Citations in New York
Comprehensive analysis of citations, statistics, 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
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on each shift, as required.
During two observed lunch meals, food and drink were served at improper temperatures, with hot items below 135°F and cold items above 41°F. Several residents reported that the food was not palatable, describing it as cold, bland, dry, or tough. Staff interviews confirmed that food temperatures were not always maintained or recorded as required, leading to dissatisfaction among residents.
Multiple failures were observed in maintaining a clean and safe environment, including dirty linens and soiled briefs left in resident rooms, stained ceiling tiles and privacy curtains, unclean window shades, and a soiled wheelchair. Staff interviews revealed inconsistent cleaning practices and unclear responsibilities for maintaining cleanliness and infection control in resident areas and equipment.
Surveyors identified that food was frequently served cold, bland, or overcooked, with test trays showing improper temperatures and lack of flavor. Multiple residents reported dissatisfaction with meal quality, and staff interviews confirmed ongoing complaints about food temperature and palatability. Facility policies required regular audits and proper food handling, but food preparation and delivery practices led to inconsistent results.
The facility did not have an infection prevention and control program in place, as observed by surveyors. This deficiency reflects the absence of systematic measures to prevent and control infections among residents and staff.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility's Facility Assessment did not accurately reflect current staffing levels, documenting the need for two RN Supervisors overnight and one RN on the first floor during the day, while actual staffing consisted of one RN Supervisor overnight and three LPNs on the first floor during the day. Staff interviews and records confirmed that the assessment was not updated after staffing changes, resulting in discrepancies between documented and actual staffing needs.
A resident bathroom was found with mold, water damage, missing and stained ceiling tiles, exposed wall damage, loose floor tiles, and a strong urine odor. Multiple work orders for plumbing issues were documented, but maintenance staff were unaware of ongoing leaks. These conditions demonstrated a failure to provide necessary housekeeping and maintenance services.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the lack of adequate staffing and the absence of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Serve Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable, flavorful, and appetizing temperatures during two observed lunch meals. During meal observations, food items such as baked chicken breast, fried potatoes, pork cutlet, zucchini, and rice were served below the required hot holding temperature of 135 degrees Fahrenheit, with some items measured as low as 96 degrees Fahrenheit. Cold items such as applesauce, water, and milk were served at temperatures above the required 41 degrees Fahrenheit or below. Residents reported that the food was not palatable, with specific complaints about food being cold, bland, dry, and tough to chew. Interviews with staff revealed that food was cooked in the kitchen and held in hot holding boxes or refrigerators before being distributed to the units. Food service aides were responsible for measuring and recording food temperatures prior to serving, and were instructed to notify supervisors if temperatures were not within the required range. Despite these procedures, food was served at improper temperatures, and residents expressed dissatisfaction with the palatability and temperature of their meals. The facility's policy required hot foods to be maintained at 135 degrees Fahrenheit or greater and cold foods at 41 degrees Fahrenheit or below, but these standards were not consistently met during the survey period.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment across several resident units. Observations included dirty linens and a soiled brief left on the floor next to a resident's bed, stained ceiling tiles, and unclean privacy curtains in resident rooms. In one instance, a resident's family reported frequently seeing soiled briefs on the floor and dirty linens on the overbed table. Staff interviews confirmed that soiled linens and incontinence products should not be left on the floor, as this poses a contamination and infection control issue, but acknowledged that such items had been found and removed in the past. Additional deficiencies were observed in the maintenance and cleanliness of resident areas and equipment. Stained ceiling tiles were noted in multiple rooms, with maintenance records showing repeated tile replacements due to recurring leaks. Privacy curtains were found to be soiled, and documentation of their cleaning was inconsistent or missing. In one lounge area, bed components and electrical items were left scattered, and staff acknowledged that repairs should not have been conducted in resident areas. Window shades with visible stains were reported by a resident, who expressed embarrassment about their condition, and there was no record of cleaning or replacement for these items. Wheelchair cleanliness was also found to be lacking, with one resident's wheelchair armrests observed to be soiled with food particles. Staff interviews revealed confusion about cleaning responsibilities and schedules, with some staff believing cleaning was the responsibility of the night shift, while others stated that all staff were expected to clean dirty wheelchairs when noticed. Housekeeping logs and schedules for deep cleaning and wheelchair maintenance were inconsistent, and there was a lack of clear documentation regarding the cleaning or replacement of soiled items.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
Surveyors found that the facility failed to ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service. During the survey, test trays from two lunch meals were evaluated and found to have food items that were either not flavorful, overcooked, or served at improper temperatures. Specifically, hot foods such as pot roast and potatoes were sometimes below the recommended temperature, while cold items like juice and gelatin were above the safe cold temperature range. Residents at a council meeting reported that food was often cold, overcooked, and not palatable. Observations and interviews with staff confirmed that residents frequently complained about the quality and temperature of the food, and that alternate meals were sometimes provided when complaints were made. The facility's policies required that meals be nourishing, palatable, and served at safe and appetizing temperatures, with regular audits and test trays to monitor compliance. However, interviews revealed that food was prepared in advance, sometimes up to five days, and reheated on the units, which may have contributed to temperature inconsistencies. Staff acknowledged that food sometimes appeared overcooked or dry, and that delays in tray delivery and issues with food positioning on plates could affect temperature. Documentation and staff statements indicated that test tray temperatures were sometimes out of range, and that flavor and presentation were not consistently maintained.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents, staff, or incidents were detailed in the report, and there were no direct observations of infection events or outcomes related to this deficiency.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Inaccurate Facility Assessment of Nursing Staffing Levels
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately reflected current staffing levels and needs, as required by its own policy and regulatory standards. The Facility Assessment, last updated in March 2025, documented the need for two Registered Nurse (RN) Supervisors on the 11:00 PM-7:00 AM shift and one RN on the first floor during the 7:00 AM-3:00 PM shift. However, review of staffing sheets and interviews with staff revealed that only one RN Supervisor was scheduled for the overnight shift, and the first floor was staffed with three Licensed Practical Nurses (LPNs) instead of an RN during the day shift. The staffing coordinator and Director of Nursing confirmed that the par level sheet, which determines minimum staffing, had been updated to reflect these changes, and that the RN position on the first floor had been replaced by an LPN about a month prior to the survey. Despite these changes, the Facility Assessment was not updated to reflect the current staffing model, leading to discrepancies between documented and actual staffing practices. The Administrator acknowledged that the numbers in the Facility Assessment were based on staffing from specific dates in March 2025 and did not represent daily or current needs. The failure to update the Facility Assessment as required resulted in inaccurate documentation of the resources necessary to provide competent care to residents during both routine operations and emergencies.
Failure to Maintain Safe and Clean Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, and homelike environment in one resident room, as evidenced by the presence of mold, water leaks, and physical damage in the bathroom. Observations revealed stained and mold-spotted ceiling tiles, a missing ceiling tile, and an unsealed gap in the concrete slab between floors. The baseboard cove molding was peeled off, exposing wall damage, and several floor tiles were missing or loose below the sink. A strong odor of urine was also noted in the bathroom. These conditions were directly observed during the survey. Review of the facility's work order system showed multiple entries for a clogged toilet in the same room over several months and a work order for a fallen ceiling tile, but no entries specifically addressing ceiling leaks. During interviews, the Acting Director of Maintenance was unaware of leaks in the room but acknowledged that toilet overflows sometimes affect rooms below. A resident reported a ceiling leak occurring a few months prior. These findings indicate that the facility did not provide adequate housekeeping and maintenance services necessary to ensure a safe and comfortable environment for residents.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Some of the Latest Corrective Actions taken by Facilities in New York
- Provided competency-based infection-control education to all in-house staff to reinforce proper precautions (K - F0880 - NY)
- Established a mandate for infection-control education of all oncoming staff before each shift to promote ongoing compliance (K - F0880 - NY)
- Planned continuous infection-control in-service education for staff not currently on the schedule to maintain workforce competency (K - F0880 - NY)
Widespread Failure to Administer Prescribed Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as evidenced by multiple instances where residents did not receive prescribed medications over several days. For example, one resident with a history of kidney transplant and chronic kidney disease did not receive critical medications such as prednisone, nifedipine, and cyclosporine due to pharmacy delays and order entry errors. There was no documentation that the physician was notified of these missed doses, and in some cases, medications were administered at incorrect frequencies due to transcription errors from hospital discharge summaries. Staff interviews confirmed that nurses were responsible for entering and verifying orders, but lapses occurred, resulting in missed or incorrectly administered medications. Other residents with complex medical conditions, including end-stage renal disease, diabetes, bipolar disorder, and high blood pressure, also experienced missed doses of essential medications such as insulin, antihypertensives, antipsychotics, antidepressants, antibiotics, and antiplatelets. Medication Administration Records (MARs) showed blank entries for multiple medications on several days, with no documentation explaining the omissions or indicating that the medical team had been notified. Residents reported going extended periods without receiving their medications, and staff interviews revealed that staffing shortages contributed to the inability to administer medications as ordered. A facility-wide audit of medication administration revealed that a significant number of residents did not receive multiple medications on multiple days, affecting nearly the entire resident population. The Director of Nursing and Administrator acknowledged awareness of the issue, attributing it to staffing challenges and lapses in oversight. The Medical Director confirmed that all prescribed medications were significant and that missing doses, especially of antirejection medications, was unacceptable. The deficiency was determined to have resulted in the likelihood of serious injury, harm, or death for all residents in the facility.
Removal Plan
- The medical team was notified of all residents who had medication errors (missed medications), medical assessments were in process and daily vital signs were initiated and will be ongoing.
- 100% of all onsite day and evening shift licensed nursing staff education was completed and included the facility's policies Administering Medications and Adverse Consequences and Medication Errors, the missed medication daily review process and proper communication of staffing emergencies related to coverage.
- Interviews with licensed nurses onsite were completed to verify the above education including the evening nurse supervisor. An attestation that 100% of all facility licensed nurses including agency nurses would be educated prior to their next shift.
- A facility wide Medication Administration Audit Report for every shift for any missed or omitted medications will be conducted by the Nursing Supervisor or the Director of Nursing (or designee).
- Interviews with facility Administrator, Director of Nursing and Corporate Director of Nursing were completed regarding a root cause analysis of significant medication errors as related to staffing issues and plans initiated to prevent ongoing issues including closing one resident unit down and increased agency presence in the facility as needed.
Failure to Prevent Accident Hazards and Inadequate Supervision for Aspiration Precautions
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision or assistive devices to prevent accidents for residents on aspiration precautions. Multiple residents with diagnoses such as dysphagia, dementia, and cognitive impairment were observed eating meals without the required supervision or assistance, despite care plans and physician orders specifying the need for direct supervision, upright positioning, and thickened liquids. In several instances, residents were left alone in their rooms while eating, were not properly positioned, or were given liquids that were not thickened as ordered, resulting in coughing and increased risk of aspiration. Staff interviews revealed a lack of awareness regarding which residents required aspiration precautions and inconsistent practices in meal preparation and supervision. Additionally, the facility's dietary and nursing staff did not consistently ensure that meal trays matched the prescribed diet consistencies. For example, one resident received regular coffee instead of thickened liquids, and staff were unaware of the resident's dietary needs. Observations showed that staff often left residents unsupervised during meals, even when care plans required direct supervision or assistance. Staff interviews indicated that supervision was sometimes limited to walking by rooms or peeking in, rather than providing the direct oversight required for residents at high risk of aspiration. The facility also failed to address physical hazards related to heating surfaces in resident areas. Radiator covers and heating units in multiple rooms and common areas were found to have surface temperatures well above 125 degrees Fahrenheit, with some exceeding 150 degrees. These hot surfaces were accessible to residents, including those with wandering behaviors, and were located near beds, dining tables, and common areas. Maintenance staff did not keep records of temperature checks and were unaware of the potential hazard, despite the proximity of residents to these hot surfaces.
Removal Plan
- Review of residents identified to be on aspiration precautions, medical records, physician orders and care plans.
- Educate nursing, dietary and therapy staff, unit clerks, and resident assistants on aspiration precautions, checking meal tickets against tray contents, how to properly supervise and assist residents on aspiration precautions, and the correct procedure for feeding and recognizing signs of aspiration. Complete and review post-tests.
- Director of Dietary (or designee) to review meal tickets during tray preparation, and licensed staff to verify the meal tickets against meal trays for accuracy prior to passing.
- Review lunch trays on units to ensure correct food item consistencies, and interview staff to verify knowledge of the process.
- Review unit binders containing lists of residents on aspiration precautions and guidance on diet consistencies.
- Observe kitchen/dietary staff preparing thickened liquids before meal trays leave the kitchen.
- Review the facility's Aspiration policy.
- Ensure trays of residents on aspiration precautions arrive separate from other trays (per the facility's removal plan) and inform staff of the new process. Interview staff to verify knowledge of the new process.
- Observe staff supervising and assisting residents on aspiration precautions with meals.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple lapses in infection control practices for six of eight residents reviewed. Several residents who were on contact or droplet precautions for communicable diseases such as Clostridium difficile, COVID-19, and metapneumovirus did not have the appropriate isolation precaution signage posted on their doors. In some cases, precaution signs were missing, posted late, or incorrectly identified the resident on precautions. Staff frequently entered and exited rooms of residents on isolation precautions without donning the required personal protective equipment (PPE) or performing proper hand hygiene. For example, staff were observed entering rooms without PPE, removing PPE outside of rooms, and failing to wash hands after glove removal. In one instance, a physical therapist wore PPE but left the resident's room to take phone calls without changing PPE, and a nurse entered a room with only a surgical mask when an N95 was required but unavailable in the PPE caddy. Laundry and housekeeping practices also failed to meet infection control standards. Contaminated laundry from residents on contact precautions was not consistently separated from general population laundry, and laundry staff were not always informed when items required special handling. Housekeeping staff did not consistently use PPE when handling refuse from isolation rooms and did not follow enhanced cleaning protocols, such as using bleach for rooms of residents with Clostridium difficile. Some staff reported cleaning all rooms the same way, regardless of isolation status, and using plain water for mopping instead of disinfectant. Additionally, staff responsible for laundry and housekeeping were not always aware of which residents were on precautions and did not consistently wear appropriate PPE due to discomfort or lack of communication. The facility's own policies required the use of color-coded precaution signs, proper PPE usage, and specific cleaning and laundry protocols for residents on isolation precautions. However, observations and staff interviews revealed widespread non-compliance with these policies. Staff were often unaware of the correct precautions, did not follow signage, and failed to implement required infection control measures, increasing the likelihood of transmission of communicable diseases among residents and staff.
Removal Plan
- The facility ensured all residents on precautions were reviewed and had the appropriate isolation precaution signage in place.
- All in-house staff were educated on infection control with competency-based training.
- All oncoming staff would be educated prior to the start of their shift.
- The facility provided in-service education to staff, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
Failure to Provide Preferred Communication Methods for Deaf Residents
Penalty
Summary
The facility failed to ensure the rights of two residents who were Deaf to choose activities and health care services consistent with their interests, assessments, and care plans, and to participate in social and community activities. Both residents were not provided with their preferred method of communication, which was American Sign Language (ASL), and instead were limited to using whiteboards and written communication. Staff interviews revealed a lack of knowledge and training on how to use available technology, such as tablets with video relay interpreting services, and there was no consistent provision of in-person or video ASL interpretation for daily communication, medical care, or participation in activities. One resident, who was cognitively intact but non-speaking and Deaf, reported feeling isolated and unable to communicate needs, socialize, or participate in meaningful activities. The resident's care plan and speech therapy recommendations specified the use of live ASL interpreting services via tablet, but this was not implemented. Staff relied on whiteboards, which the resident was not comfortable using due to limited English proficiency, and staff were unaware of or unable to use the tablet for interpretation. The resident experienced psychosocial harm, including feelings of isolation, inability to communicate about medication changes, and lack of participation in activities due to the absence of interpreters. The second resident, who was also Deaf with highly impaired vision and moderate cognitive impairment, was similarly not provided with their preferred communication method. Although care plans and therapy notes recommended live ASL interpretation and the use of tablets, these were not made available to the resident on a regular basis. Staff and family interviews confirmed that the resident could not effectively communicate needs or participate in care discussions, and staff often resorted to writing, which was ineffective due to the resident's vision and handwriting difficulties. The lack of appropriate communication support resulted in the residents' inability to express preferences, participate in activities, and communicate with staff and peers.
Removal Plan
- Facility provided Residents #50 and #162 tablets programmed with the video relay interpreting service that were always accessible to the resident.
- Education was provided to the staff and residents on the use of the tablets.
- Tablets were to be kept in the resident's rooms.
- Facility provided in-service education to staff with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
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