Citations in New York
Statistics, citations and compliance trends for long-term care facilities in New York.
Statistics for New York (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in New York
A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident with a table, and used profanities toward the resident. The RN supervisor and DON did not initiate an immediate abuse investigation, did not complete a resident assessment or incident documentation, did not notify the provider, and did not remove the accused CNA from access to the resident. The resident had dementia with moderately impaired cognition and a care plan noting potential for abuse related to resistance of care, verbal aggression, and physical aggression.
Failure to Follow Care Plans and Resident Rights: A cognitively intact resident sustained a skin tear when a CNA rolled the resident without the required 2-person assist, another cognitively intact resident reported that a CNA grabbed the resident’s arm and pushed the resident back into the room when the resident tried to leave, and a resident with dementia was transported in a wheelchair without required leg rests, causing the resident’s foot to drag and resulting in a right ankle sprain. The facility’s investigation identified the first event as a care plan violation and documented the abuse allegation involving the second resident.
Missed Ordered Wound Treatments: A resident with a pressure ulcer did not receive ordered Santyl ointment and dry dressing care to the foot as scheduled. Records and staff statements showed the dressing was left in place, treatments were documented as completed before they were actually done, and the wound was noted to be larger with a light tan film over the wound bed.
Failure to notify legal representative of significant change in condition: A resident with dysphagia, CKD, and moderate cognitive impairment had a vasovagal episode in the shower and later vomited, but the family was not immediately informed. Staff notified the PA and monitored the resident, yet the legal representative said the first notice from the facility was after the resident had died. The facility policy required notification of the resident or legal representative for significant changes such as vomiting or vital sign changes.
Failure to Protect Resident From Alleged Abuse: A CNA reported that another CNA used profanities toward a resident, forcibly grabbed and pushed the resident in a wheelchair, and blocked the resident with a table. The resident had dementia and moderately impaired cognition, and the care plan identified a potential for abuse and verbal or physical aggression. Although the allegation was reported to supervisory staff, the accused CNA remained assigned to the resident, and there was no documented resident assessment, MD notification, psych consult, incident report, or abuse investigation.
Failure to Timely Report Alleged Abuse: A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident’s movement with a dining table, and used profanities toward the resident. The allegation was reported to an LPN and RN supervisor, but the facility did not notify DOH within the required timeframe; the resident had dementia and moderately impaired cognition.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident and failed to implement immediate protective actions after a CNA reported observing another CNA forcibly grab the resident, push the resident into a wheelchair, and use a dining room table as a barrier to keep the resident from getting out of the wheelchair. The reporting CNA also stated they heard repeated profanities directed at the resident. The resident had diagnoses including dementia, depression, and anemia, and the admission MDS documented moderately impaired cognition. The resident’s psychosocial care plan identified a potential for abuse related to resistance of care, verbal aggression, and physical aggression. After the allegation was reported to an LPN and an RN supervisor, the RN supervisor did not initiate an immediate investigation at the time of discovery. The resident was not assessed for physical injury or psychosocial harm, no incident report or abuse investigation was documented, and the medical provider was not notified. The resident’s representative was not contacted until later, and there was no documented psychiatric consultation. The staff member accused of abuse was not removed from access to the resident or other residents, and the resident continued to be assigned to that staff member on subsequent shifts. Statements obtained from staff reflected conflicting accounts of the interaction in the dining/dayroom area of the locked memory care unit. One CNA reported seeing the resident being pushed and blocked in by a table, while the accused CNA stated the resident was yelling, cursing, and being redirected, and denied pinning the resident against a wall or blocking the resident with a table. The RN supervisor acknowledged that no accident and incident report, investigative summary, body assessment, resident assessment, or abuse investigation was completed on the day the allegation was reported, and that the accused CNA remained on the unit. The DON and administrator also stated the allegation was not reported as abuse because it was not believed abuse had occurred.
Failure to Follow Care Plans and Resident Rights
Penalty
Summary
The facility failed to ensure residents were free from neglect and abuse for three residents. The report states that Resident #2 and Resident #18 were injured when their care plans were not followed, and Resident #15 reported being physically prevented from leaving their room by a staff member. The facility policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, and neglect as the failure to provide timely, consistent, safe, adequate, and appropriate services, treatment, and care. Resident #2 was cognitively intact and required substantial to maximum assistance from two staff members for bed mobility and bathing. On 09/09/2025, while care was being provided, Certified Nurse Aide #1 rolled the resident without additional assistance and the resident sustained a skin tear to the right upper arm measuring 4.3 cm by 3 cm. The resident, the CNA, and the nurse all stated the injury occurred during turning or changing, and the facility’s investigative report concluded there was reasonable cause to believe abuse, neglect, or mistreatment occurred and identified the event as a care plan violation. Resident #15 was cognitively intact and reported that Certified Nurse Aide #4 grabbed the resident’s arm and pushed the resident back in a wheelchair when the resident attempted to leave a semi-private room, stating, "I'm not letting you leave." The incident was reported to an LPN, the supervisor was notified, and the facility investigation documented the allegation. Resident #18, who had dementia, anemia, and GERD, had a care plan requiring a standard wheelchair with cushion and standard leg rests. On 10/15/2025, the resident was transported from therapy without leg rests, causing the resident’s foot to drag and turn while being pushed in the wheelchair, and the resident later reported ankle pain; an x-ray showed a right lateral ankle sprain.
Missed Ordered Wound Treatments
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when Resident #1 did not receive ordered wound treatments to the left medial foot. The resident was admitted with diagnoses including paroxysmal atrial fibrillation, history of venous thrombosis and embolism, and diaphragmatic hernia without obstruction or gangrene. The Minimum Data Set dated 02/27/2026 documented that the resident could be understood and understood others and had moderately impaired cognition. The facility policy titled Skin & Wound Care stated that licensed practical nurses would change dressings per order and document wound appearance and changes. Review of the Treatment Administration Record showed completion of treatment to the left medial foot on multiple dates in December 2025, but a nursing progress note dated 12/10/2025 documented that during weekly wound rounds the resident was found with a dressing dated 12/03/2025 still in place. The wound nurse documented that the ordered daily Santyl ointment with dry gauze had not been completed as ordered, and the wound was larger in size with a very light tan film over the wound bed. The Director of Nursing’s investigation included statements from staff that treatments were omitted in error, that treatment was signed for before being completed, and that one nurse did not return to finish the treatment after documenting it as done. Interviews with two LPNs later confirmed that treatments should be documented only after completion.
Failure to Notify Legal Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify the resident's legal representative of a significant change in condition for one resident reviewed for notification of changes. The resident was admitted with pneumonitis due to inhalation of food and vomit, dysphagia, and stage 3 chronic kidney disease. The Minimum Data Set dated 05/06/2026 documented that the resident could sometimes be understood, could sometimes understand others, and had moderate cognitive impairment. On 05/14/2026, the resident experienced a vasovagal episode while in the shower and later had episodes of vomiting, including brown-colored emesis. Progress notes documented that staff notified the PA of the resident's condition, assessed the resident, and monitored vital signs. The facility policy titled Notification Policy required the attending physician or designee and the resident or resident's legal representative or interested family member to be notified by the nurse of a significant change in condition, including vomiting, change in mentation, change in vital signs, or respiratory distress. There was no documented evidence that Family Member #2 was immediately notified of the vasovagal episode or the vomiting. Family Member #2 stated they were not informed of these events and first learned from the facility when told the resident had passed away at 12:07 PM. Staff interviews confirmed that family notification was expected for significant changes, and the PA stated they were contacted about the vasovagal episode, the vomiting, and later the resident's death.
Failure to Protect Resident From Alleged Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA reported observing another CNA forcibly grab the resident, push the resident against a wheelchair, use a dining room table as a barrier to keep the resident from getting out of the wheelchair, and repeatedly use profanities toward the resident. The resident had diagnoses including dementia, depression, and anemia, and the admission MDS documented moderately impaired cognition. The resident’s care plan identified a potential for abuse and verbal or physical aggression, and the behavior care plan documented the resident could become verbally aggressive when frustrated or confused. The allegation was reported to supervisory staff on the day it occurred, and staff statements were obtained. However, the resident remained routinely assigned to the accused CNA after the allegation and until the onsite visit when the CNA was reassigned. The report states there was no documented resident assessment, physician notification, psychiatric or psychology consult, accident and incident report, investigation summary, law enforcement notification, care plan review or update, or abuse investigation related to the allegation. Interviews showed conflicting accounts of the event, but multiple staff acknowledged the allegation was reported and that the accused CNA was not removed from the unit. The DON stated the allegation should have been investigated and the accused CNA should have been removed from assignments pending the investigation. The Administrator stated the alleged incident should have been investigated and an accident and incident report should have been initiated. The Medical Director stated arguing in front of residents can cause psychological harm and residents should be evaluated if that occurs.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported to the New York State Department of Health within the required timeframe. Certified Nurse Aide #1 reported observing Certified Nurse Aide #2 forcibly grab the resident, force the resident into a wheelchair, place a dining room table in front of the resident to prevent movement, and repeatedly use profanities toward the resident. The allegation was reported to an LPN and an RN supervisor on 05/11/2026, but the facility did not report the allegation to the Department of Health until 05/21/2026. The resident involved was admitted with diagnoses including dementia, depression, and anemia, and the admission MDS dated 04/11/2026 documented moderately impaired cognition. During interviews, Certified Nurse Aide #1 stated the resident was yelling profanities near the nurses' station and asking to be toileted while pants were down, and that Certified Nurse Aide #2 yelled profanities back, aggressively pushed the resident into the wheelchair, and later positioned the wheelchair and dining room table to prevent the resident from getting out. The RN supervisor stated the allegation was reported to the DON on 05/11/2026, while the DON stated the allegation was not reported because it was not believed that abuse had occurred.
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Compliance trends in New York
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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