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
Two residents were involved in a deficiency related to supervision and wander alert safety. One resident with severe cognitive impairment and known elopement risk exited the facility unnoticed through unsecured doors and was found miles away by police. A second resident’s wander alert bracelet failed to alarm during an elevator transfer, and staff later found the bracelet battery was dead. Leadership and nursing staff stated there was no policy for door checks or for the current wander alert system.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
A facility failed to maintain effective wandering and elopement safeguards for cognitively impaired residents. One resident with Alzheimer’s disease and severe cognitive impairment exited through an unsecured maglock door and was found by police hours later, while another resident’s wander alert bracelet failed to alarm when tested. Staff, including the DON, ADM, and DOR, reported there was no policy or documented process for testing the current wander alert system or monitoring bracelet function, and the facility had no system for checking the maglock doors before the incident.
Failure to Obtain Ordered Urine Specimen for Suspected UTI: A resident with severe dementia, poor decision-making capacity, and frequent incontinence developed lethargy, increased confusion, urinary frequency, and strong urine odor. An NP ordered a UA with C&S to rule out UTI, but the order was not transcribed, no lab requisition was created, and no specimen was collected in the facility despite ongoing poor intake and family concern. The resident was later sent to the ED, where the urine sample was obtained by the hospital.
Failure to Verify Advance Directives Before CPR: A resident with severe cognitive impairment, Parkinson’s Disease, and a MOLST indicating DNR and comfort measures only became unresponsive. An LPN who was unfamiliar with the resident’s plan of care activated the emergency response system and started CPR without first checking the MOLST or confirming the resident’s code status, even though the HCP later stated they did not want CPR or other life-sustaining treatment.
Failure to Prevent Elopement and Ensure Wander Alert Device Functionality
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for two residents. One resident had diagnoses including Alzheimer’s disease, alcohol abuse, and COPD, and was assessed as having severe cognitive impairment. The resident was identified on admission as having wandering, exit-seeking, and elopement risk, and the baseline care plan noted the resident wore a wander alert bracelet on the right wrist. On the morning of the incident, the resident was not found in the room during breakfast service, and staff initiated a search and notified leadership, the spouse, and law enforcement. The resident was later found by police approximately three miles from the facility and returned that evening. Video surveillance showed the resident walking alone through the third-floor west wing, past the nurses’ station, toward an emergency exit door, then continuing down the east wing hallway toward a stairwell door that led to the first-floor exit to the parking lot. The surveillance outside the building showed a laundry aide arriving and remaining in a vehicle while the resident exited the facility. The report also states that the stairwell door had a keypad and magnetic locking system, but the first-floor exit door near the parking lot had no alarm system, and the wander alert system did not cover the doors the resident used to leave the building. During interviews, maintenance staff stated that magnets on the magnetic-locked doors had previously slipped and disengaged the locking mechanisms, and the administrator stated the facility did not have a policy regarding door checks. A second resident had diagnoses including hypertension, diabetes mellitus, and depression. The resident was listed on the facility’s wander alert list as a wanderer, but the resident’s assessment documented independence with transfers and wheelchair mobility and no wandering behaviors. During observation, a unit clerk wheeled the resident to the elevator, and the wander alert device did not alarm when the resident entered the elevator. When the assistant director of nursing replaced the bracelet with a new one and tested it, the system sounded. The assistant director of nursing stated the old bracelet’s battery was no good and did not know how long it had been dead. Staff and leadership stated they did not have a policy for the current wander alert system, and the director of nursing stated routine checks had been stopped when the new system was implemented.
Failure to Respond to Alleged Sexual Abuse and Assess Resident Distress
Penalty
Summary
The facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately after an allegation of staff-to-resident sexual abuse. The resident had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan included psychosocial well-being interventions such as orienting the resident to the environment, introducing compatible peers, and addressing concerns. During incontinence care, the resident alleged that a CNA raped them. The incident report documented that the resident told an LPN they were raped, and the LPN notified a supervisor. The supervisor assessed the resident and noted redness in the perineal area. A nursing progress note later documented that the resident complained of burning in the sacral and vaginal area after incontinence care and that the DON was aware. Video review showed the CNA in the resident’s room for 36 minutes. The CNA stated they provided incontinence care, applied A and D ointment to the resident’s pubis, groin crease, and vagina, and remained in the room because the resident had multiple bowel movements, although the bowel record did not document multiple bowel movements. The resident remained in the facility for about five and a half hours after the allegation without documentation of a medical or psychosocial assessment. Family members reported the resident was hysterically crying, contacted law enforcement, and requested hospital transfer. The resident later stated they felt something enter their anus and vagina, that they told the CNA to stop, and that they became distressed, tearful, fearful, and distrustful of facility staff. The facility concluded abuse did not occur because of conflicting statements, and the DON and administrator stated the allegation was not reported to the state because the resident later described rough handling. The PCP stated the facility should have called law enforcement and the Department of Health if the allegation was rape, and stated a psychosocial assessment should have been completed. The social worker stated they were aware of the incident after it occurred and did not know what interventions should be put in place.
Failure to Report Alleged Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse was reported to the New York State Department of Health and local law enforcement within two hours of the allegation. The deficiency involved one resident who had diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan showed the resident required assistance with ADLs, including two staff members for transfers and toileting and extensive assistance for dressing, bathing, grooming, and bed mobility. According to the facility’s incident report, the resident told an LPN that they had been raped by a CNA while receiving care. The resident later described that the CNA entered the room to change a wet brief, applied cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina while asking the CNA to stop. The CNA stated they provided incontinence care and applied A and D ointment to the perianal area, and the video review showed the CNA entered the room at 4:43 AM and exited at 5:19 AM. The resident’s family member reported that the resident called them, said to come immediately, and later stated that a staff member had raped them. The family member contacted law enforcement and requested hospital transfer. Facility leadership acknowledged awareness of the allegation but did not report the alleged rape to the Department of Health, stating they believed the allegation changed to rough handling and did not meet the reporting threshold. The DON, Administrator, and Social Worker each described differing understandings of the allegation and reporting status, and the report states there was no documented evidence that the allegation was reported to local law enforcement or the Department of Health within two hours as required.
Unsafe wandering and elopement safeguards were not effectively managed
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of residents because it failed to ensure a safe environment for cognitively impaired residents who wander or are at risk for elopement. The report identified two separate events involving wandering safety systems and noted that the deficiency affected seven residents identified as at risk for unsafe wandering and elopement. Resident #1 had diagnoses including Alzheimer's disease, alcohol abuse, and COPD, and the Minimum Data Set dated 06/08/2026 assessed the resident as having severe cognitive impairment. On 06/04/2026, the resident was located by local police approximately 12 hours later and about three miles away. Staff interviews indicated that the resident exited through a door associated with the third-floor east stairwell area, and the Maintenance Assistant stated the maglock may have slipped and disengaged, causing the door to inactivate and the alarm not to sound. The Director of Maintenance stated the third-floor east wing stairwell door used a keypad and magnetic locking system, that the first-floor exit door near the parking lot had no alarm system, and that the facility had no system for checking the doors prior to the incident. Resident #2 had diagnoses including hypertension, diabetes mellitus, and depression. The Minimum Data Set documented the resident as independent with chair/bed-to-chair transfers and wheelchair mobility and as having no wandering behaviors. During testing on 06/29/2026, the resident's wander alert device failed to alarm. Staff interviews further revealed there was no documented policy for testing the wander alert system or resident bracelets, and the facility had no current system for monitoring bracelet functionality weekly per manufacturer recommendations. The Director of Maintenance stated they could not find a policy for the wander alert system and only obtained manufacturer guidance after contacting the manufacturer, while the Administrator stated they assumed the system monitored bracelet functionality.
Failure to Obtain Ordered Urine Specimen for Suspected UTI
Penalty
Summary
The facility failed to ensure services arranged or provided met professional standards of quality for a resident with syncope, a right femoral neck fracture status post right hemiarthroplasty, and unspecified non-Alzheimer’s dementia. The resident’s MDS showed severely impaired cognition, dependence on staff for toileting hygiene and transfers, frequent bladder and bowel incontinence, and need for nutrition/hydration interventions. A lack of capacity form signed by the health care proxy and NP documented poor medical decision-making capacity. On 10/10/2024, the RN unit manager documented the resident had been lethargic for several days, had decreased appetite, increased confusion, urinary frequency with odor, needed more physical assistance, and had a dry intermittent cough. The resident stated they did not feel well. NP was notified and ordered a urinalysis with culture and sensitivity to rule out UTI, along with cough syrup. The order documented collection of urine for increased confusion, urinary frequency, and malodor, but there was no documented evidence that the order was transcribed to the treatment administration record, that a laboratory requisition was created, or that a urine specimen was collected. The resident’s intake record showed refusals of fluids on 10/10, 10/11, and 10/12, and there was no documented evidence that a provider was notified about the decreased fluid intake or change in condition. On 10/12, nursing notes documented the family was insistent the resident be sent to the ED because of increased confusion and that they did not want to wait until Monday for results. The resident initially refused the ED, then changed their mind and was sent by EMS. A urine sample was later documented by the hospital lab while the resident was an inpatient in the ED, not from the facility. Interviews with nursing leadership and staff confirmed that if UTI symptoms were present, an infection screening questionnaire, provider notification, lab slip, and urine collection were expected, and that results were usually available within a day.
Failure to Verify Advance Directives Before CPR
Penalty
Summary
The facility failed to provide resident-centered care in accordance with a resident’s advance directives, preferences, goals for care, and professional standards of practice when Resident #1 became unresponsive. Resident #1 had diagnoses including Parkinson’s Disease and metabolic encephalopathy, and the Minimum Data Set documented severe cognitive impairment with dependence for all activities of daily living and mobility. The comprehensive care plan and physician orders documented do not resuscitate and comfort measures only, and the Medical Order for Life Sustaining Treatment form, signed by the Health Care Proxy, also documented do not resuscitate, do not intubate, comfort measures only, do not send to the hospital, no feeding tube, no intravenous fluids, no dialysis, and to determine antibiotic use when infection occurs. When the resident was found not breathing and without a pulse, an LPN who was not familiar with the resident’s current plan of care activated the emergency call system and initiated CPR without first verifying the resident’s advance directives or reviewing the MOLST form. During the resuscitative efforts, the Health Care Proxy stated they did not want CPR or any other life-sustaining interventions. The emergency response team later terminated the efforts, and the resident was pronounced deceased with family at the bedside.
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Compliance trends in New York
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 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 2-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): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 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 2 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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