement and had orders for frequent visual checks across all shifts. After an earlier incident where the resident was found off the unit in a kitchen area, staff were to perform 15‑minute visual checks, but documentation showed multiple omissions and no recorded checks during the later period when the resident left the unit and exited through a fire exit door. Video showed the resident self‑propelling a wheelchair outside onto the grounds and toward the employee parking lot before being assisted back inside by staff, while the door alarm sounded during change of shift and unit staff were unaware the resident had left. No active care plan specifically addressed wandering behavior at the time of the elopement, despite the resident’s high‑risk status and prior elopement‑related assessment findings.
Unsafe and Poorly Maintained Resident Areas: The facility failed to maintain a clean, comfortable, and homelike environment. A resident room had leaking radiators with wet towels/sheets placed on the floor, another room had a missing baseboard, and the Forest Unit had torn or missing wallpaper, rust-stained trim, low shower water pressure, and hot water that measured only 91.9°F during observation. Residents also reported ongoing low water pressure, delayed hot water, and poor lighting in the Town Hall Common area, where about 25% of fluorescent lights were not working.
Failure to protect residents from abuse and wandering-related unsafe interactions. A resident with dementia and wandering behaviors was found in another resident’s room during a sexual abuse incident, and the record did not consistently document ordered 15-minute visuals afterward. Another resident with severe cognitive impairment repeatedly wandered into other residents’ rooms and slept in their beds, and staff did not consistently observe or redirect the behavior during multiple observations. Staff interviews described frequent wandering on the unit and limited CNA coverage at times.
Failure to Thoroughly Investigate Abuse and Missing Property Reports: The facility did not promptly and thoroughly investigate a resident-to-resident sexual incident involving a resident with severe cognitive impairment, and it also failed to document complete investigations after residents reported missing personal items, including a ring, a purse, and a wallet. Interviews showed staff and leadership were unclear about reporting, follow-up, and Administrator review, and the missing items process was not consistently completed.
Improper Food Storage and Labeling: Surveyors found multiple unlabeled and undated food items in kitchen refrigerators, freezers, and dry storage, including opened products without dates and food not kept in original containers. A staff member’s personal drink was also stored in a refrigerator used for resident food, and a malodor was noted in the meat refrigerator.
Kitchen Dishwasher Leak and Standing Water: Water was observed leaking from the kitchen dishwasher, leaving standing water on the floor around the unit. The Acting Dietary Director stated the standing water had been present for some time, and the Maintenance Supervisor stated the leak was in a different area, the floor drain was obstructed by debris, and maintenance had not been able to repair the leak or clean the drain.
A resident with Alzheimer's disease and a history of falls experienced a fall from a wheelchair. Following an occupational therapy assessment, a safety intervention was recommended to remove an additional mechanical lift pad after outside appointments to reduce fall risk. The care plan was not updated to include this intervention, despite facility policy and staff awareness.
Call Bells Not Kept Within Residents’ Reach: Two residents with significant cognitive and functional impairment were repeatedly observed with call bells out of reach. One resident with CVA, PVD, and CAD and another resident with anoxic brain damage, anxiety, and epilepsy had care plans stating the call bell must remain within reach, yet the devices were seen across the room, on the bed behind the resident, hanging on the wall, or wrapped on a bed rail instead of being accessible.
Failure to address missing resident property: Two cognitively intact residents reported missing belongings, including a ring and a purse containing rosary beads, cash, a debit card, and a pacemaker card. Staff were aware of the concerns, but the facility had no documented missing-item records in the logs, and the Administrator stated they were unaware of one resident’s missing purse.
Failure to Report Alleged Abuse Immediately: A resident with Alzheimer’s disease and severely impaired cognition was found in another resident’s room during a resident-to-resident incident in which the other resident was masturbating in front of her. Although staff recognized the event as abuse and notified nursing leadership, the DON and ADON stated it was not reported to the NYSDOH, and the Administrator did not recall the incident or any report being made.
A resident with dementia and a contracted left hand did not have a care plan developed or implemented to address contracture management and OT-recommended left-hand roll use. OT had educated staff on the handroll schedule, ROM, hygiene, and skin checks, but observations showed the resident repeatedly resting in a wheelchair with the left hand contracted and no hand roll in place. The record contained no documented care plan or physician orders for this intervention, and an LPN, RN UM, and ADON each stated the intervention should have been care planned and documented.
A resident with dementia, psychotic disorder, and anxiety did not receive documented follow-up psychiatry or psychology services ordered after an in-house consult, despite a care plan calling for ongoing psych services. The resident was observed with behavioral outbursts and later calling out for help. Another resident with dementia, stroke, and hemiplegia was repeatedly observed seated in a wheelchair with feet dangling unsupported above the footrests and without a leg board in place; staff said the device had been used before and that positioning information should be communicated through care instructions.
Heel Boots Not Applied as Ordered for a Resident at Risk for Pressure Ulcers. A resident with dementia, stroke, hemiplegia, severe cognitive and functional impairment, and pressure-ulcer risk had a physician order and CNA instructions for heel boots at all times, but was observed in a wheelchair and in bed without the offloading boots in place. Staff reported confusion about when the boots should be worn and noted the boots were sometimes missing after laundry, while the DON said CNA care information should include positioning and off-loading devices.
A resident with cerebral infarction, dementia, and limited ROM was repeatedly observed with a contracted left hand and without the recommended left-hand splint in place. OT had recommended the splint be worn at all times except for care and ROM, but there was no documented care plan or MD order to address contracture management or splint use, and staff interviews confirmed there was no CNA accountability for daily splint application.
Medication Administration Error Rate Exceeded Threshold: An LPN combined three crushed meds and administered them together via G-tube, then combined three liquid meds and administered them together for a resident with MDD, epilepsy, and gastrostomy status. The facility policy required meds to be crushed and given separately, and the DON stated the meds should have been administered one at a time with a flush after each medication.
An LPN administered medications via a gastrostomy tube to a resident on enhanced barrier precautions without wearing a gown. The resident had dysphagia, a gastrostomy, and severe cognitive impairment. The LPN said they forgot to follow PPE guidelines, and the DON and Unit Manager RN stated staff were expected to wear a gown during close interaction and medication administration when enhanced barrier precautions were in place.
The facility did not maintain adequate CNA and LPN staffing levels as outlined in its own assessment, leading to multiple shifts where staff numbers were below required minimums. As a result, residents did not receive essential medications, and staff reported frequent understaffing, mandatory overtime, and the need to cover multiple units. Administrative and nursing leadership confirmed these deficiencies and acknowledged that units were often left without proper nurse coverage.
A resident with severe cognitive impairment and physical disabilities was assisted with eating by an LPN who stood over them rather than sitting at eye level, contrary to facility policy. The LPN stated this was due to being the only nurse present and needing to assist multiple residents. The DON confirmed that staff should sit to ensure a dignified dining experience.
The facility did not conduct a thorough facility-wide assessment to determine necessary resources for competent care during daily operations and emergencies. The assessment lacked details on minimum staffing requirements for CNAs and LPNs, did not address behavioral health staffing, and omitted review dates and signatures with QAPI. The Administrator confirmed these omissions and cited reliance on PBJ reports and frequent staffing changes as reasons for not specifying exact staffing numbers.
Failure to Develop and Implement Behavior Care Plans for Residents With Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, measurable behavior care plans for residents with severe cognitive impairment and documented behavioral symptoms. Facility policy required that a comprehensive care plan, including measurable goals and timetables, be developed within seven days after completion of the comprehensive assessment to address medical, nursing, mental, and psychosocial needs. Despite this, for two residents with Alzheimer’s disease, encephalopathy, and other conditions, there was no behavior care plan documented in the electronic medical record, even though both had repeated episodes of wandering, resistance to care, and verbal and physical aggression documented by CNAs and in nursing progress notes. One resident with Alzheimer’s disease, type 2 diabetes, and difficulty walking had an annual MDS showing severe cognitive impairment with inattention, disorganized thinking, delusions, and wandering. CNA documentation over a one‑month period showed frequent wandering and resistance to care across all shifts, and nursing progress notes recorded wandering and aggression on multiple dates, including an episode of confusion and agitation where the resident was fixated on missing belongings and past employment, requiring repeated phone calls to the spouse and 30‑minute visual checks. However, review of the resident’s care plans revealed no behavior care plan and no documentation in the ADL care plan that the resident was resistive to care. During interviews, a CNA and an LPN described the resident as confused, wandering, sundowning, repetitive, physically aggressive, and often refusing care, while the Unit Manager stated the resident did not have behaviors and acknowledged that no behavior care plan had been initiated. Another resident with encephalopathy, syncope and collapse, and difficulty walking had an admission MDS indicating severe cognitive impairment with inattention and disorganized thinking. Although initially documented as having no behaviors, subsequent CNA documentation over several days showed wandering, verbally and physically abusive behavior, socially inappropriate or disruptive behavior, and resistance to care on multiple shifts. Nursing progress notes also documented frequent attempts to leave the unit and episodes of verbal and physical aggression during morning care. The resident had an elopement risk order and a potential for elopement care plan with interventions such as structured activities, identification, 15‑minute visual checks, and a WanderGuard device, but there was no documented evidence of a separate behavior care plan in the electronic medical record. The Unit Manager explained that behavior care plans should be developed for combative or physically/verbally aggressive residents and confirmed that care plans are to be initiated and updated timely, but acknowledged that a behavior care plan had not been created for this resident.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free of accident hazards and to provide adequate supervision to prevent elopement for one resident identified as high risk. The resident had Alzheimer’s disease, severe cognitive impairment with inattention and disorganized thinking, delusions, and wandering behaviors occurring 1 to 3 days, as documented on an annual MDS. The resident used a wheelchair for locomotion, required supervision or assistance with most ADLs, was frequently or always incontinent, and had an order indicating they were incapable of making their own decisions. An elopement risk assessment showed a history of attempted elopement, wandering behavior, cognitive impairment, verbalizations about wanting to go home or leave the unit/building, and independent mobility, resulting in a high-risk elopement score of 19. Despite this high-risk status, the facility did not consistently implement and document required monitoring interventions. Following an incident on which the resident was found off their unit in the kitchen by dietary staff, the resident was placed on 15‑minute visual checks and identified as an elopement risk with a medical alert and visual check orders spanning all shifts. However, review of visual check documentation revealed omissions on multiple days, including 8/12/2025, 8/13/2025, and 8/14/2025, and there was no documentation of visual checks during the time period when the resident later eloped from 3:00 p.m. to 3:30 p.m. on 8/27/2025. Staff on the resident’s unit were not aware when the resident was off the unit during the earlier kitchen incident, and the DON acknowledged the lack of documentation for ordered visual checks. On 8/27/2025, video surveillance showed the resident exiting the building through a west wing fire exit door at 3:04 p.m., self‑propelling in their wheelchair onto the lawn and moving toward the employee parking lot, and then returning through the front entrance at 3:15 p.m. The Occupational Therapy Supervisor reported seeing the confused resident near the end of the employee parking lot and observing a social services staff member approach and assist the resident back toward the main entrance, after which therapy staff returned the resident to their unit and notified security. The DON and Administrator stated that the door alarm did sound when the resident exited, but staff may not have heard it because it was change of shift and staff were congregated near the nurse’s station. The DON also stated that an elopement risk assessment is completed on admission and after a resident wanders, and that the resident had been on visual checks since the earlier wandering incident, but could not recall whether the resident had a history of wandering beyond what was documented. Review of care plans showed no active care plan specifically addressing wandering behavior at the time, although a prior potential elopement care plan existed with interventions related to confusion/dementia and attempts to leave.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility did not maintain a clean, comfortable, and homelike environment in the Forest Unit and Town Hall Common area. During observation, resident rooms had leaking radiator units, with wet towels or sheets placed on the floor in front of the radiators to absorb water. One resident room also had a missing baseboard between the wall and radiator. The Forest Unit hallways and common areas had torn or missing wallpaper, scuffed walls and doors, and rust stains on ceiling trim. The Forest Unit shower room also had low water pressure, and the shower hot water temperature was measured at a highest recorded temperature of 91.9 degrees Fahrenheit during the observation period. Resident Council members reported ongoing concerns about low water pressure on units and hot water taking an extended time to reach a comfortable temperature. They stated these concerns had been discussed in monthly meetings and reported to CNAs, and that maintenance staff had responded at times, but the problems returned. They also stated that the mixers added to the shower rooms a few years earlier made the pressure and hot water concerns worse, and that hot water delays caused cares to be rushed. In addition, residents reported that lighting in the Town Hall Common area was not sufficient during activities and that non-functioning fluorescent lights made it difficult to read bingo cards and documents. The Plant Operations Manager stated the radiators were leaking due to condensation and that drip pans could become clogged, causing leakage to the floor. They stated they were not aware of the leaking radiators in the affected rooms and did not recall receiving maintenance requisitions for them. They also stated there was no set schedule for radiator maintenance and that the maintenance department relied on unit staff to report concerns. For the Town Hall Common area, approximately 25% of the fluorescent ceiling lights were not functioning, and the Plant Operations Manager stated they had not contacted a contractor to replace them and were not aware of any recent replacement of non-functioning bulbs. The manager also stated they were not aware of the Resident Council concerns about weak water pressure and delayed hot water in the building.
Failure to Protect Residents from Abuse and Wandering-Related Unsafe Interactions
Penalty
Summary
The facility did not ensure residents were protected from abuse and did not consistently provide or document interventions to maintain resident safety. One resident had diagnoses including Alzheimer’s disease, osteoarthritis, and atrial fibrillation, with severe cognitive impairment, wandering, and verbal behaviors toward others. Another resident had unspecified dementia with agitation, psychotic disorder with delusions, and major depressive disorder, with severe cognitive impairment and behavioral symptoms toward others. Both residents had care plans addressing potential for abuse and wandering-related behaviors, including instructions to remove residents from unsafe situations and provide frequent visualization and intervention as needed. On 4/25/24, a nurse found the wandering resident seated in the bed of the other resident’s room while the other resident was masturbating in front of and pushing their penis against the wandering resident’s face. The nurse immediately removed the wandering resident from the room, assessed them for injury, and notified the nurse supervisor. The incident report documented that the physician was notified the next day, the resident was assessed two days later, no injuries were found, and the resident was placed on fifteen-minute visuals. The wandering resident’s care plan was updated to include fifteen-minute visuals, but the record did not show consistent documentation of those visuals for several time periods after the incident. The record also showed the wandering resident had a long history of entering other residents’ rooms and taking belongings, but there was no documented evidence that the care plan was reviewed or revised to address the ongoing behavior before the incident. Staff interviews indicated the unit had frequent wandering and that redirection could be difficult, with staffing sometimes limited to three CNAs on day shift. In a separate issue, another resident with dementia and behavioral disturbance was repeatedly observed wandering into other residents’ rooms and sleeping in their beds. On 7/15/25, that resident entered another resident’s room and the resident yelled for them to get out. The same resident was also observed entering another room and using the bathroom, and later sleeping in another resident’s bed while staff were occupied elsewhere and did not observe or redirect the behavior. Additional observations showed the resident sleeping in yet another resident’s room without staff present in the hallway to supervise or redirect them.
Failure to Thoroughly Investigate Abuse and Missing Property Reports
Penalty
Summary
The facility did not ensure that alleged abuse and missing property incidents were promptly and thoroughly investigated. The report identified failures involving a resident-to-resident sexual incident and multiple resident complaints of missing personal items, with no documented evidence that the investigations were completed in a timely or thorough manner as required by facility policy. Resident #218 had diagnoses including Alzheimer's disease, osteoarthritis, and atrial fibrillation, and the annual MDS documented severely impaired cognition, dependence with toileting, and partial to moderate assistance with other ADLs. On 4/25/24, RN #30 found Resident #218 in Resident #147's room while Resident #147 was masturbating in Resident #218's face. The resident-to-resident incident report documented that staff immediately separated the residents and placed Resident #218 on 15-minute checks, and later supervisory review described the incident as Resident #147's penis being in Resident #218's mouth. However, there was no documented evidence that the Accident/Incident Report was completed until 6/19/24, and witness statements from CNAs were not obtained until 5/23/24. Interviews with the RN, ADON, DON, and Administrator showed uncertainty about when the incident was reported, why the report was not signed by the Administrator, and whether the event was considered abuse at the time. The facility also did not complete documented investigations after residents reported missing personal property. Resident #19, who had anxiety, hypertension, and depression and intact cognition, reported a missing Dottie ring and stated they informed the RN Unit Manager but received no further information. The facility's missing items logs had no documented evidence of the loss. Resident #99, who had chronic atrial fibrillation, a pacemaker, and type 2 diabetes and was cognitively intact, reported a missing purse containing rosary beads, a $20 bill, a debit card, and a pacemaker card; staff interviews confirmed the missing purse was reported and a form was completed, but there was no follow-up documented and the Administrator stated they were unaware of the missing purse or wallet. Resident #25 also reported a missing wallet, and the record stated there was no documented evidence that a thorough complete investigation was conducted after that report.
Improper Food Storage and Labeling
Penalty
Summary
The facility did not ensure proper storage of food in accordance with professional standards for food safety. During the recertification survey, surveyors observed multiple containers of food in the kitchen refrigerators and freezers that were unlabeled, undated, and not in their original containers, including two bags of liquid eggs in the dairy refrigerator, several items in the meat freezer such as french toast, round waffles, meatballs, and chicken tenders, and sandwiches in Mobile #2 refrigerator that were not properly labeled or dated. The Food Service Supervisor identified the items and stated they were not labeled or dated properly. Surveyors also observed food items in the dry storage area that had been opened but did not have dates showing when they were opened, including graham crackers, pasta, spaghetti noodles, vegetable oil, vanilla syrup, brown/season mix, and baking soda. In addition, a kitchen staff member's personal drink was found in a refrigerator used to store resident food, and a malodor was observed in the meat refrigerator. The Acting Dietary Director confirmed the odor and stated it could not be determined where it was coming from, and the Maintenance Supervisor later confirmed the odor and stated the compressor would be assessed to determine the source.
Kitchen Dishwasher Leak and Standing Water
Penalty
Summary
The facility did not ensure all mechanical and electrical equipment was in safe operating condition when water was observed leaking from the kitchen dishwasher, leaving standing water on the floor in and around the unit. During observation and interview, the Acting Dietary Director stated the standing water had been present for some time and that staff were working with maintenance to determine whether a new drain should be installed or a path provided in the floor for the water to flow. The Maintenance Supervisor later stated the dishwasher was leaking in a different area, the water was not able to flow into the floor drain as designed, the floor drain was obstructed by debris, and standing water around the dishwasher had been a problem in the past. The Maintenance Supervisor also stated maintenance had not been able to repair the leak or clean the floor drain and would need to contact an outside contractor to address the issue.
Failure to Update Care Plan After Fall and Therapy Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a comprehensive care plan was reviewed and revised to reflect a resident's current condition following a fall. The resident, who had diagnoses including Alzheimer's disease, dependence on renal dialysis, and a history of falls, experienced a fall from their wheelchair. After the incident, an occupational therapy assessment recommended that an additional mechanical lift pad, used during outside appointments such as dialysis, should be removed immediately upon the resident's return to reduce the risk of sliding forward and falling again. This recommendation was communicated to the nursing staff and the unit manager nurse. Despite the occupational therapist's recommendation and the facility's policy requiring care plans to be updated after a fall investigation, there was no documented evidence that the care plan was revised to include the new safety intervention. Both the occupational therapist and the unit manager nurse confirmed during interviews that the care plan did not reflect the recommended intervention, and the unit manager acknowledged responsibility for updating the care plan but had not done so.
Call Bells Not Kept Within Residents’ Reach
Penalty
Summary
The facility did not reasonably accommodate resident needs and preferences because two residents were repeatedly observed with their call bell devices out of reach. Resident #187 had diagnoses including cerebrovascular accident, peripheral vascular disease, and coronary artery disease, and the Annual Minimum Data Set documented moderately impaired cognition and maximum and/or dependent staff assistance for most activities of daily living. Resident #187’s Fall Care Plan, initiated 8/19/2019, stated the call bell must remain within the resident’s reach and prompt staff response ensured. During observation and interview, Resident #187 was seen sitting in a wheelchair in their room with the call bell across the room and not within reach, and on another observation the call bell was on the bed behind the resident and not within reach; the resident stated the call bell was often out of reach. Resident #119 had diagnoses including anoxic brain damage, anxiety disorder, and unspecified epilepsy, and the Annual Minimum Data Set documented severely impaired cognition and dependence on staff for assistance with activities of daily living. Resident #119’s Fall Care Plan, initiated 3/22/2016, stated the call bell must remain within the resident’s reach and prompt staff response ensured. On multiple observations, Resident #119 was in bed with the call bell hanging on the wall or wrapped on the lower part of the bed rail, and it was not within reach. During interview, the RN Unit Manager stated Resident #119 was not always able to use the call bell because ability varied, but also stated call bells should be accessible to all residents even if capacity was limited.
Failure to Address Missing Resident Property
Penalty
Summary
The facility did not ensure residents were free from misappropriation of property when it failed to properly address reports of missing belongings for two residents. Resident #19, who had diagnoses including anxiety, hypertension, and depression and was documented as cognitively intact with no behaviors, reported a missing Dottie ring that had been lost less than a year earlier. The resident stated the concern was reported to the RN Unit Manager, but no further information was provided. The facility’s 2024 and 2025 missing items logs contained no documented evidence of the missing ring, and the RN Unit Manager could not recall whether a missing item form had been completed. Resident #99, who had diagnoses of chronic atrial fibrillation, presence of a pacemaker, and type 2 diabetes and was documented as cognitively intact, reported that a purse had been missing since before Easter. The resident stated the purse contained grandmother’s rosary beads, a $20 bill, a debit card, and a pacemaker card, and that the incident was discussed in resident council. There was no documented evidence in the concern logs for 2023, 2024, or 2025 regarding the missing items. A nurse manager stated they were aware of the missing purse and had completed the form, but did not follow up, while the Administrator stated they were unaware of the missing purse and/or wallet.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility did not ensure that all alleged violations of abuse were reported immediately, and no later than 2 hours, to the state survey agency for one resident reviewed for abuse. After a 4/25/24 incident, Resident #218, who had a history of wandering in and out of other residents’ rooms, was found seated in the bed in Resident #147’s room while Resident #147 stood and masturbated in front of Resident #218. The facility’s policy required reports of abuse, mistreatment, neglect, exploitation, and injuries of unknown origin to be promptly and thoroughly investigated, and federal and state regulations required alleged violations to be reported immediately to the Facility Administrator or designee. Resident #218 had diagnoses including Alzheimer’s disease, osteoarthritis, and atrial fibrillation, and the annual MDS dated 4/27/24 documented severely impaired cognition. The resident-to-resident incident report stated that an RN found Resident #218 in the room with a male resident who was masturbating into Resident #218’s face and standing in front of her, and that the nurse supervisor was notified. During interviews, the RN stated they called the DON immediately because they knew incidents involving abuse needed to be reported immediately. The ADON stated the incident was not reported to the NYSDOH and that the DON or ADON would have been responsible for reporting, while the DON stated the incident was not reported to the NYSDOH. The Administrator stated they did not recall the incident and did not recall discussing or reporting it to the NYSDOH.
Failure to Care Plan Contracture Management and Hand Roll Use
Penalty
Summary
A comprehensive person-centered care plan was not developed and/or implemented for Resident #214 to address the resident’s medical and nursing needs related to muscle weakness and left-hand contracture. The resident had diagnoses including dementia, and the Quarterly MDS dated 6/15/25 documented severely impaired cognition, no functional limitation in range of motion, and substantial/maximal assistance with all other ADLs. The OT discharge note dated 6/20/2025 documented that staff/caregivers were educated and instructed on the use of a left upper extremity handroll schedule, ROM, hygiene, and skin checks for irritation. During observations on 7/15/2025, 7/16/2025, 7/17/2025, and 7/18/2025, Resident #214 was resting in a wheelchair with the left hand contracted and no hand roll in place. The record review found no documented evidence that a care plan was developed, and physician orders were obtained, to address contracture management and the use of a left-hand roll as recommended by OT. An LPN stated the resident had a contracted left hand and that if an intervention such as a hand roll was needed it should have been care planned. The RN Unit Manager stated that when therapy recommended the hand roll and educated staff, an order should have been placed, a care plan developed, and it should have been documented on the CNA Assignment Instructions. The ADON stated that if OT recommended a hand roll, it was the Unit Manager’s responsibility to develop a care plan for contracture management and add the hand roll to the CNA Assignment Instructions.
Failure to Provide Ordered Psychiatric Follow-Up and Proper Wheelchair Positioning
Penalty
Summary
Resident #6, who had diagnoses including unspecified dementia, psychotic disorder, and anxiety disorder, did not receive documented follow-up psychiatric services after an in-house psychiatric consultation on 10/16/2024, despite an order for follow-up in one month. The care plan for psychotropic drug use documented continued psychiatric medications and follow-up with psychiatry services, and a later physician order on 4/3/2025 documented a psychology consultation for possible gradual dose reduction and evaluation of effectiveness, but there was no documented evidence that this consultation occurred. The Annual MDS dated 4/27/2025 documented severely impaired cognition, no behaviors, and antipsychotic medication use. During observations in July 2025, Resident #6 was seen in the common area knocking water containers and cups onto the floor and later in the room alone, where they made repeated requests for help and reassurance. Resident #171, who had diagnoses including dementia, stroke, and hemiplegia, was assessed as having severely impaired cognition and requiring partial to maximal assistance for all activities of daily living. During multiple observations in July 2025, the resident was seated upright in a special wheelchair with leg/footrests, but the feet did not reach the footrests and were dangling unsupported; the wheelchair did not have a leg board in place. Staff interviews indicated the resident had previously used a leg board, that therapy would need to evaluate positioning concerns, and that the Unit Nurse Care Manager was responsible for ensuring CNAs had the information needed regarding positioning devices. The DON stated the Unit Nurse Care Manager should ensure staff had the care instructions documented in care plans and assignment instructions when appropriate.
Heel Boots Not Applied as Ordered for Resident at Risk for Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for Resident #171, who had diagnoses including dementia, stroke, and hemiplegia. The Quarterly MDS dated 6/8/25 documented severely impaired cognition, functional impairment on both sides of the upper and lower body, dependence with all ADLs, and risk for pressure ulcers. A physician order dated 6/23/25 directed heel boots to both feet at all times, and the current CNA instruction also documented that the resident should have heel boots at all times. During multiple observations, Resident #171 was seen out of bed in a wheelchair without offloading boots on the feet, and when the resident was in bed asleep, heel booties were also not in place. A CNA stated they thought the boots were only to be worn in bed, then acknowledged after reviewing the instruction that the resident should wear them at all times. An LPN stated the heel boots were missing and sometimes did not come back from laundry, and a PT stated they were asked to see the resident because the bilateral heel boots were missing. The DON stated the Nurse Care Managers were responsible for ensuring CNAs had the information needed to care for the resident, including positioning and off-loading devices. The wound care NP stated the heel booties were ordered for pressure relief of the heels and should be worn at all times except during care, showers, or if not tolerated.
Failure to Implement OT Splinting and Contracture Management
Penalty
Summary
The facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Resident #10 had diagnoses including cerebral infarction and dementia, and the quarterly MDS documented severely impaired cognition, dependence with all activities of daily living, and functional limitation in range of motion on both sides of the upper and lower extremities. An OT progress note documented a long-term goal to increase range of motion in the left wrist and hand to enable splinting and positioning for functional positioning, and OT recommended that the left-hand splint be worn at all times except during care and range of motion exercises. OT also provided in-service education to nursing staff on bilateral hand range of motion stretches and hand splints. Despite this recommendation, there was no documented care plan or physician orders in the electronic medical record to address contracture management and the use of a left-hand splint. During observations, Resident #10 was seen on multiple occasions with a contracted left hand and without the left-hand positioning device in place. Staff interviews confirmed the resident had hand contractures, that nursing staff had received in-service education on hand braces, and that there was no order, care plan, or CNA accountability for daily splint use as recommended by OT. The Medical Director and DON stated that therapy recommendations were to be entered into the electronic health record by nursing and signed off by a medical provider, and that LPNs or RNs would be responsible for applying and removing the hand splints.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
Medication administration error rates were not maintained below 5% for one of four residents reviewed for medication administration. Resident #114 had diagnoses including Major Depressive Disorder, epilepsy (seizure disorder), and gastrostomy status, and the care plan directed that medications be administered as ordered. The physician orders included Famotidine 20 mg tablet daily by gastrostomy tube, Lamotrigine 100 mg tablet daily by gastrostomy tube, Hydrocortisone 5 mg tablet daily by gastrostomy tube, Potassium chloride 20 mEq/15 mL oral liquid 22 mL daily by gastrostomy tube, Lactulose 10 g/15 mL oral solution 30 mL twice daily by gastrostomy tube, and Keppra 100 mg/mL oral solution 10 mL every 12 hours by gastrostomy tube. During the medication administration observation, an LPN crushed Hydrocortisone, Lamotrigine, and Famotidine and combined the crushed tablets in a cup with water before administering them together via the gastrostomy tube. The LPN then placed Keppra, Potassium chloride, and Lactulose into a medication cup and administered all three liquid medications together, followed by a flush. The facility policy stated medications are to be crushed and administered separately whether given orally or via gastrostomy tube. In interview, the LPN stated they combined all the tablets, administered them, and then flushed, and then placed all three liquids in a cup, administered them, and then flushed. The DON stated the nurse should have administered the medications one at a time and flushed after every medication.
Failure to Use Gown During Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Infection control prevention practices were not maintained for 1 of 4 residents reviewed for nutrition when an LPN administered medications via gastrostomy tube to a resident on enhanced barrier precautions without wearing a gown. The facility policy titled Infection Control Practices Precaution Guidelines, revised 11/2023, stated that residents suspected or known to have an infection and/or transmissible disease would be clinically managed to prevent and control outbreaks and cross contamination, and that enhanced barrier precautions include the use of a gown for high contact resident care. The resident involved had diagnoses including dysphagia and encounter for attention to gastrostomy, and a significant change MDS dated 6/20/25 documented severe cognitive impairment. During observation, the LPN administered medications via the gastrostomy tube without a gown. The LPN stated they were aware they did not wear a gown or follow personal protective guidelines and said they forgot. The DON and a Unit Manager RN stated staff were expected to wear a gown during close interaction, including medication administration, with a resident on enhanced barrier precautions, and that staff should be supervised to ensure PPE policies were followed.
Insufficient Nursing Staff Resulting in Missed Medications
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as required by their own facility assessment and regulatory standards. On multiple occasions, the number of Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) scheduled for shifts fell below the minimums documented in the facility assessment. For example, on several evening and night shifts, the facility was short by several CNAs and LPNs compared to the required staffing levels. The facility assessment itself was not properly signed or reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee, and staff responsible for scheduling were unaware of the minimum staffing requirements outlined in the assessment. Due to these staffing shortages, there were documented instances where residents did not receive their prescribed medications, including critical drugs such as antibiotics, anticoagulants, insulins, and psychotropics. Interviews with residents confirmed that there were times when no nurse was present on their unit to administer medications, and some residents reported these issues to administration and during resident council meetings. Staff interviews corroborated these findings, with CNAs and LPNs reporting frequent understaffing, the need to split coverage across multiple units, and being mandated to work overtime or double shifts due to inadequate staffing. Administrative staff, including the Staffing Coordinator, Director of Staff Resources, Director of Nursing, and the Administrator, acknowledged the ongoing staffing issues and confirmed that units were often left without adequate nurse coverage. The Director of Nursing and Administrator both stated that the facility sometimes had to split nurses between units or have supervisory staff pass medications when regular staff were unavailable. The Union President and other staff also reported that complaints about short staffing and missed medications were common, particularly on the overnight shift.
Failure to Promote Dignity During Dining Assistance
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) was observed standing over a resident while assisting them with eating dinner, rather than sitting at eye level as required by facility policy. The resident involved had diagnoses including Alzheimer's disease with late onset, hemiplegia, hemiparesis, and dysphagia, and was documented as having severely impaired cognition and being dependent on assistance for eating. The LPN acknowledged awareness of the correct procedure but stated that due to being the only nurse on the floor and needing to assist multiple residents, they found it easier to stand while feeding. The Director of Nursing confirmed that staff are expected to sit and provide a comfortable dining experience for residents.
Incomplete Facility-Wide Assessment and Documentation Deficiencies
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations, including nights and weekends, and emergencies. The assessment did not address what constitutes sufficient staffing, particularly on weekends, nor did it differentiate the care required on weekend shifts from other shifts. Additionally, the assessment lacked information on the number of staff needed for behavioral health services and did not specify the minimum staffing requirements for Certified Nurses' Aides (CNAs) and Licensed Practical Nurses (LPNs). The assessment also omitted the date it was reviewed with the Quality Assurance and Performance Improvement (QAPI) committee and lacked signatures of approval. During interviews, the Administrator acknowledged that the facility assessment did not include the exact number of CNAs or LPNs required, citing frequent staffing changes and reliance on Payroll-Based Journal (PBJ) reports for staffing information. The Administrator was unable to provide documentation that the assessment was reviewed by QAPI and agreed that the assessment should have been signed and dated. The deficiencies were identified through record review and staff interviews during abbreviated surveys, with the most recent revisions of the facility assessment still lacking required details and documentation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Goshen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sapphire Nursing And Rehab At Goshen | 3.3 mi | ★★★★★ | 0 | 0 |
| Glen Arden Inc | 3.3 mi | ★★★★★ | 11 | 0 |
| Schervier Pavilion | 6.5 mi | ★★★★★ | 0 | 0 |
| Middletown Park Rehab & Health Care Center | 6.6 mi | ★★★★★ | 1 | 0 |
| Highland Rehabilitation And Nursing Center | 7.3 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.