Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Yonkers Gardens Center For Nursing And Rehab during CMS and state inspections, most recent first.
Kitchen food storage, labeling, and sanitation deficiencies were observed during survey. Expired dairy and beverage items were found in the walk-in refrigerator, an opened and uncovered box of frozen vegetables and an unlabeled bag of chicken patties were found in the freezer, and prepared sandwiches and cold cuts lacked proper labeling. Staff also used unlabeled refill bottles for grape jelly, one cook was not wearing a beard covering, and kitchen equipment and surfaces showed heavy grease buildup, a slippery floor area, and dripping pot wash faucets.
The facility failed to maintain an effective pest control program on multiple residential floors, as shown by resident and staff reports of roaches and mice and surveyor observations of live roaches and pest traps with dead bugs in resident rooms. Several residents reported seeing cockroaches in bathrooms and rooms and stated during resident council that roach and rat issues persisted despite pest control efforts. Review of pest control logs over several months documented ongoing roach infestation with repeated sightings on the units. The Administrator and the pest control company both acknowledged continued roach and mice activity, and CNAs reported seeing roaches in resident rooms and not noticing improvement, indicating that pest control measures were not effectively controlling the infestation.
Unsafe and unclean resident environment on floors 3 and 4. Surveyors observed damaged bathroom fixtures, broken furniture, stained doors and walls, a soiled mechanical lift, a clock hanging by a wire, damaged radiator and ceiling tiles, mismatched wall patches, rust-colored stains, and a stained privacy curtain. The D of M stated the issues were not reported by staff and were missed during rounds; a housekeeper also stated prior evening cleaning duties for hallways, doors, and resident equipment had been eliminated and not reassigned.
Failure to Provide Needed ADL Assistance for Grooming and Bathing: Three residents who were dependent on staff for hygiene, bathing, and grooming were observed or reported to have unmet ADL needs. One resident had long unshaven facial hair, another reported not having a shower for a long time and had unwashed hair, and a third was seen with greasy hair and a scraggly beard despite being scheduled for showers and requiring total assistance. Staff interviews showed grooming and bathing assistance was expected, but care was not consistently provided or documented.
A medication room was found unlocked with medications in unlocked cabinets, and a medication cart was observed unlocked and unattended when an RN stepped away. Methadone for two residents was also stored with other narcotics in a double-locked cabinet, despite the facility policy requiring methadone for addiction to be stored separately from other controlled meds.
Improper Linen Handling and Storage: Facility personnel did not ensure linens were handled and stored per policy. Surveyors observed clean linens, towels, gowns, pillows, and resident clothing stored on top of resident hampers in multiple rooms, while dirty linens, gloves, and socks were found on the floors of the 4th- and 5th-floor shower rooms. An RN UM, CNA, and IP all described expected linen handling practices, but the observed storage and disposal practices did not match those expectations.
Unsafe and Unclean Smoking Area and Damaged Elevator Interior: Surveyors observed the designated outdoor smoking area covered with snow and ice and littered with more than 50 cigarette butts, while elevator #1 had damaged wall paneling and air vent grates with exposed sharp metal prongs. The DON/maintenance and housekeeping leadership stated the area cleaning and snow removal responsibilities were split, but there was no set cleaning schedule for the smoking area and no current plan to repair the elevator damage.
A resident with opioid dependency and other medical conditions was readmitted from the hospital with an existing order for daily methadone, but the facility did not have the methadone on hand and the scheduled dose was not administered. Nursing documentation showed the medication was unavailable, and the resident became upset and verbally agitated when it was not provided. Staff interviews indicated the facility had not received discharge paperwork or prior notice of the resident’s return, the methadone clinic was closed on weekends, and coordination with the hospital to ensure methadone availability before discharge did not occur.
The facility failed to use its QAPI program to address ongoing pest control problems despite being aware of roach and mouse sightings on resident units. Review of QAPI meeting agendas for multiple quarters showed discussion of topics such as staffing, dignity, maintenance repairs, accident/incident reports, smoking compliance, pressure ulcers, antibiotic stewardship, exercise of rights, and documentation, but no inclusion of pest control. Staff and resident interviews confirmed continuing concerns about roaches and mice, and the Administrator acknowledged awareness of these issues while also stating that they had not been discussed within the QAPI process.
A resident with cerebral infarction, epilepsy, and HTN, and documented as cognitively impaired, was observed having blood drawn in the dining room while residents were waiting for lunch. A phlebotomist removed the resident’s sweater sleeve, performed the blood draw at the table, and then moved the supply tray to another resident’s table before an RN unit manager told the phlebotomist to leave the dining room. The facility’s Resident Rights policy required privacy for direct resident care procedures.
A resident with intact cognition and diagnoses including HTN, hepatitis, and major depressive disorder was not allowed to choose their bedtime despite care plan directions to offer as many choices as possible. The resident stated staff told them when to go to bed, that they preferred to stay up later, and that they did not feel free or given choices. A CNA said residents were told to go to bed near shift change, and an RN unit manager said the resident had to be in bed by shift change due to hourly fall monitoring and non-ambulatory status.
Quarterly personal funds statements were not made available to a resident’s designated representative. The resident had dementia and hydrocephalus with severe cognitive impairment, and the account had been managed by the facility for over two years. The representative said statements had stopped arriving and had to be requested from the business office, while the Medicaid Coordinator could not provide documentation showing the quarterly statements were sent.
Failure to thoroughly investigate alleged abuse: A resident with DM, depression, and epilepsy, who needed help with showering, was reported by family to have been beaten in the shower by CNAs and forced into a cold shower. The resident later told surveyors they were grabbed, stripped, showered, and beaten by two staff members. The facility documented that no one witnessed the incident and that the named aide did not work there, but it could not produce written staff statements or other documented evidence of a complete and thorough investigation.
A resident with CVA-related hemiplegia, CKD, worsening cognition, increased dependence with eating, urinary incontinence, and severe unplanned weight loss did not receive a significant change MDS within the required timeframe. Records showed progressive weight loss, poor PO intake, meal refusal, and notes from the dietitian and NP documenting significant decline, while the MDS Coordinator, Clinical Nutrition Manager, and DON acknowledged that a significant change assessment should have been completed but was missed.
Late Transmission of MDS Assessments: The facility failed to ensure that two completed MDS assessments were transmitted on time. An MDS coordinator stated the assessments had been completed but not sent, and another MDS nurse had entered an old validation code into the EMR, making it appear the records had been transmitted when they had not. The Administrator stated the MDS coordinator was responsible for timely completion and submission and was unaware the assessments were late.
A resident’s MDS did not accurately code tobacco use even though the care plan identified the resident as a known smoker, a nursing smoking assessment documented smoking, and a smoking contract was signed. The resident stated they smoked cigarettes three times a day in the smoking room, and the MDS Coordinator acknowledged that tobacco use should have been coded on the assessment.
Inadequate supervision and smoking reassessment for a resident with repeated smoking noncompliance. A cognitively intact resident with nicotine dependence, PTSD, and behavioral issues had a smoking plan that was not updated after repeated reports of smoking in the room, a strong smoke odor, and disputes with another resident. Surveyors observed smoke residue and burn marks in the resident’s room, while staff said nursing had not reassessed the resident’s smoking safety in years and there was no special monitoring plan in place.
Oxygen Delivered at Incorrect Flow Rate: A resident with COPD, DM2, and asthma had a physician order and care plan for continuous O2 at 4 L via NC, but was observed receiving 2 L via NC. The resident stated they had been on 2 L for years, while an LPN said the resident was always on 2 L and did not check the order daily. An RN unit manager stated oxygen should have been given as ordered, and the DON noted the TAR did not show the order and could not explain the discrepancy.
The facility did not ensure its QAPI committee had the required members, including the Infection Control Practitioner, Medical Director, Administrator, and DON. Record review showed the Infection Control Preventionist did not attend or sign in for three quarterly QAPI meetings, and the Administrator acknowledged the absence and could not explain it.
Three residents with cognitive impairments exited the facility unsupervised on separate occasions due to failures in supervision, monitoring, and response to exit alarms. In each case, staff did not promptly identify the residents' absence, and required safety measures such as wander guards and sign-out procedures were not consistently implemented or enforced. Security staff did not respond to alarms or ensure proper monitoring of exits, resulting in residents leaving the premises without authorization.
A resident with a history of cognitive impairment and sexually inappropriate behaviors was not adequately monitored or managed after multiple incidents, including a serious episode involving another cognitively impaired resident. Despite repeated observations and staff awareness of the behaviors, care plans were not updated and interventions were not implemented to prevent further abuse, resulting in Immediate Jeopardy and substandard quality of care.
A resident with moderate cognitive impairment was found in a sexually inappropriate situation with another resident who had severe cognitive impairment. Although administration was notified promptly, the incident was not reported to the Department of Health within the required two-hour window due to staff being off-site and lacking computer access, resulting in a delay that violated state reporting requirements.
A deficiency was identified when two residents with cognitive impairment were involved in an alleged sexual abuse incident, and the facility failed to conduct required head-to-toe assessments, did not ensure both were sent for hospital evaluation, and lacked documentation of 1:1 monitoring, contrary to facility policy and staff instructions.
A resident with a history of inappropriate sexual behaviors towards others was involved in multiple incidents, including physical contact and attempts to enter other residents' rooms. Despite these events being documented by staff, the care plan was not updated with new interventions or monitoring strategies to address the behaviors or protect other residents. Nursing leadership confirmed that the care plan was not revised after these incidents, resulting in a deficiency related to abuse prevention and care plan management.
A survey found that several residents were dressed in hospital gowns, contrary to their care plans, due to issues with clothing management and availability. Additionally, a nurse improperly assisted a resident with a meal by standing over them. Staff interviews revealed inconsistencies in the process of obtaining and managing clothing for residents, contributing to the deficiency.
A facility failed to protect residents from abuse, with multiple incidents of resident-to-resident altercations involving six residents. One resident repeatedly engaged in physical altercations, causing injuries, while another resident exhibited aggressive behavior towards peers. The facility's policies on abuse prevention were not effectively enforced, and care plans were not consistently updated, leading to ongoing risks of harm.
The facility failed to submit timely 5-day investigative reports for resident altercations, as required by state law. Incidents involved residents with conditions like dementia and anxiety disorder, resulting in injuries such as bruising and lacerations. Despite internal documentation, reports were submitted late or not at all, with the DON unable to explain the delays.
The facility failed to maintain adequate staffing levels on the 3rd floor Dementia Unit, with staffing consistently below the required levels across various shifts. Despite efforts to schedule additional staff and use agency staff, frequent call-outs led to understaffing, leaving CNAs to manage 35-40 residents with insufficient support. The Director of Nursing acknowledged the staffing challenges, noting improvements but persistent issues with lateness and call-outs.
The facility was found to have multiple environmental deficiencies, including chipped paint, scuff marks, and visible dirt across various floors. Interviews with the Director of Maintenance and the Administrator revealed challenges in maintaining the facility due to limited staff and experience constraints. Both acknowledged the need for additional maintenance staff to address these ongoing concerns effectively.
A resident with severe cognitive and physical impairments developed a Stage 3 pressure ulcer due to the facility's failure to provide consistent turning and repositioning care. The resident's care plans lacked a Braden scale assessment, and there was no documented physician order for necessary interventions, leading to inadequate care as evidenced by missing documentation on certified nurse assistant accountability forms.
The facility's assessment failed to include a detailed staffing plan necessary for competent resident care during routine operations and emergencies. The assessment, last updated in November 2024, did not specify staff assignments or the number of staff needed per unit per shift. The Administrator was unaware of the requirement to include unit-specific staffing needs.
Kitchen Food Storage, Labeling, and Sanitation Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, and distributed in accordance with professional food safety standards, and it did not maintain essential kitchen equipment in a clean and sanitary condition. During the kitchen tour, surveyors observed three 10-pound plastic containers of sour cream with an expiration date of 1/19/2026 and a half-gallon container of unsweetened Almond Breeze with an expiration date of 1/24/2026 stored in the walk-in refrigerator. Sandwiches and cold cuts prepared for distribution were wrapped in plastic but were not properly labeled. In the walk-in freezer, surveyors observed an opened and uncovered box of diced butternut squash and a bag of Tyson breaded white chicken patties outside of its original box and without an expiration date. Additional observations showed food preparation and sanitation issues throughout the kitchen. A Food Service Worker was using unlabeled bottles of grape jelly in food preparation and stated that empty grape jelly bottles were washed, relabeled by removing the original label, and refilled with regular grape jelly. During tray line observation, a staff member was not wearing a beard covering and stated they had forgotten to put it on. The glass doors of the countertop hot box food warmers were covered with large brown and black accumulations of burned grease, the floor area adjacent to the warmers was slippery, and the faucets at the pot wash sink were dripping despite being turned off. The Clinical Nutrition Manager stated employees were not permitted to use unlabeled bottles or refill containers with different products, and the Food Service Director stated the kitchen was to be cleaned after each food preparation and that maintenance work orders were submitted for malfunctioning equipment.
Failure to Maintain Effective Pest Control Program for Roaches and Mice
Penalty
Summary
The facility failed to maintain an effective pest control program on three of five residential floors, as evidenced by ongoing roach and mice activity observed and reported by residents and staff. During the recertification and abbreviated surveys, residents reported seeing cockroaches on bathroom floors and described a lot of mice and roaches, with one resident stating that a housekeeper told them nothing could be done. Surveyors observed a pest trap with dead bugs under a heating unit in one room and a live roach on the floor under an overbed table in another room. Multiple residents at a resident council meeting reported issues with roaches and rats and stated that pest control efforts were ineffective. Review of the facility’s Pest Control Log from September 2025 through February 2026 documented repeated pest concerns and an ongoing roach infestation, with numerous entries noting roaches and bugs observed on the units over several months. The Administrator acknowledged awareness of roach and mice issues on the units and confirmed that the pest problem had not been discussed as part of the facility’s QAPI program. The pest control company confirmed an active contract, frequent site visits, awareness of continued roach and mice sightings, and changes in chemicals due to ongoing issues. CNAs reported an ongoing roach problem in residents’ rooms, believed pest control visits were infrequent, and had not noticed improvement, further demonstrating that the pest control program was not effectively preventing or addressing the infestation.
Unsafe and Unclean Resident Environment on Floors 3 and 4
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment on two of five resident floors, specifically floors 3 and 4. On floor 3, observation found a resident bathroom with missing wall tiles behind the toilet and a toilet seat that was peeling and cracked. In another room on floor 3, the dresser had broken and missing drawers, the closet door had a detached loose doorknob and was hanging off the track, and the wall and door had dried food stains. A mechanical lift on floor 3 also had dried brown streaks and dust and grime on the bottom metal base. On floor 4, observation found a clock hanging off the wall by a wire, a damaged and missing portion of the radiator, wall patches that did not match the surrounding paint, warped and stained ceiling tiles, and large rusty brown dried stains running from the ceiling down to the radiator. The resident hall bathroom on floor 4 had a privacy curtain with brown stains on the floor. The Director of Maintenance stated these issues had not been reported by staff and were missed during prior rounds. Housekeeping and nursing staff described routine rounds and reporting processes, and a housekeeper stated an evening position that had previously cleaned hallways, doors, mechanical lifts, wheelchairs, and other resident equipment had been eliminated in 10/2025 and those duties were not reassigned.
Failure to Provide Needed ADL Assistance for Grooming and Bathing
Penalty
Summary
The facility did not ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain good grooming and personal hygiene for three residents reviewed. The deficiency involved Resident #11, Resident #7, and Resident #78, all of whom had assessments and care plans showing they needed staff help with hygiene, bathing, and grooming tasks. Resident #11 had diagnoses including non-Alzheimer's dementia, schizophrenia, and depression. The resident's assessment documented moderately impaired cognition and the need for partial assistance with personal hygiene and substantial assistance with toileting hygiene and showering. During observations, Resident #11 was seen with long, unshaven facial hair and stated a preferred staff member usually shaved their face, but the resident could not recall when that had last occurred. A CNA stated they were responsible for grooming, including shaving, but had not been able to shave the resident on the last assigned date because they were busy with showers for other residents, and they could not remember when the resident was last shaved. The CNA also stated the facial hair was too long to shave with a razor and would need trimming first. An RN stated CNAs were responsible for grooming activities and had not received report that the resident refused care. Resident #7 had diagnoses including hypertension, hepatitis, and major depressive disorder. The resident's assessment documented slight cognitive impairment and dependence on staff for oral hygiene, toileting, and showering, and the care plans documented dependence on staff for hygiene, grooming, bathing tasks, and daily ADL needs. The resident stated they had not had a bath or shower for a very long time, only received bed baths, and wanted to wash their hair; the resident's hair appeared unwashed during observation. A CNA stated the resident had not received a shower since admission and that the resident refused every time a shower was offered. However, the CNA accountability record for January and February did not document any shower refusals, and the unit manager stated they could not recall any report that the resident was not getting showers and that refusals should have been documented. Resident #78 had diagnoses of dementia and hydrocephalus and was severely cognitively impaired, totally dependent on staff for transfers, bathing, shower transfers, and personal hygiene, with no rejection of care documented. The resident was observed in bed wearing a hospital gown with greasy, unkempt hair and a full scraggly beard. The designated representative stated the resident should be transferred out of bed daily, showered twice weekly, and clean shaven. A CNA stated the resident required total assistance of two staff for bathing, transfers, and personal hygiene, did not refuse care, and was scheduled for a shower but instead received a bed bath; the CNA stated they only slightly wet the resident's head and dried it with another towel because the water was cold and there was no shower stretcher on the unit. The nursing supervisor stated every floor had a shower stretcher available and that the resident should be transferred out of bed for showers, while the DON stated there were concerns with residents receiving assistance with ADLs and that CNAs were expected to document the assistance provided.
Unsecured medication storage and improper methadone storage
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional standards when a 5th floor medication room was observed unlocked and unattended, with medications stored in unlocked cabinets over the sink. During interview, the RN Supervisor stated the room should have been locked and did not know why it was unlocked, and an LPN stated they were aware the room should have been locked. A 6th floor medication cart was also observed unlocked and unattended in the hall when an RN stepped away to enter the medication room, and the RN stated the cart should have been locked when they left it. The facility also did not store methadone separately as required by its policy. The facility policy stated that when methadone is prescribed for narcotic addiction only, it must be stored separately from other controlled medications in a double locked cabinet designated for that purpose. On observation, methadone for two residents was stored in a double locked cabinet with other narcotics in the 5th floor medication room. The DON stated medication rooms and carts should always be locked and that methadone was supposed to be stored separately from other narcotics, while the Pharmacy Consultant and Medical Director also stated methadone should be stored separately and staff needed to abide by the rules when storing it.
Improper Linen Handling and Storage
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when facility personnel did not ensure linens were handled and stored in a manner to prevent the spread of infection. During observations, clean linens and towels were seen stored on top of resident hampers in multiple resident rooms, and linens and resident clothing were also observed stored on top of hampers in additional rooms. Dirty linens were observed in a pile on the floor of the 4th-floor shower room, and dirty linens, gloves, and socks were observed on the floor of the 5th-floor shower room. A pillow, linens, towels, and gowns were also observed stored on top of resident hampers in resident rooms. During interview, the RN Unit Manager stated CNAs were responsible for bringing linens into resident rooms and were responsible for putting dirty linens into the laundry, and stated they were not aware that linen was stored on top of resident hampers. A CNA stated they had been trained on proper storage of linens, said linens should be stored in the clean utility room and/or the cart in the hall, and stated they left linens on the laundry bin or a chair in resident rooms. The Infection Preventionist stated proper handling of linen was part of environmental in-service, clean linen was to be stored in carts on units, and dirty linen should be bagged and placed in the laundry chute, but stated they did not know why linen was being stored elsewhere.
Unsafe and Unclean Smoking Area and Damaged Elevator Interior
Penalty
Summary
The facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During observation, the designated outdoor smoking area had a large accumulation of snow and ice bordering a narrow-shoveled path from the facility door to benches on the left, and there were more than 50 cigarette butts littering the ground and mixed in with the ice and snow. The facility policy titled Homelike Environment stated that outdoor areas would be maintained for the safety and access of residents and visitors and that grounds, walkways, and entrances would be free of tobacco-related waste. Elevator #1 also had damaged conditions observed during the survey. Two damaged metal air vent grates at the base of the right wall had exposed sharp protruding metal prongs, and the right wall paneling had a large section broken off at the lower left-hand corner. The Director of Maintenance stated the elevator was functioning and the air vents were working despite the damaged grate covers, and there were no current plans to repair the wall paneling and metal grates. The Director of Housekeeping stated Maintenance was responsible for clearing snow and ice from the outdoor smoking area, Housekeeping was responsible for sweeping cigarette butts, and there was no set cleaning schedule for the area.
Failure to Ensure Availability of Methadone for Readmitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed methadone medication was available and administered to meet the needs of a resident upon readmission. The resident had diagnoses including opioid abuse with unspecified opioid-induced disorder, anxiety disorder, and obstructive uropathy, and the MDS documented that the resident was cognitively intact and received opioid medication daily. A physician’s order directed that methadone oral solution 40 mg be given once daily for opioid dependency, and the comprehensive care plan instructed staff to administer medications as ordered. The resident was hospitalized for hypoxia and pneumonia and later returned to the facility with medications documented as unchanged and with two antibiotics added. On the day following readmission, the MAR showed the methadone order, but a progress note documented that the methadone dose was not given because the medication was not on hand. Nursing notes recorded that the resident was unable to receive methadone, became upset, and was yelling and using profanity due to not getting the medication. The RN Supervisor was informed that there was no methadone bottle available, and the physician was notified and indicated the resident would obtain methadone from the clinic on Monday. Interviews with the RN Supervisor, DON, Director of Admissions, and Medical Director revealed that the facility did not receive discharge paperwork or prior notification of the resident’s return from the hospital, that the methadone clinic was closed on weekends, and that there was an expectation for coordination with the hospital before discharge to ensure methadone availability. As a result, the resident did not receive the scheduled methadone dose after readmission.
Failure to Integrate Ongoing Pest Infestation Issues into QAPI Activities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assurance and Performance Improvement (QAPI) program made good faith efforts to identify and correct known quality deficiencies related to pest control. Surveyors reviewed the facility’s QAPI policy, last revised in March 2025, which described a QAPI committee/subcommittee working with facility leadership and the Quality Assessment & Assurance committee. They also reviewed 2025 quarterly QAPI meeting attendance sheets and agendas dated 4/8/2025, 7/23/2025, and 11/12/2025. These agendas documented discussion topics such as staffing, dignity, maintenance repairs, accident/incident reports, smoking compliance, pressure ulcers, antibiotic stewardship, exercise of rights, and documentation, but did not include pest control or infestation issues. During recertification and abbreviated surveys conducted in early February 2026, surveyors identified ongoing concerns about roaches and mice in the facility, as referenced in F925. Interviews with staff and residents during this period confirmed that there were continuing sightings of roaches and mice on the units. In an interview, the Administrator acknowledged being aware of these pest issues but stated that the pest problem had not been discussed as part of the QAPI program. There was no evidence that the QAPI process had been used to address or correct the pest control concerns, despite the facility’s awareness of the problem.
Failure to Provide Privacy During Blood Draw
Penalty
Summary
Resident #181, who was admitted with diagnoses including cerebral infarction, epilepsy, and hypertension and was documented on the 12/15/2025 MDS admission assessment as cognitively impaired with no behavior, did not have dignity maintained during a blood draw. During an observation on 02/06/2026 at 12:49 PM, in the dining room where residents were waiting for lunch, a phlebotomist stood in front of Resident #181 with a tray of supplies, removed the resident’s left sweater sleeve, and drew blood from the resident’s left arm. The phlebotomist then walked to another table in the dining room and placed the tray of supplies in front of another resident. Registered Nurse Unit Manager #19 arrived in the dining room, spoke to the phlebotomist, and told them to leave the dining room. The facility’s Resident Rights policy stated that for any procedure involving direct resident care, privacy should be provided for the resident.
Resident Choice for Bedtime Not Supported
Penalty
Summary
The facility did not promote and facilitate resident self-determination through support of resident choice for one resident reviewed for choices. Resident #7 had diagnoses including hypertension, hepatitis, and major depressive disorder. The admission MDS dated 5/27/2025 documented intact cognition and noted that it was somewhat important to the resident to be able to choose their bedtime. The comprehensive care plan for behavior disturbance, last updated 01/10/2026, documented to give the resident as many choices as possible about care and activities. During interview, the resident stated that staff told them when they had to go to bed, that they did not like to go to bed early, and that their preference was to stay up later. The resident also stated that they did not feel free in the facility and were not given choices. A CNA stated that the next shift of aides got mad when residents were still up and that if it was close to shift change, residents were told they had to go to bed. The CNA added that residents who could get themselves into bed could stay up, but those who could not must go into bed. An RN unit manager stated that the resident had to be in bed by shift change because they were on hourly monitoring for fall risk and because they were non-ambulatory.
Quarterly Personal Funds Statements Not Provided
Penalty
Summary
The facility did not ensure quarterly statements of a resident’s personal funds account were made available to the resident’s Designated Representative. Resident #78 had diagnoses of dementia and hydrocephalus, and the MDS 3.0 assessment documented severe cognitive impairment with family participation in the assessment. The Resident Account Statement dated 02/10/2026 showed the facility had managed the resident’s funds since 08/10/2023, but there was no documented evidence that quarterly statements were provided to the Designated Representative. During a telephone interview, the Designated Representative stated they had previously received quarterly statements of the resident’s personal funds account activity until about 18 months earlier, but then had to repeatedly contact the facility’s business office to request copies. The Designated Representative reported concerns to the business office, but said the facility had not changed its accounting practices. The Medicaid Coordinator stated they were responsible for providing quarterly account statements to cognitively intact residents, while the off-site corporate business office was responsible for sending quarterly statements to designated representatives of residents with cognitive impairments, but no documented evidence could be provided showing the resident’s quarterly statements were sent to the Designated Representative.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who had diagnoses including diabetes mellitus, depression, and epilepsy and who required partial/moderate assistance with showering. The resident’s care plan identified a risk for verbal, physical, or sexual abuse, neglect, or mistreatment. After the resident’s family reported that certified nurse aides had beaten the resident in the shower, the facility documented that no staff or individuals witnessed the incident and that there was no staff member by the name reported by the family. The record shows that on the morning of the event, the resident was found in the hallway asking for help putting on pants, was pale and not at baseline, stated they had a seizure, had an oxygen saturation of 66% on room air, and was transferred to the hospital. The resident was later hospitalized with pulmonary emboli. The facility’s incident report stated the family alleged the resident was punched in the head, face, arms, and legs, forced to take a cold shower, and let fall to the floor, but the facility also documented that there were no bruises or injuries observed at transfer and that the resident’s statement could not be obtained. During the survey, the resident stated they remembered being forced to take a shower and being beaten by two staff members who grabbed them, removed their clothes, and showered them while they screamed and yelled. The family representative repeated the allegation of being beaten in the shower room and given a cold shower. Although the DON stated an internal investigation would include interviews and written statements, and the Administrator stated staff were called by telephone, the facility was unable to provide written statements from staff. The investigation documentation relied on interviews with staff and residents and on the absence of a staff member with the name provided by the family, but there was no documented evidence of a complete and thorough investigation with statements.
Failure to Complete Significant Change MDS for Resident With Major Decline
Penalty
Summary
The facility did not ensure that a significant change MDS assessment was completed within the 14-day requirement for a resident who experienced major changes in condition. The resident was admitted with diagnoses including cerebral infarction with hemiplegia and hemiparesis affecting the left non-dominant side and stage 3 chronic kidney disease. The record showed progressive weight loss from 178.0 lbs. in September 2025 to 165.0 lbs. in October 2025, 147.0 lbs. in November 2025, 132.2 lbs. in December 2025, 130.2 lbs. in January 2026, and 117.6 lbs. in February 2026. The resident’s 11/29/2025 Medicare 5-day MDS documented intact cognition, substantial/maximum assistance for eating, frequent urinary incontinence, and weight loss meeting criteria for significant loss. The 01/05/2026 quarterly Medicare 5-day MDS documented impaired cognition, dependence with eating, always incontinent of urine, and continued significant weight loss. A 01/23/2026 dietitian note documented 21% weight loss over 3 months, multiple hospitalizations, puree diet, suboptimal oral intake, and use of Ensure Plus to support weight goals. A 02/04/2026 dietitian note documented 9.6% unplanned weight loss in less than 30 days and 20% significant weight loss over 3 months, with staff and SLP reporting meal refusal and very poor intake. A 02/09/2026 nurse practitioner note documented acute delirium, auditory and visual hallucinations, HIV, failure to thrive in adult with weight loss and poor oral intake, and UTI contributing to acute mental status change. During interviews, the MDS Coordinator stated the resident had changes in ADLs, urine incontinence, cognition, and weight loss between the November and January assessments and that a significant change MDS should have been completed when identified. The Clinical Nutrition Manager and DON also stated the resident’s significant weight loss and related changes should have triggered a significant change MDS, but it was missed.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required timeframe for two residents reviewed for MDS compliance. Resident #83’s discharge MDS 3.0, with an assessment reference date of 09/22/2025 and completion date of 10/07/2025, was not transmitted until 02/09/2026. Resident #96’s discharge MDS 3.0, with an assessment reference date of 09/26/2025 and completion date of 10/07/2025, was also not transmitted until 02/09/2026. The facility’s MDS policy stated that MDS completion should be timely in accordance with State and Federal operation manuals. During interview, the MDS Coordinator stated that after reviewing the MDS schedule, two assessments had not been transmitted even though they were completed, and that another MDS nurse had entered an old code from a validation report into the electronic medical record software, which made it appear the records had been transmitted when they had not. The Administrator stated the MDS Coordinator was responsible for ensuring MDSs were completed and submitted timely and was unaware the assessments were transmitted late.
MDS Did Not Accurately Reflect Tobacco Use
Penalty
Summary
The facility did not ensure that the Minimum Data Set assessment accurately reflected Resident #46’s tobacco use. During the recertification survey, surveyors reviewed the 12/10/2025 MDS admission assessment and found that it documented the resident as cognitively intact, with no upper extremity impairment, and as not using tobacco, even though other facility records identified the resident as a smoker. The resident’s care plan for psychosocial history documented that the resident was a known smoker, and a smoking assessment completed by the RN Unit Manager documented that the resident smoked. A smoking contract also contained the resident’s and Recreation Director’s signatures. During interviews, the resident stated they smoked cigarettes three times a day in the smoking room and kept their lighter and cigarettes locked up in the cart downstairs. The MDS Coordinator stated they were responsible for the accuracy and completeness of MDS assessments and acknowledged that tobacco use should have been coded on the assessment.
Inadequate supervision and smoking reassessment for a resident with repeated smoking noncompliance
Penalty
Summary
The facility did not ensure adequate supervision to prevent accidents for a resident who smoked and had a history of noncompliance with smoking rules. The resident had diagnoses including adjustment disorder, post-traumatic stress disorder, and nicotine dependence, was cognitively intact, and required supervision or setup assistance with activities of daily living. The resident’s smoking assessment documented understanding of the smoking policy and no history of noncompliance, but several questions about smoking behavior were left unanswered, and there was no documented reassessment of the resident’s ability to smoke safely after later incidents of noncompliance. The resident’s record showed repeated concerns related to smoking behavior. Notes documented that the resident reportedly smoked in the room, had a strong cigarette smell in the room, and was involved in disputes with another resident about smoking in the bathroom. The resident also had a smoking contract that addressed storage of tobacco and smoking materials and warned of possible loss of smoking privileges, but the record did not show that the smoking contract was consistently reviewed with the resident after continued agitation and smoking-related incidents. The care plan related to smoking stated the resident would smoke in designated areas under supervision, but it was not revised to include additional interventions after the resident’s noncompliance. Survey observations on 02/05/2026 found the resident’s room empty with the door open, a strong smell of stale smoke, a soda can with cigarette ashes on the baseboard near the radiator, burned edges on the can, and three brown burn marks on the floor near the bed. The resident stated they had violated the smoking policy in the past but denied smoking in the room recently. Staff interviews confirmed that nursing was responsible for assessing smoking ability, but staff were unsure how often reassessments occurred and stated the resident had not been reassessed since 2024. Staff also stated there were no special monitoring instructions for the resident in the designated smoking area and no plan in place to more closely monitor the resident for smoking noncompliance.
Oxygen Delivered at Incorrect Flow Rate
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for one resident reviewed for respiratory care. Resident #92 had diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, and Asthma. The quarterly MDS documented that the resident’s cognition was intact, the resident required supervision or touching assistance with activities of daily living, and the resident used oxygen. A physician order dated 08/26/2025 documented continuous oxygen at 4 liters via nasal cannula, and the Oxygen Therapy Care Plan dated 01/26/26 also documented oxygen at 4 liters via nasal cannula. During observations on 02/05/2026 and again on 02/09/2026, Resident #92 was receiving oxygen via nasal cannula at 2 liters per minute. The resident stated they had been on oxygen at 2 liters for 5 years. During interview, an LPN stated the resident was on 2 liters of oxygen via nasal cannula and that they did not check the order every day because it was documented on the TAR, adding that as far as they knew the resident was always on 2 liters. An RN unit manager stated oxygen should have been delivered as prescribed in the physician order. The DON reviewed the TAR and stated they did not see the order, did not know why the resident would receive 2 liters if the order documented 4 liters, and was unsure why the care plan documented oxygen at 4 liters; they also stated that if the resident had been on 2 liters for a while, the medical provider should have been consulted regarding the discrepancy.
QAPI Committee Missing Required Infection Control Participation
Penalty
Summary
The facility did not ensure the Quality Assurance & Performance Improvement Committee included the required members, specifically the Infection Control Practitioner, the Medical Director, the Administrator, and the Director of Nursing. Record review showed the facility’s QAPI policy, revised in March 2025, described a QAPI committee/subcommittee working with facility leadership and the Quality Assessment & Assurance committee. The committee member list included the Administrator, DON, Director of Social Services, MDS Coordinator, Medical Director, Infection Preventionist, and two RN Unit Managers, but review of the 2025 quarterly QAPI attendance sheets for 4/8/2025, 7/23/2025, and 11/12/2025 showed the Infection Control Preventionist did not sign in. During interview, the Administrator stated QAPI meetings were held quarterly and acknowledged that the Infection Control Practitioner/Preventionist had not been attending the meetings and could not explain the absence for the three quarterly meetings in 2025.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision to prevent elopement for three residents. In one instance, a resident with schizoaffective disorder, a history of wandering, and moderately impaired cognition exited the facility unsupervised through an alarmed rear exit patio door. The alarm was triggered, but the security officer did not respond, and the resident was not located until they arrived at the hospital emergency department. The resident had previously refused to wear a wander guard, and staff did not notice the resident's absence during routine activities such as dinner service. Another resident with schizophrenia, alcohol abuse, and moderately impaired cognition left the facility unsupervised and was later found at a friend's house. The resident was not identified as missing until after the last staff observation, and it was determined that the resident likely exited through the front door, which was not alarmed at the time. The security desk's location partially obstructed the view of the lobby, and the security officer did not ensure that all individuals leaving the facility signed out, as required by policy. A third resident with dementia and moderately impaired cognition was last seen interacting with peers and was later found missing during dinner service. The resident was not previously assessed as being at risk for elopement and did not have a wander guard in place. The resident was located by police the following day and returned to the facility. Family members expressed concern about the lack of supervision and questioned why a resident with dementia did not have additional safety measures in place. Staff interviews revealed inconsistent practices regarding monitoring, safety checks, and the use of elopement prevention tools.
Failure to Prevent and Address Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically failing to implement and update care plans and interventions after multiple incidents of sexually inappropriate behavior by a resident with a history of cerebral infarction and vascular dementia. Despite documented incidents where this resident engaged in inappropriate touching and behavior towards other residents, there was no evidence that the care plan was revised or that effective interventions were put in place to prevent further abuse. The care plans in place included general monitoring and support, but did not address the specific behaviors or provide targeted strategies to protect other residents after each incident. On several occasions, the resident was observed engaging in or attempting sexually inappropriate acts with other residents, including an incident where the resident was found half-naked on top of another cognitively impaired resident, with their mouth on the other resident's genital area. Staff interviews and documentation revealed that after these incidents, the resident's care plan was not updated to reflect new interventions, and there was no evidence of consistent 1:1 monitoring or other measures to prevent recurrence. Additionally, after being moved to a different unit, the resident was able to return undetected to the original resident's room, indicating a lack of effective supervision and monitoring. Documentation gaps were also noted, as some incidents were not recorded in the residents' progress notes, and there was confusion among staff regarding protocols for monitoring and updating care plans. Interviews with staff and administration confirmed that protocols for separating residents, notifying physicians, and transferring residents to the hospital were not consistently followed. The failure to implement adequate interventions and update care plans after repeated incidents resulted in a situation of Immediate Jeopardy and substandard quality of care, with a likelihood of serious harm to the residents involved.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse to the New York State Department of Health within the required two-hour timeframe. On 1/5/2025 at approximately 1:30 PM, a resident with moderate cognitive impairment and ambulatory status was found half naked on top of another resident with severe cognitive impairment, with their mouth on the other resident's genital area. The incident was observed by staff, and administration was notified at 1:43 PM. However, the incident was not reported to the Department of Health until 4:10 PM, exceeding the mandated reporting window. The facility's abuse policy requires immediate reporting of suspected abuse, neglect, or mistreatment to the appropriate authorities. Documentation and staff interviews confirmed that the delay in reporting was due to lack of computer access and staff not being present on-site during the weekend. The residents involved had significant cognitive and physical impairments, with one requiring assistance for most activities of daily living. The failure to report the incident in a timely manner constituted noncompliance with state regulations.
Failure to Investigate and Ensure Safety After Alleged Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an incident of alleged sexual abuse involving two residents. One resident with moderate cognitive impairment and ambulatory status was found half naked on top of another resident, with their mouth on the other resident's genital area. The facility's abuse and incident investigation policies required thorough assessment and reporting, including head-to-toe assessments and hospital evaluations for involved residents. However, there was no documented evidence that these assessments were performed for either resident, nor that both residents were transferred to the hospital for medical evaluation as required by policy and as instructed by the Director of Nursing. The incident was reported to administration, law enforcement, and the Department of Health. Nursing notes indicated that one resident was to be placed on 1:1 monitoring and the other was to be sent to the emergency room, but documentation did not confirm that these actions were carried out. Interviews with facility staff, including the Assistant Director of Nursing and the Medical Director, confirmed that both residents should have been assessed and transferred to the hospital, but this did not occur. There was also no evidence that 1:1 monitoring was implemented for the resident as indicated in the investigative summary. Both residents involved had significant cognitive impairments and required varying levels of assistance with activities of daily living. The facility's failure to conduct thorough assessments, ensure hospital evaluations, and document required monitoring and interventions constituted a violation of its own policies and regulatory requirements regarding the response to alleged abuse.
Failure to Revise Care Plan After Repeated Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to review and revise the comprehensive care plan with measurable objectives, time frames, and appropriate interventions for a resident with a history of sexually inappropriate behaviors. Despite multiple documented incidents where the resident engaged in inappropriate sexual contact or behaviors towards other residents, there was no evidence that the care plan was updated to address these behaviors or to implement interventions to prevent further incidents. The care plan remained unchanged after several events, including the resident being observed touching another resident inappropriately, standing outside other residents' rooms, and being found in a compromising position with another resident. The resident in question had diagnoses of cerebral infarction and vascular dementia, with assessments indicating varying levels of cognitive impairment and ambulatory status over time. Progress notes and staff interviews documented repeated incidents of inappropriate sexual behavior, including physical contact with other residents and attempts to enter other residents' rooms. Despite these documented behaviors, the care plan did not reflect any new strategies or interventions to address the resident's actions or to protect other residents from potential abuse. Staff interviews revealed that while some monitoring and reporting occurred, there was a lack of clear documentation or care plan updates specifying how the resident should be monitored or what interventions should be implemented. The responsibility for updating care plans was acknowledged by nursing leadership, but it was confirmed that the care plan for the resident was not revised following the incidents. This failure to update the care plan as required by facility policy and regulation resulted in a deficiency related to the prevention of abuse and the management of resident behaviors.
Resident Dignity and Clothing Management Deficiency
Penalty
Summary
The facility failed to ensure the residents' right to a dignified existence, as observed during an abbreviated survey. On the 6th floor, four residents were seen dressed in hospital gowns while seated in the hallway. These residents had various diagnoses, including dementia, bipolar disorder, and traumatic brain injury, and required different levels of assistance with daily activities. The facility's policy on resident rights emphasizes the importance of dignity and respect, yet these residents were not dressed appropriately, which contradicts their care plans that aim for them to be well-groomed and dressed daily. Additionally, in the 5th floor dining room, a registered nurse was observed standing over a resident while assisting them with their meal, which is against the facility's guidelines for meal assistance. This resident also had multiple diagnoses, including dementia and major depressive disorder, and required moderate assistance with eating. The nurse acknowledged awareness of the proper procedure but did not adhere to it during the observation. Interviews with staff revealed issues with clothing availability and management. Certified Nurse Assistants reported that some residents lacked personal clothing due to housekeeping issues or lack of family support. There were also inconsistencies in the process of obtaining donated clothing for residents, leading to some being left in hospital gowns. The Director of Nursing and the Director of Housekeeping outlined procedures for addressing clothing needs, but these were not effectively implemented, resulting in the observed deficiencies.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents of resident-to-resident altercations involving six out of nine residents. Resident #2 was involved in several physical altercations with other residents, including hitting Resident #5 with a walker, resulting in bruising, and engaging in a physical fight with Resident #4, causing lacerations. Despite being cognitively intact, Resident #2's aggressive behavior was not adequately managed, leading to repeated incidents. Resident #6 also exhibited aggressive behavior, hitting Resident #9 and threatening Resident #7. These incidents were not isolated, as Resident #6 continued to display aggression towards other residents, including Resident #8. The facility's failure to implement effective interventions to manage Resident #6's behavior contributed to the ongoing risk of harm to other residents. The facility's policies on abuse prevention were not effectively enforced, as evidenced by the repeated altercations and lack of adequate interventions to separate aggressive residents from their peers. The care plans for residents involved in altercations were not consistently updated to reflect new incidents, and the facility did not ensure that residents with known aggressive behaviors were kept apart, increasing the likelihood of further incidents.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to submit timely 5-day investigative conclusion reports to the New York State Department of Health for incidents involving resident-to-resident altercations, as required by state law. Specifically, there were delays in reporting incidents involving multiple residents, including one where a resident hit another with a walker, resulting in bruising, and another where two residents engaged in a physical altercation, leading to lacerations. In some cases, the reports were submitted late, and in one instance, there was no documented evidence of submission at all. The incidents involved residents with various diagnoses, including dementia and anxiety disorder, and occurred over several months. Despite the facility's internal documentation of these incidents and the completion of investigative summaries, the required reports were not submitted within the mandated timeframe. The Director of Nursing was unable to provide explanations for the delays or omissions in reporting, indicating a lapse in the facility's compliance with state reporting requirements.
Inadequate Staffing on Dementia Unit
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents on the 3rd floor Dementia Unit, as evidenced by a review of staffing schedules and interviews with staff. The staffing grid indicated that the unit required 5 certified nurse assistants (CNAs) during the day shift, 4 during the evening shift, and 2 during the night shift. However, the actual staffing levels were consistently below these requirements across various shifts in January, February, and March 2024. This discrepancy was particularly pronounced on certain days when only 1 or 2 CNAs were present, despite the unit housing 35-40 residents. Interviews with staff, including the Staffing Coordinator and several CNAs, revealed that the facility frequently experienced call-outs, leading to understaffing. The Staffing Coordinator mentioned attempts to schedule additional staff and use agency staff to fill gaps, but these efforts were not always successful. CNAs reported starting shifts with fewer staff than scheduled, sometimes working alone or with just one other CNA for the entire unit. This situation was exacerbated by the need to pull CNAs from the unit to accompany residents to appointments, further reducing the available staff to care for the remaining residents. The Director of Nursing acknowledged the staffing challenges, noting that while the Provider Average Ratio (PAR) for the day shift was 5 CNAs, the facility often operated with only 3 or 4. The Director also mentioned that staffing had improved compared to earlier in the year, but issues with lateness and call-outs persisted. The deficiency in staffing was particularly concerning given the high acuity and specific needs of the dementia unit residents, who require consistent and attentive care to maintain their well-being.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility was found to have multiple environmental deficiencies during an abbreviated survey. Observations revealed that on every unit, there were areas with chipped paint, scuff marks, visible dirt, and stains on the walls and floors. Baseboards were chipped and coming off the walls, there were holes in the walls, chipped tiles, caving ceiling tiles, and foul odors present. These issues were noted across various floors, including the 2nd, 3rd, 4th, 5th, and 6th floors, affecting hallways, dining rooms, and resident rooms. Interviews with the Director of Maintenance and the Administrator highlighted challenges in maintaining the facility's environment. The Director of Maintenance, responsible for repairs and maintenance, stated that they have limited staff and experience constraints, which impacts their ability to address the numerous repair needs promptly. They mentioned that tasks are generally completed within a day, but more complex repairs requiring additional materials may take longer. The Director also noted that they are actively trying to hire more skilled staff to manage the workload effectively. The Administrator, who has been with the facility since February 2024, conducts environmental rounds at least weekly, focusing on ensuring the facility is free of clutter and identifying maintenance issues. They communicate identified issues to the maintenance department and expect repairs to be completed within a reasonable timeframe, depending on the severity of the issue. Both the Director of Maintenance and the Administrator acknowledged the need for additional maintenance staff to address the ongoing environmental concerns effectively.
Failure to Provide Adequate Care Leads to Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, resulting in the development of a Stage 3 pressure ulcer. The resident, who was dependent on staff for all care due to conditions including dementia, quadriplegia, and legal blindness, did not have a documented physician order for turning and repositioning. The certified nurse assistant accountability forms for February and March 2024 showed no evidence of consistent assistance with bed mobility, with 30 and 32 occasions, respectively, lacking documentation of care. The resident's care plans noted the need for skin care and monitoring, but there was no Braden scale assessment to classify the resident's risk for pressure ulcers. A Registered Nurse's assessment on March 12, 2024, documented the development of a Stage 3 pressure ulcer on the resident's left hip. The Director of Nursing confirmed that if turning and positioning orders were present, they would be reflected in the accountability forms, and the absence of documentation indicated the care was not provided.
Facility-Wide Assessment Lacks Detailed Staffing Plan
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, last updated on 11/7/2024 and reviewed on 9/18/2023, did not specify individual staff assignments, systems for coordination, or continuity of care required for day-to-day operations, including nights and weekends. During a review on 12/19/2024, it was found that the assessment lacked a detailed staffing plan, including the number of staff needed per unit per shift. The Administrator acknowledged the omission, stating they were unaware of the requirement to include unit-specific staffing needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 1,503 citations issued within 25 miles in the last 12 months — including the 18 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 Yonkers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudson Hill Center For Rehabilitation & Nursing | 0.6 mi | ★★★★★ | 9 | 0 |
| Sans Souci Rehabilitation And Nursing Center | 1 mi | ★★★★★ | 3 | 0 |
| Park Gardens Rehabilitation & Nursing Center L L C | 1.5 mi | ★★★★★ | 6 | 0 |
| Hebrew Home For The Aged At Riverdale | 1.6 mi | ★★★★★ | 14 | 0 |
| Methodist Home For Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Yonkers Gardens Center For Nursing And Rehab.
100% money-back within 48 hours.
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.