Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Valley View Manor Nursing Home during CMS and state inspections, most recent first.
The facility failed to keep the North and South units and the main entrance clean and homelike. Surveyors observed strong urine odors in hallways and rooms, peeling paint, wall disrepair, scuff marks, spills, food on the floor with ants, ripped linens, used incontinence items on the floor, and trash littering the front walkway. Staff interviews confirmed the odors and visible damage were not homelike, and the Director of Housekeeping/Maintenance/Laundry stated staffing shortages affected cleaning coverage.
A resident with RA, spinal stenosis, respiratory failure, dry eye syndrome, and DM had multiple referrals to neurology, rheumatology, pulmonology, and ophthalmology that were not followed up in a timely manner. Several specialty offices reported missed appointments, some were rescheduled without the resident attending, and the chart lacked nursing progress notes documenting the missed visits. Staff said medical records handled scheduling and transportation, but they could not locate documentation for several of the missed appointments, and the DON noted staffing gaps and weather-related transportation cancellations.
A resident’s right to privacy and confidentiality was compromised when staff maintained a white communication binder in a wall holder outside the resident’s room, marked with a STOP sign and accessible to anyone in the hallway. The binder, used by CNAs, nurses, and other staff to sign in and out and document care, contained detailed entries about incontinence care, refusals of morning care with requests for coffee, and PRN pain medication requests, along with dates, times, and staff identifiers. The resident, who was cognitively intact and had depression, reported concern about the book and had raised the issue with a social worker. An LPN unit manager acknowledged the binder’s location and that it was used to record all care and services provided whenever anyone entered the room, without considering that visitors could view the information.
A dependent resident with quadriplegia, depression, and moderately impaired cognition, who required staff assistance with ADLs and personal hygiene, was repeatedly observed with significant facial hair despite expressing a preference to be shaved. Facility records lacked documentation of the resident’s shaving preferences, and staff reported they relied on the resident to request shaving or on their own observation of facial hair. An LPN unit manager acknowledged that shaving is part of ADLs for dependent residents, that the resident should not have to ask to be shaved, and that it was undignified for the resident to have facial hair if it was not their preference, demonstrating a failure to provide necessary grooming assistance.
Enteral feeding supplies for a resident with esophageal cancer and gastrostomy status were not properly dated, timed, or labeled. Observations found the tube feeding formula bottle, water flush bag, and tubing missing required dates, times, and staff initials on multiple occasions, and an RN stated opened formula is only good for 24 hours. The DON confirmed tube feeding bottles and tubing should be dated and timed.
A resident with ESRD and dependence on HD did not receive consistent pre- and post-dialysis oversight. Communication sheets sent with the resident were often incomplete or missing, with absent VS, weights, and staff signatures, and staff gave conflicting accounts about who was responsible for assessments. An RN did not complete the post-dialysis assessment or check the fistula when the resident returned after shift change, and the DON stated these assessments were often missed.
A resident with a history of sexually inappropriate behaviors was not effectively monitored, leading to multiple incidents of abuse towards other residents. Despite being on 15-minute checks, the resident continued to engage in inappropriate behaviors such as touching other residents and exposing themselves. The facility failed to implement timely interventions, assess the impact on affected residents, and update care plans, resulting in a deficiency in protecting residents from abuse.
A resident with cognitive impairment exhibited inappropriate sexual behavior towards other residents, but the facility failed to conduct thorough investigations or timely assessments. Multiple incidents were not documented or reported promptly, and affected residents' families and medical providers were not notified. Staff interviews revealed inconsistencies in incident reporting and assessments.
The facility failed to maintain proper water temperatures in the kitchen's three-bay sink system, with wash and rinse sinks below the required 110 degrees Fahrenheit. The Food Service Director admitted to not monitoring temperatures since a hot water loss, and the Administrator confirmed the policy required hot water for manual washing.
The facility did not ensure annual performance reviews for two certified nurse aides, as required by their In-Service Training Program. The Corporate Director of Nursing and the DON, who started in November 2023, were unable to locate the performance reviews, even after searching the Human Resources office and storage units.
A resident with a traumatic brain injury and right upper extremity weakness did not have their prescribed right hand resting splint applied as ordered. Observations and staff interviews revealed that the splint was often not applied, and there was no documentation of refusals or efforts to ensure compliance with the order.
The facility failed to ensure that two licensed nurses received annual competency evaluations, as required by the facility's assessment and regulations. The staff educator position had been vacant, and the Director of Nursing had been performing this role since January 2024. No documentation of the required evaluations was found.
The facility failed to ensure that food and drink provided to residents were at appetizing temperatures. During a survey, it was found that the food items on a resident's meal tray were below the acceptable temperature range, contrary to the facility's policy.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. The kitchen ventilation hood was unclean and laden with grease and dust, the walk-in freezer floor had food items and ice buildup, and a section of flooring in front of the dish machine was broken and unclean. The Food Service Director and Director of Facilities were aware of these issues but had not resolved them.
The facility failed to update the care plan for a resident with a traumatic brain injury and aggressive behaviors after multiple altercations. Despite incidents on two occasions, the care plan was not reviewed to assess the effectiveness of current interventions or to add new strategies. Staff interviews confirmed that the resident was not properly supervised, and the care plan was not adequately updated.
Unclean and Non-Homelike Environment on Resident Units and Front Entrance
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for the North and South units and the main front entrance. Survey observations and record review identified strong urine odors in hallways and resident rooms, unclean walls and floors, peeling paint, disrepair behind a bed, and trash littering the walkway at the front entrance. The facility policy for daily cleaning stated that trash should be emptied, odors controlled, spots and spills cleaned from walls and surfaces, and floors dry mopped and wet mopped, including under beds and behind doors. On the North and South units, surveyors observed multiple rooms with strong urine odors, unknown spills, food on the floor with ants present, yellow dripping stains on a wall, ripped bed sheets, black pants, a used towel, and used incontinence briefs on the floor. One room had peeling paint and a wall behind the bed in disrepair, and another had scuff marks on the walls and heater, along with an area above the heater that lacked paint and had a noticeable gap in the drywall. The hallway near resident rooms also had a strong urine odor on another observation. During interviews, the CNA who was working extra as housekeeping stated rooms should not have peeling paint, scuff marks, or urine odors because that was not homelike, and that floors should be mopped daily. The Director of Housekeeping/Maintenance/Laundry stated the facility did not have enough staff and that CNAs were being used to help with cleaning. Maintenance staff stated they used a maintenance book for work orders and knew some areas needed paint, and they acknowledged that peeling paint was not homelike. The maintenance logs reviewed did not include rooms with scuff marks or rooms needing painting.
Missed Specialist Appointments Not Timely Followed Up
Penalty
Summary
The facility failed to ensure timely follow-up on outside specialist referrals for one resident who had rheumatoid arthritis, spinal stenosis, respiratory failure, chronic dry eye syndrome, diabetes, and intact cognition. The resident had referrals to neurology, rheumatology, pulmonology, and ophthalmology, but the record showed missed appointments and no documented nursing progress notes addressing several of those missed visits. The facility policy stated outside appointments and consultations were to be coordinated, documented, and followed up on, including when appointments were missed or refused. The resident was scheduled for neurology, pulmonology, rheumatology, and retina vitreous surgery appointments, but multiple offices reported the resident did not show up for appointments and some were rescheduled without the resident attending the later visits. The neurology office reported missed appointments and no current scheduled visits; the pulmonology office reported missed appointments and rescheduling; the retina vitreous surgery office reported a missed appointment with no reschedule; and rheumatology could not confirm the resident was seen or provide current appointment information. The record did not contain nursing progress notes documenting these missed appointments. The resident stated that multiple specialist appointments were often cancelled by the facility because staff were unavailable to accompany the resident or transportation was not coordinated, and that this had been occurring for several months since the scheduler left. Facility staff stated medical records was responsible for scheduling appointments and transportation, and that staff were assigned to accompany residents, but they could not locate documentation for several of the resident’s missed specialty appointments. The DON stated the facility had been without medical records staff for three months, which contributed to missed appointments, and also noted transportation cancellations in bad weather.
Resident Privacy Breach Due to Hallway Communication Binder
Penalty
Summary
The facility failed to protect a resident’s right to privacy and confidentiality of personal and medical information by maintaining a white communication binder in a wall holder outside the resident’s room, accessible to anyone passing by. Facility policies on Resident Rights and Quality of Life – Dignity required that confidential clinical information be protected and that signs indicating clinical status or care needs not be openly posted unless specifically requested. The resident, who had diagnoses including depression and intact cognition, had a Comprehensive Care Plan noting potential accusatory behavior related to attention-seeking, with an intervention directing staff to document on a log prior to entering and exiting the room, but the care plan did not specify the log’s location. Surveyor observation found the binder outside the room, marked with a red STOP sign, containing detailed entries of care and services provided. Record review of the binder showed multiple daily entries documenting incontinence care, refusal of morning care and a request for coffee, and a request for PRN pain medication, along with dates, times, and staff identifiers. Interviews confirmed that staff used the binder to record when they entered and exited the room and what they did for the resident, including snacks, care offered, medications administered, and activities. The Ombudsman reported the binder was in the hallway and accessible to anyone. The resident stated they had a problem with the book outside their door, knew staff were supposed to write down what they were doing, and had spoken to the social worker about it without any change. The LPN Unit Manager acknowledged the binder’s hallway location, stated it was placed high enough to be out of reach of other residents, and admitted they had not considered that visitors could access it.
Failure to Provide Needed Shaving and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically grooming and shaving, to a dependent resident. Facility policy revised in April 2025 required that appropriate care and services, including hygiene such as bathing, dressing, grooming, and oral care, be provided to residents unable to carry out activities of daily living independently, in accordance with their care plan and with resident consent. The resident involved had quadriplegia, depression, moderately impaired cognition, and was documented on a November 2025 MDS as dependent on staff for personal hygiene. The comprehensive care plan revised in February 2026 indicated the resident required assistance with ADLs and functional mobility, and March 2026 care instructions documented the resident needed moderate assistance for bathing and standby assistance for personal hygiene. There was no documented evidence of the resident’s shaving preferences or facial hair in the care plan or records. Surveyor observations over multiple days showed the resident with black facial hair approximately one inch long on both sides of the chin in a beard-like fashion and scant hair on the upper lip, while the resident reported that staff did not offer shaving and that they preferred to be shaved and hoped staff would offer to shave them. A CNA stated that the resident could verbalize if they wanted to be shaved and that CNAs would shave the resident if asked or if they observed facial hair and the resident agreed, and reported there were enough staff to meet residents’ needs. The LPN unit manager stated that ADLs for dependent residents included shaving, that this resident was cognitively able to make needs known and should not have to ask to be shaved, and that CNAs should offer shaving. The LPN unit manager also stated it was undignified for the resident to have facial hair if it was not the resident’s preference. These findings demonstrated that the facility did not ensure the resident received needed grooming assistance to maintain personal hygiene as required by 10NYCRR 415.12(a)(3).
Enteral Feeding Supplies Not Dated or Timed
Penalty
Summary
The facility failed to ensure appropriate care for a resident receiving enteral nutrition. Resident #37 had diagnoses including esophageal cancer and gastrostomy status, and the 02/24/2026 MDS documented moderately impaired cognition and the need for enteral feeding. The care plan noted the resident was at risk for malnutrition related to multiple factors, including cancer diagnoses, low body weight, low albumin, and a history of sporadic meal intake, and that the resident required a feeding tube for adequate nutrition and hydration. The physician order directed Jevity 1.5 at 75 cc per hour for 18 hours twice daily, with 130 cc water flushes before and after feeding. During observations, the resident’s tube feeding formula, water flush containers, and tubing were not dated, timed, or labeled as required. On one observation, the formula bottle was empty and had no date, time, or staff initials, and the flush bag was full with no date, time, or staff initials; the tubing was not labeled. On another observation, a full formula bottle was dated but the flush bag and tubing were not dated or labeled. On a later observation, the formula bottle and flush bag were dated, but there was no time or staff initials on the bottle. An RN stated the formula bottles were only good for 24 hours once opened and should be changed, and the DON stated tube feeding bottles and tubing should be dated and timed.
Dialysis Resident Lacked Required Pre- and Post-Treatment Oversight
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with end stage kidney disease who required hemodialysis three times weekly. The resident was cognitively intact and had a care plan that called for monitoring weights before and after dialysis, monitoring vital signs, and checking the dialysis fistula site. The facility policy also required communication sheets to accompany residents going out for hemodialysis so information could be exchanged between the nursing home and the dialysis center. Records showed the resident attended dialysis repeatedly, but many of the communication sheets were incomplete, with missing vital signs, pre-dialysis weight, and staff signatures. In addition, multiple dialysis communication sheets were missing entirely for numerous treatment dates. The dialysis center charge nurse stated that the resident was often sent with the communication book, but the form was missing information such as vital signs, medications, changes, updates in condition, or weight. The Director of Nursing also stated that the communication book contained outdated information, missing pages, and blank pages that should have been completed. During observation, the resident was preparing to leave for dialysis and stated that vital signs had not yet been taken. Staff interviews showed inconsistent oversight before and after dialysis. One LPN stated dialysis residents did not require care prior to dialysis, while another nurse stated the resident should have had vital signs and weight documented before transport and an assessment after return, but did not complete the assessment because the resident had not returned before the end of the shift. The RN responsible for preparing the resident for dialysis stated they did not complete the post-dialysis assessment and had not checked the fistula because the resident had not returned during their shift. The DON stated post-dialysis assessments were often not completed because the resident returned at shift change.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving a resident with a history of sexually inappropriate behaviors. This resident, who was cognitively impaired and had a history of sexual dysfunction, engaged in multiple incidents of inappropriate sexual behavior towards other residents. Despite being on 15-minute checks, the resident continued to exhibit behaviors such as touching other residents inappropriately, exposing themselves, and masturbating in common areas. The facility did not have effective interventions in place to prevent these behaviors from recurring, and there was a lack of timely assessment and documentation of the incidents. The incidents involved multiple residents, including two identified residents who were cognitively impaired. One resident was touched inappropriately on the breast, and another had their back and buttocks rubbed. There were also several unidentified residents who were exposed to the inappropriate behaviors. The facility's policies required immediate steps to ensure resident safety and to provide medical attention when necessary, but these were not effectively implemented. There was a lack of timely notification to the provider and the residents' families, and the care plans were not updated promptly to address the ongoing issues. The facility's failure to document and assess the impact of these incidents on the affected residents further contributed to the deficiency. Staff interviews revealed that incident reports were not consistently completed, and there was confusion about the responsibilities for assessing and documenting the incidents. The facility's Corporate Director of Nursing acknowledged that incident reports should have been initiated immediately, and assessments should have been conducted by a registered nurse. However, these actions were not consistently carried out, leading to a failure to protect residents from further abuse.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 F 600 483.12 Abuse and Neglect 1. Immediate Corrective Action: - Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. - Resident #2 was discharged from Valley View Manor on 3/26/24. - Resident #5 had an RN assessment and was interviewed by the Director of Nursing on 12/20/24 and stated she is not terrified and is no longer uncomfortable around resident #1. Resident #5 stated that I just ignore him or move away if I find myself too close to him. Resident #1 has not engaged with me since our encounter previously. - Resident #1 had his care plans reviewed on 12/20/24. No revisions are currently needed. Interventions will include, 1:1 monitoring following any incidents, ongoing medical review to focus on medication management to address any underlying conditions contributing to behavioral issues. Will continue with routine psychiatric evaluations and adjust treatment plans as needed. - Resident #1 refused to be seen by the psychiatrist on 12/5/24, was sleeping when the psychiatrist attempted to see him on 12/19/24 and is scheduled to be seen 1/2/24. - There are no updates regarding resident #1 transfer to an all-male unit or another facility, However the facility actively investigating all available options. - LPN #4, LPN #8, LPN #1 and RN #7 will be educated on the Abuse prevention and Reporting Policy and procedures by 12/27/24. - LPN #16, LPN #14, LPN #9, RN #19, LPN #15 and RN #20 are no longer employed at Valley View Manor. 2. Identification of Others: - The facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. - The Director of Nursing conducted interviews with all cognitive residents residing on resident #1 unit on 12/20/24 regarding the care and services they receive. There were no other allegations of abuse, neglect, misappropriation and exploitation made at the time of these interviews. During the interviews all residents denied being fearful or expressed psychological effects as a result of resident #1 or any other resident. 3. Measures/ Systemic Changes: - The facility will conduct the following to prevent this practice from occurring in future: - Abuse Prevention and Reporting Policy was reviewed with revisions to include: - Investigation: - victim and aggressor assessment, - obtaining statements from involved residents and witnessing residents, - Resident statements will be attempted despite cognitive status - All involved and witnessing residents will be monitored to determine psychological effects or change in behavior by social services or designee. - The following information must be available for the investigators upon request: - All statements obtained - The Administrator/Director of Nursing will be notified immediately of any allegation of Abuse. An investigation will be initiated, the Victim and Aggressor will have a timely assessment completed, Accident and Incident initiated with staff statements, resident(s) statements, and any other potential witnesses. Emergency contact and medical provider notified timely and immediate care plan interventions initiated. Involved and witnessing residents will be interviewed and followed up for any potential psychological effects or change in behavior. Pending the outcome of the investigation, timely notification to state and local agencies will be completed. All staff that provide care to the involved residents will be notified of the interventions. - Education and in-servicing will be provided to all employees on the Abuse Prevention and Reporting Policy and revisions with emphasis on the importance of reporting immediately to the Administration team to ensure a full and timely investigation is completed and the procedures found in the policy are followed. Education and in-servicing will be completed upon new hire, annually and as needed by the Director of Nursing/Designee. 4. Quality Assurance Monitoring: - The Administrator/Designee will investigate all reports of Abuse and Neglect to ensure a full investigation is completed and the Abuse Prevention and Reporting policy and procedures are followed. All accident and incident reports will be reviewed in the morning report to ensure that Accident and Incident reports are completed accurately, timely, and thorough. Accident and Incident reports will be audited weekly to ensure that all reports are completed timely, nursing assessments, witness statements obtained and notifications of family and medical have been completed. Any issues identified from these audits will be corrected immediately, and the information obtained from the audits will be reviewed at the Quality Assurance meeting. 5. Responsible Party and Expected Date of Completion: - The Administrator/ Designee is responsible for correcting this deficient practice and completion date (MONTH) 26, 2025.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of allegations of abuse and neglect involving multiple residents. Specifically, incidents involving inappropriate sexual behavior by a resident with cognitive impairment were not adequately addressed. For instance, a cognitively impaired resident was touched inappropriately by another resident, but there was no timely assessment or notification to the family and medical provider. Additionally, interventions to protect the affected resident and other vulnerable residents were not implemented promptly. Another incident involved a resident with dementia who exhibited sexually inappropriate behaviors towards other residents on multiple occasions. Despite these repeated incidents, the facility did not conduct thorough investigations to identify the residents involved or assess the impact on them. There was a lack of documentation regarding the assessment of the affected residents and notification of their families and medical providers. Furthermore, the facility's incident reporting process was inadequate, as several incidents were not documented or investigated in a timely manner. Staff interviews revealed inconsistencies in the completion of incident reports and assessments, with some staff unable to recall details of the incidents or the residents involved. The facility's failure to adhere to its abuse prevention and reporting policy resulted in a lack of protection and support for the residents involved.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 F 610 483.12 Abuse and Neglect 1. Immediate Corrective Action: - Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. - Resident #2 was discharged from Valley View Manor on 3/26/24. - Resident #5 had an RN assessment and was interviewed by the Director of Nursing on 12/20/24 and stated she is not terrified and is no longer uncomfortable around resident #1. - Resident #1 had his care plans reviewed on 12/20/24. No revisions are currently needed. - LPN #4, LPN #8, LPN #1 and RN #7 will be educated on the Abuse prevention and Reporting Policy and procedures by 12/27/24. - LPN #16, LPN #14, LPN #9, RN #19, LPN #15 and RN #20 are no longer employed at Valley View Manor. 2. Identification of Others: - The facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. - The Director of Nursing conducted interviews with all cognitive residents residing on resident #1 unit on 12/20/24 regarding the care and services they receive. There were no other allegations of abuse, neglect, misappropriation and exploitation made at the time of these interviews. During the interviews all residents denied being fearful or expressed psychological effects as a result of resident #1 or any other resident. 3. Measures/ Systemic Changes: - The facility will conduct the following to prevent this practice from occurring in future: - Abuse Prevention and Reporting Policy was reviewed with revisions to include: - Investigation: - victim and aggressor assessment, - obtaining statements from involved residents and witnessing residents, - Resident statements will be attempted despite cognitive status - All involved and witnessing residents will be monitored to determine psychological effects or change in behavior by social services or designee. - The following information must be available for the investigators upon request: - All statements obtained - The Administrator/Director of Nursing will be notified immediately of any allegation of Abuse. An investigation will be initiated, the Victim and Aggressor will have a timely assessment completed, Accident and Incident initiated with staff statements, resident(s) statements, and any other potential witnesses. Emergency contact and medical provider notified timely and immediate care plan interventions initiated. Involved and witnessing residents will be interviewed and followed up for any potential psychological effects or change in behavior. Pending the outcome of the investigation, timely notification to state and local agencies will be completed. All staff that provide care to the involved residents will be notified of the interventions. - Education and in-servicing will be provided to all employees on the Abuse Prevention and Reporting Policy and revisions with emphasis on the importance of reporting immediately to the Administration team to ensure a full and timely investigation is completed and the procedures found in the policy are followed. Education and in-servicing will be completed upon new hire, annually and as needed by the Director of Nursing/Designee. 4. Quality Assurance Monitoring: - The Administrator/Designee will investigate all reports of Abuse and Neglect to ensure a full investigation is completed and the Abuse Prevention and Reporting policy and procedures are followed. All accident and incident reports will be reviewed in the morning report to ensure that Accident and Incident reports are completed accurately, timely, and thorough. Accident and Incident reports will be audited weekly to ensure that all reports are completed timely, nursing assessments, witness statements obtained and notifications of family and medical have been completed. Any issues identified from these audits will be corrected immediately, and the information obtained from the audits will be reviewed at the Quality Assurance meeting. 5. Responsible Party and Expected Date of Completion: - The Administrator/ Designee is responsible for correcting this deficient practice and completion date (MONTH) 26, 2025.
Deficiency in Kitchen Sanitation Due to Inadequate Water Temperature
Penalty
Summary
The facility failed to ensure that food-related equipment functioned according to professional standards for food service safety in the main kitchen. Specifically, the water temperatures in the wash and rinse sinks of the three-bay sink system were below the required levels, with the wash sink at 92 degrees Fahrenheit and the rinse sink at 87 degrees Fahrenheit, both of which are below the minimum standard of 110 degrees Fahrenheit. This deficiency was observed during an abbreviated survey, where it was noted that the facility's policy required sanitizing utensils by immersion in hot water of at least 171 degrees Fahrenheit or using chemical sanitizing solutions. The Food Service Director acknowledged that since the loss of hot water on 10/21/2024, they had not been monitoring the water temperatures in the sinks and admitted that the temperatures recorded were not considered hot. The Director also stated that the soap was dispensed through cold water, and no cold water was added to the rinse sink. The Administrator confirmed that the facility's sanitation policy required hot water for manually washing kitchen equipment and expected the food service staff to measure the water temperature to ensure compliance.
Failure to Complete Annual Performance Reviews for Certified Nurse Aides
Penalty
Summary
The facility did not ensure certified nurse aide performance reviews were completed once every 12 months for two of three certified nurse aides reviewed. Specifically, certified nurse aides #9 and #10 did not have performance reviews documented at least once every 12 months. The facility's In-Service Training Program, revised in October 2017, required annual performance reviews for certified nurse aides, with records to be filed in the employee's personnel file or maintained by the department supervisor. During a review of personnel files, there was no documented evidence of performance reviews for certified nurse aides #9 and #10. The Corporate Director of Nursing and the Director of Nursing, who started in November 2023, were unable to locate the performance reviews, even after searching the Human Resources office and storage units on the facility's grounds.
Failure to Apply Prescribed Hand Splint
Penalty
Summary
The facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Specifically, Resident #39, who had a diagnosis of diffuse traumatic brain injury with right upper extremity weakness, did not have their right resting hand splint applied as ordered. The resident's care plan and physician order required the splint to be worn for 4 hours after AM care, but this was not consistently documented or followed by the staff. Observations over several days showed the resident without the splint, and interviews with staff revealed that the resident often did not wear it, and there was no documentation of refusals or efforts to ensure compliance with the order. The facility's policy required the rehabilitation department to issue prescribed equipment and the nursing supervisor to ensure its consistent use. However, the splint was not listed on the medication administration record, treatment administration record, or certified nurse aide task documentation. Interviews with certified nurse aides and the Director of Therapy indicated that the resident was supposed to wear the splint, but it was often found on the nightstand or bed, and staff did not consistently apply it or document refusals. The Unit Manager expected staff to follow the order in the electronic resident chart and document any refusals, but this was not done, leading to a deficiency in the resident's care.
Lack of Annual Competency Evaluations for Nursing Staff
Penalty
Summary
The facility did not ensure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, two licensed nurses, a registered nurse and a licensed practical nurse, did not receive annual competency evaluations as required by the facility's assessment and regulations. Both nurses had been employed for over a year, yet their personnel records lacked documentation of these evaluations. During the survey, it was revealed that the facility did not have a policy and procedure for competency evaluations. The Corporate Director of Nursing acknowledged that the staff educator position had been vacant since Fall 2023, and the Director of Nursing had been performing the staff educator role since January 2024. Despite plans to transition a Unit Manager into the role of Assistant Director of Nursing to assist with staff education, no further documentation on nursing competencies for the two nurses could be found. The Administrator confirmed that the Director of Nursing was currently responsible for staff education and that annual nursing competencies were part of the plan moving forward.
Deficiency in Food Temperature Management
Penalty
Summary
The facility did not ensure that food and drink provided to residents were palatable, flavorful, and at appetizing temperatures. During the recertification survey, it was found that the food items on one of the two test trays sampled were not at acceptable temperatures. Specifically, the internal temperature of the chicken and gravy mix was measured to be 121 degrees Fahrenheit, and the spinach was measured to be 130 degrees Fahrenheit, both of which are below the facility's expected minimum temperature of 140 degrees Fahrenheit for resident meal trays. This deficiency was observed during the lunch meal on 4/30/2024 for a resident on the North Unit. The facility's policy on Food Holding Temperatures, dated 1/30/2024, requires that food items be reheated to specific minimum preparation temperatures if they fall below 140 degrees Fahrenheit. However, the policy on Temperatures, dated 9/2002, did not document appropriate food temperatures for meal items when conducting a test tray. Despite periodic test trays being conducted by the diet technician, registered dietitian, and Food Service Director, the food served to the resident was found to be below the acceptable temperature range. The Food Service Director expressed surprise at the low temperatures and acknowledged that the food should be warmer for eating.
Deficiencies in Kitchen Cleanliness and Maintenance
Penalty
Summary
The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the kitchen ventilation hood was observed to be unclean and laden with grease and dust buildup during multiple observations. The Food Service Director was unsure of the cleaning schedule for the hood and confirmed that the kitchen staff did not clean it. Additionally, the floor in the walk-in freezer was found to be unclean with food items such as single-serve ice cream cups and hamburger buns under the shelving storage, along with ice buildup. The facility's policy on kitchen cleaning and sanitation, dated August 2016, indicated that food service workers and cooks were responsible for maintaining a clean environment, but the weekly cleaning audits for April 2024 did not identify any issues, despite the observed deficiencies. Furthermore, a section of flooring in front of the main dish machine was in disrepair and had unclean water and food debris. The broken flooring, approximately 3 inches by 12 inches, was not smooth and cleanable, making it difficult to maintain proper sanitation. The Food Service Director and the Director of Facilities were aware of the broken flooring, but the repair had been delayed due to awaiting a quote from the contractor. The Director of Facilities was unsure of how long the flooring had been broken or when it would be replaced. These observations and interviews indicate a failure to adhere to professional standards for food service safety and cleanliness in the facility's main kitchen.
Failure to Update Care Plan After Resident Altercations
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident with a traumatic brain injury and aggressive behaviors following multiple resident-to-resident altercations. Specifically, the care plan for the resident was not updated after incidents on 3/7/2024 and 4/22/2024 to determine if current interventions were effective or if additional interventions were needed. The resident's care plan included interventions such as 15-minute checks, 1:1 monitoring, and various activities, but these were not reassessed or modified after the altercations. On 3/7/2024, the resident struck another resident, causing them to fall and hit their head. Although the resident was placed on 15-minute checks for three days, there was no documented evidence that the care plan was reviewed to assess the effectiveness of the interventions. Similarly, on 4/22/2024, the resident was involved in another altercation, and while the care plan was updated to include 15-minute checks, this intervention was already in place prior to the incident. The care plan did not reflect any new strategies to address the resident's aggressive behaviors. Interviews with staff revealed that the resident was not properly supervised during the incidents and that the care plan was not adequately updated with new interventions. The Director of Nursing and the Administrator acknowledged that the care plan should have been reviewed and updated with each incident. The facility's policies required care plans to be revised as the resident's condition changed, but this was not followed in the case of the resident with a traumatic brain injury and aggressive behaviors.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — including the 1 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
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 Norwich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norwich Rehabilitation & Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| N Y S Veterans Home | 7.4 mi | ★★★★★ | 0 | 0 |
| Chasehealth Rehab And Residential Care | 11.2 mi | ★★★★★ | 0 | 0 |
| Chestnut Park Rehabilitation And Nursing Center | 22.5 mi | ★★★★★ | 4 | 1 |
| Aurelia Osborn Fox Memorial Hospital | 22.9 mi | ★★★★★ | 0 | 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.