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
Food and beverages were not served at proper temperatures and were described as unpalatable during a lunch meal. Tray line issues included no plate warmer in use, cold drinks left unrefrigerated, and delayed tray delivery, and the test tray showed meat loaf, mashed potatoes, vegetables, milk, and coffee at suboptimal temperatures. Residents and an LPN reported the meal was cold, bland, dry, tough, or tasteless, and the FSD and RD gave differing expectations for hot and cold food temperatures.
A resident with intact cognition and diagnoses including anxiety and stroke-related hemiparesis/hemiplegia was prevented by a CNA from leaving the dining room when the CNA stood in front of the wheelchair and placed both hands on the armrests while telling the resident to stay because they were being monitored for falls. The resident and family later reported the resident was hit or pushed during the interaction, police responded, and the resident was transferred to the hospital for chest pain. The facility's investigation concluded there was no evidence of abuse, neglect, or mistreatment.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident with severely impaired cognition and bathing assistance needs was left alone in a shower room by a CNA during bathing care. The CNA left to get soap after placing the resident in a locked shower chair, and the resident was later found standing with a bump and bleeding on the forehead. The resident was sent to the hospital for a CT scan and later returned to the facility.
A resident with rhabdomyolysis, CKD, and HTN was admitted after a Level I PASRR screen identified serious mental illness and an intellectual disability, but the required Level II determination was not completed before admission. Records showed the resident was later found to need an abbreviated Level II assessment, and staff confirmed the Level II review should have been obtained prior to admission.
Failure to report and assess a resident’s reported fall: A resident with colon cancer, prostate cancer, BPH, and an indwelling catheter said they rang for help to empty the Foley bag, got no response, got up on their own, lost balance, and fell near the toilet. An LPN was told the resident had fallen but did not notify the RN supervisor because they believed the resident was confused and did not think the fall occurred. The resident was not assessed until later when they reported pain to the upper back and hip, and an x-ray was ordered.
Food and beverages served at improper temperatures and were unpalatable
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures for a second-floor South unit lunch meal. The facility policy required food to be handled and served in a safe, sanitary, and controlled manner, with hot foods held at 135 degrees Fahrenheit or above and cold foods at 41 degrees Fahrenheit or below. During the meal service, the tray line began without a plate warmer in use, milk and juice cartons were removed from refrigeration and left on top of the line without refrigeration, and coffee was poured while tray preparation continued. A ticketing error occurred when dinner tickets were accidentally placed on trays instead of lunch tickets, requiring staff to redistribute the correct tickets while plating continued. The first caddy left the kitchen at 12:08 PM and the second caddy left at 12:13 PM, but tray delivery on the unit was delayed as staff delivered trays from the first caddy before the second caddy arrived. The last resident tray was not delivered until 12:36 PM. When the test tray was sampled at 12:37 PM, the meat loaf with gravy was 115.3 degrees Fahrenheit and described as spicy, dry, and cool to the palate; mashed potatoes with gravy were 117.3 degrees Fahrenheit and cool to the palate; Capri blend vegetables were 94.8 degrees Fahrenheit, watery, bland, tasteless, and cool to the palate; lemon pudding was 77.3 degrees Fahrenheit and warm; milk was 55.2 degrees Fahrenheit and warm to the palate; and coffee was 107.7 degrees Fahrenheit, bitter, and cool to the palate. The LPN who tasted the tray stated the meat loaf tasted terrible and was cold, the mashed potatoes were bland and cool, and the vegetables had no taste and were cold and mushy. Residents reported similar concerns about the meal quality and temperature. One resident stated lunch was not tasty and was sent back to the kitchen because it was cold. Another resident stated the food was terrible, often served cold, soggy, and tasteless, and like it had been taken right out of the refrigerator. Additional residents stated the meat loaf was cold, hard, too dark, burnt at the edges, or disgusting, and the vegetables were cold, hard, tasteless, or tough to bite into. The FSD stated hot foods should be served at 140 degrees Fahrenheit and cold drinks at 40 degrees Fahrenheit, while the RD stated hot foods were expected to be served at 165 degrees Fahrenheit and should not go below 140 degrees Fahrenheit, and that milk at 55 degrees Fahrenheit was in the danger zone. Staff also stated residents frequently complained about cold food and lack of taste.
Resident Prevented From Leaving Dining Room
Penalty
Summary
The facility failed to ensure that a resident was able to exercise autonomy regarding choices important to their life. On 02/15/2026 at about 5:00 PM, Resident #1, who was alert and oriented times three and had intact cognition on the Minimum Data Set dated 02/04/2026, attempted to leave the dining room in a wheelchair. Certified Nursing Assistant #1 stood in front of the wheelchair and placed both hands on the armrests, preventing the resident from leaving the dining room while explaining that the resident should remain there because they were being monitored and were at risk of falling. Resident #1 was admitted with diagnoses including anxiety and cerebral infarction with hemiparesis and hemiplegia. The care plan documented that the resident was able to make leisure preferences known, including watching television, reading, and listening to music. During the interaction, Certified Nursing Assistant #1 stated the resident refused to return to the dining room, and the CNA positioned themself in front of the wheelchair and pushed the chair back while keeping hands on the armrests. The CNA reported that the resident then hit and kicked them in the chest area, and the CNA stated they were trying to keep the resident in the dining room until the resident's family came. The investigation record also included reports from the resident's family that the resident said they were hit on the right chest and right knee by the CNA. A nursing note documented that police responded and the resident was transferred to the hospital for chest pain. Later interviews reflected that the resident reported being pushed back into the wheelchair very hard when asking to be put back in bed because sitting in the chair hurt their hips and legs. The facility's investigation concluded there was no evidence of abuse, neglect, or mistreatment, while the Assistant DON stated staff were trained on resident rights and that residents have the right to move about freely.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Supervise Resident During Shower Care
Penalty
Summary
The facility failed to provide adequate supervision to a resident during bathing care. Resident #2 had diagnoses including Bipolar Disorder, Dementia, and Major Depressive Disorder, and the Minimum Data Set documented severely impaired cognition and the need for partial/moderate assistance with bathing and shower transfers. The resident’s care plan also identified the resident as at risk for falls and required one-person physical assistance for shower/tub transfer. On 03/15/2026 at about 4:20 AM, a CNA brought the resident to the shower/bathroom after observing a bowel movement. The CNA reported that the resident was placed in a locked shower chair and then left alone in the shower room to get soap for the dispenser. When the CNA returned, the resident was standing in the shower room and had a bump on the right side of the forehead. The CNA stated the resident should not have been left unsupervised in the shower room. A nursing assessment documented swelling to the right forehead with a small skin opening and scant sanguineous drainage. The resident was transferred to the hospital for a CT scan and later returned to the facility the same day. Interviews with the LPN, RN supervisor, NP, and DON confirmed that the resident was left unattended in the shower room and that the incident occurred during bathing care.
PASRR Level II Not Completed Before Admission
Penalty
Summary
The facility failed to ensure that a resident was screened for a mental disorder or intellectual disability before admission. Resident #373 was admitted with diagnoses including rhabdomyolysis, chronic kidney disease, and hypertension. The resident’s MDS documented that the resident was admitted from an acute hospital, was considered by the state PASRR Level II process to have a serious mental health and/or intellectual disability, and had an intellectual disability. The record showed that the Level I Review on the SCREEN DOH-695 form identified the resident as having a serious mental illness and a diagnosis or documented history of mental retardation and/or developmental disability, with a categorical determination of convalescent care. An OPWDD PASRR Level II Referral Response Letter later stated that an abbreviated Level II Assessment was required and that the categorical determination was convalescent care, not to exceed 120 days, with need for specialized services and nursing facility level of care. There was no documented evidence that the required PASRR Level II Assessment with determination and recommendation was completed prior to the resident’s admission to the facility. Staff interviews confirmed that the Level I screen had been completed in the hospital and that the Level II determination should have been obtained before admission, but the Level II determination was completed after the resident had already been admitted. The Facility Administrator stated the determination should have been received before admission, including when the referral was received on a weekday and the resident was admitted on the weekend.
Failure to Report and Assess a Resident’s Reported Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the care plan, and the resident’s choice. Resident #129 had diagnoses of colon cancer, prostate cancer, and benign prostatic hyperplasia, was cognitively intact, had an indwelling catheter, and required substantial assistance with toileting hygiene and toilet transfer. The care plan included toileting every 2 to 4 hours and as needed. Resident #129 reported that during the early morning hours they rang the call bell for assistance to empty the Foley catheter bag, but no one responded. The resident stated they got out of bed around 4:15 AM to 4:20 AM, lost balance, and fell near the toilet while trying to empty the catheter bag. The resident later reported pain to the left upper back and hip. The nursing progress note documented that the incident was reported at 11:00 AM, when the resident told the RN they had fallen earlier in the bathroom by the toilet. Licensed Practical Nurse #3 stated they were told by a CNA that the resident had fallen, but did not inform the RN supervisor on duty because they believed the resident was confused and did not think the fall actually occurred. The facility’s investigation and interviews confirmed that the LPN did not report the incident immediately as required by policy. The RN assessed the resident after the resident reported the fall, noted no bruising, redness, or swelling, and the physician ordered a left hip x-ray, which showed no acute fracture or dislocation.
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Compliance trends in New York
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 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): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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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