Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Masonic Care Community Of New York during CMS and state inspections, most recent first.
Two residents with cardiac, thyroid, cognitive, and anxiety-related conditions did not receive multiple ordered medications, including alprazolam, diltiazem, methimazole, nadolol, hydralazine, and lisinopril, because the drugs were out of stock, pending from pharmacy, or awaiting delivery. Nursing staff did not consistently reorder medications in advance, did not always use or verify the emergency medication supply, and did not reliably notify supervisors or medical providers when medications were unavailable, despite facility policies requiring these actions. Documentation showed missed doses over several days, an elevated BP reading after a missed cardiac medication, and gaps in provider notification and progress notes, while staff interviews described frequent problems with the new pharmacy’s refill and delivery processes and inconsistent monitoring of remaining medication supplies.
Staff failed to maintain resident dignity during meal assistance when CNAs stood over three cognitively impaired residents with Alzheimer’s disease and dysphagia while feeding them, despite facility policy requiring a dignified dining experience and training to sit at eye level. Observations showed CNAs repeatedly standing while assisting residents on puree or mechanically altered diets who required maximal or total assistance with eating. In interviews, a CNA, an LPN, and an RN manager all acknowledged that staff were expected to be seated when assisting with meals and that standing while feeding residents was not dignified, even though chairs were available.
Two residents with cognitive impairment and mobility risks exited the facility undetected on separate occasions, despite being identified as at risk for elopement or accidents. Staff failed to consistently monitor, respond to alarms, or follow protocols for supervision and notification, resulting in residents leaving the premises without detection and placing them at risk for harm.
The facility failed to ensure a proper grievance process for 6 of 8 anonymous residents, who were unaware of how to file a grievance. The facility lacked a process for anonymous grievances, and staff were generally unsure of the grievance procedures.
The facility failed to ensure that two residents' ability to safely self-administer medications was clinically appropriate. One resident was observed with eye drops and nasal sprays at their bedside without an assessment or order, while another resident with dementia and glaucoma had eye drops in their room despite being cognitively impaired and not allowed to self-administer. Staff interviews revealed a lack of clarity and adherence to the facility's policy on self-administration of medications.
A resident with a history of venous thrombosis and embolism, who was on anticoagulant therapy, did not have a care plan that included interventions related to their anticoagulant medication use. Interviews with facility staff confirmed that the care plan should have included these interventions, but the specific template for anticoagulant therapy had not been initiated.
A resident with multiple health conditions did not receive a prescribed left heel float boot for nearly two weeks, despite multiple staff observations and documentation of its absence. This delay led to additional skin issues, highlighting a failure to follow the care plan and physician's orders.
The facility failed to assess a resident for the risk of entrapment from bed rails, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent before installing the bed rails. The resident had multiple diagnoses and required assistance for various movements, but the necessary assessments and consents were not completed. Staff interviews revealed inconsistencies in following the facility's policy on bed rail use.
A resident with Parkinson's Disease missed four consecutive doses of carbidopa-levodopa due to unavailability, and the nursing staff failed to notify the medical team as required by facility policy. The missed doses were documented, and the pharmacy was contacted, but the medication was not delivered in time. Interviews revealed that the medical team was not informed, which could have led to worsening symptoms for the resident.
The facility failed to maintain proper infection control for a resident with a urinary catheter, as the drainage bag was repeatedly observed resting on the floor without a barrier. Staff interviews confirmed awareness of the policy but revealed inconsistent implementation, posing an infection risk.
Failure to Provide and Administer Ordered Medications Due to Unavailable Pharmacy Supply
Penalty
Summary
The deficiency involves the facility’s failure to ensure that routine and emergency medications were available and administered as ordered for two residents, despite policies requiring timely ordering, use of emergency supplies, and notification of supervisors and providers when medications were unavailable. Facility policy stated that if a medication was not available at the scheduled administration time, the nurse was to notify the neighborhood manager or supervisor, who would then explore alternate methods for obtaining the medication, including the emergency medication supply and contacting the pharmacy or medical provider. Another policy required nurses to order all new medications and refills electronically, monitor refill requests, address transmission errors or rejections with the pharmacy, and communicate urgency for medications needed before scheduled pharmacy runs. These processes were not consistently followed, resulting in multiple missed doses of ordered medications. One resident with atrial fibrillation, hypothyroidism, congestive heart failure, and hypertension had multiple cardiac and thyroid medications ordered, including diltiazem ER, methimazole, nadolol, hydralazine, and lisinopril. The Medication Administration Records showed that doses of hydralazine, diltiazem, lisinopril, methimazole, and nadolol were not administered on several dates because the medications were out of stock, awaiting delivery, or not available from the pharmacy. Documentation indicated that on some occasions the supervisor was aware, but on other occasions there was no evidence that a supervisor was notified. There was also no documented evidence that medical providers were notified of several missed doses, including missed doses of diltiazem, hydralazine, lisinopril, and methimazole. The emergency medication supply inventory showed that hydralazine tablets were stocked, yet a scheduled hydralazine dose was missed. On one date, after a missed diltiazem dose, the resident’s blood pressure was recorded as elevated, and there was no documentation that the provider was notified of either the missed medication or the elevated blood pressure. Another resident with Alzheimer’s disease, anxiety, and depression had an order for alprazolam four times per day. The Medication Administration Record documented that three doses of alprazolam were not administered because the medication was pending from pharmacy or not available. Staff interviews confirmed that the alprazolam was not available from the pharmacy or in the automated medication cabinet when the resident returned from the hospital. Multiple nurses and managers reported frequent issues with the new pharmacy’s timeliness in delivering medications, inconsistent use of the automated or emergency medication supplies, and late ordering of medications. They also described that not all nurses checked remaining medication supply when administering medications and that there were complications with obtaining medications from both the pharmacy and the automated medication cabinet. These actions and inactions led to residents not receiving ordered medications and to a lack of timely notification and documentation to supervisors and providers as required by facility policy. Staff interviews further detailed that medications were sometimes ordered late, that nurses sometimes failed to check the emergency medication supply, and that there were recurring problems with pharmacy delivery and insurance-related refill denials. One LPN reported that a resident’s diltiazem dose was missed because the medication was out and that the pharmacy cited an insurance timing issue with no alternative provided and no additional monitoring initiated. The RN neighborhood manager stated that medications should be reordered when a three-day supply remained and that if medications were not available in the emergency supply, medical staff should be contacted to determine whether the resident could safely miss a dose or needed an alternative, with documentation of missed doses and provider notification. However, the RN neighborhood manager was only aware of one missed nadolol dose and not the other missed medications documented in the records. The DON stated that if medications were not available, staff should check the emergency supply, notify the physician for possible alternatives, call the pharmacy for delivery timing, and document missed medications and provider notification, but the documentation reviewed showed these steps were not consistently carried out for the residents involved.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Surveyors identified a deficiency in resident dignity related to how staff assisted residents with meals. Facility policy on Resident Dignity, revised 09/2025, stated that all residents were to be treated with dignity and provided a dignified dining experience. Three residents with Alzheimer’s disease, dysphagia, severely impaired cognition, and care plans indicating a need for substantial/maximal or total assistance with eating and mechanically altered/puree diets were observed being assisted with meals while staff stood over them. On multiple meal observations, one CNA stood while assisting two different residents with breakfast, and another CNA stood while assisting a resident with lunch; the same resident was again assisted by a standing CNA at a subsequent breakfast. Interviews with staff confirmed that they had been trained to sit at eye level with residents during feeding for dignity reasons and that the facility had enough chairs available. The CNA who was observed standing stated that they were supposed to be seated when assisting residents at meals and acknowledged that standing while feeding was not dignified, explaining that they stood because several residents required assistance at the same time. An LPN and the RN Neighborhood Manager both stated that staff should be seated when assisting residents with meals and that standing while assisting residents was not dignified. These observations and statements showed that staff did not follow the facility’s dignity policy or accepted practice regarding seated, eye-level feeding assistance for the three residents.
Failure to Prevent Elopement and Inadequate Supervision of Residents
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents identified as being at risk for elopement or accidents. One resident with Alzheimer's dementia, severely impaired cognition, and a history of repeated falls was assessed as high risk for elopement and was equipped with a wander detection device. Despite multiple prior incidents where this resident was found in or near stairwells and exit doors with alarms sounding, the resident was able to exit the facility undetected on two separate occasions. On both occasions, staff were either occupied providing care to other residents or did not fully investigate the source of the alarm, resulting in delayed recognition that the resident was missing. Documentation of required 15-minute checks was incomplete, and there was no evidence of additional interventions being implemented after the first elopement. Staff interviews revealed confusion about alarm response protocols, with some staff silencing alarms without fully searching the area or notifying supervisors as required by facility policy. Another resident with severely impaired cognition, multiple comorbidities, and independent use of a motorized scooter was allowed to move freely throughout the facility and its grounds. The resident was assessed as low risk for elopement and did not have a wander detection device. On one occasion, the resident left the facility grounds undetected and traveled approximately four miles away to a fast-food restaurant, where they were later found and returned by family. There was no documented plan to monitor or account for the resident's whereabouts when they left the building, and staff were unaware of specific monitoring expectations for residents using scooters independently on the grounds. The facility did not require the resident to notify staff or sign out when leaving the unit, and there was no restriction or supervision in place for off-campus mobility. Facility policies required staff to monitor residents' whereabouts, respond promptly to alarms, and notify supervisors in the event of a missing resident or elopement. However, staff interviews and documentation revealed inconsistent adherence to these protocols, including failure to expand searches beyond immediate areas, inadequate communication among staff, and incomplete documentation of supervision. These failures resulted in residents exiting the facility undetected, placing them at risk for serious harm and triggering Immediate Jeopardy and Substandard Quality of Care findings.
Removal Plan
- The facility's immediate plan was reviewed and accepted.
- 85% of staff had been educated on elopement risk and wander detection device door alarm response. The remaining staff will be educated prior to the start of their next shift or upon return from their leave.
- Staff education was verified onsite during interviews. Multiple staff including nursing, maintenance, housekeeping, and activities were interviewed.
- Staff were able to report content of education, confirmed the day they received the education, and the facility staff who presented the education.
Deficiency in Grievance Process
Penalty
Summary
The facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 6 of 8 anonymous residents. Specifically, 6 anonymous residents present at the Resident Council meeting stated they did not know how to file a grievance. Additionally, the facility did not have a process for residents to file a grievance anonymously. The facility policy on Resident Grievances, dated 11/2016, did not state how residents were informed of their right to file a grievance or how to do so anonymously. The grievance log for the year 2024 documented only one grievance in total for the facility. The grievance policy was observed in the front lobby inside a locking glass wall case in the upper right top corner, which was above head height when standing. During interviews, the Social Services Director stated they were unaware of how residents were educated on the grievance process and mentioned that grievances or concerns were a team approach. They also noted that there was no internal process to file an anonymous grievance. Licensed Practical Nurse #13 and Certified Nurse Aide #12 were both unsure of the process for residents to file a grievance. The Administrator mentioned that they had two different processes for addressing resident grievances but had never had a resident file an anonymous grievance. They also stated that if a resident had an anonymous grievance, they were encouraged to call the Ombudsman. The Administrator was unsure if the right to file grievances was addressed in the admission packet and would have to check with the admissions department and social workers to confirm this.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents' ability to safely self-administer medications was clinically appropriate. Resident #96 was observed with prescribed eye drops and nasal sprays at their bedside without documented evidence of an assessment or order to self-administer these medications. Despite having a comprehensive care plan that included self-administration of certain medications, there was no specific order for the nasal spray and eye drops. The resident was seen self-administering these medications, and staff were unsure if there was an order for self-administration. The resident had a history of non-compliance and impaired vision, which further complicated the situation. Resident #155, who had diagnoses including dementia and glaucoma, was also found with prescribed eye drops at their bedside without an assessment or order to self-administer them. The resident's care plan and physician notes indicated that the resident was not allowed to self-administer eye drops due to cognitive decline. However, the resident was observed with eye drops in their room, and staff admitted to sometimes allowing the resident to self-administer the drops under supervision, despite knowing there was no order for it. The resident's care plan was not updated to reflect the current status, causing confusion among the staff. Interviews with staff revealed a lack of clarity and adherence to the facility's policy on self-administration of medications. Licensed Practical Nurse #14 and Registered Nurse Manager #15 both acknowledged that a physician order and competency assessment were required for self-administration, but these were not consistently followed. The Assistant Director of Nursing confirmed that care plans should be accurate and up-to-date, and no medications should be left at the bedside without a specific order. The failure to follow these protocols led to the observed deficiencies.
Failure to Include Anticoagulant Therapy in Resident's Care Plan
Penalty
Summary
The facility did not ensure a comprehensive, person-centered care plan was developed and implemented to meet a resident's medical and nursing needs. Specifically, a resident with a history of venous thrombosis, embolism, and pulmonary embolism, who was on anticoagulant therapy, did not have a care plan that included interventions related to their anticoagulant medication use. The resident's care plan, dated 11/21/2022, only documented fall risk interventions and did not address the anticoagulant therapy despite physician orders indicating the resident took apixaban twice daily. Interviews with facility staff, including a Certified Nurse Aide, Licensed Practical Nurse, Nurse Manager, and Assistant Director of Nursing, revealed that the care plan should have included anticoagulant therapy interventions. The Nurse Manager confirmed that the specific template for anticoagulant therapy had not been initiated in the resident's care plan. The Assistant Director of Nursing emphasized that care plans should always be accurate and up-to-date to ensure proper care is provided to residents.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident #106 received necessary treatment and services to promote wound healing and prevent new pressure ulcers. Resident #106, who had diagnoses including peripheral vascular disease, diabetes mellitus type 2 with diabetic neuropathy, and heart failure, was ordered to have bilateral heel float boots on 4/29/2024. However, the resident did not receive the left heel float boot until 5/12/2024, despite multiple documentation entries indicating the absence of the left boot and the resident's own statements that they had never received it. This delay in providing the necessary equipment was noted by various staff members, but no immediate action was taken to rectify the situation until 5/12/2024, when the left heel float boot was finally provided from the second-floor storage room. The facility's policies required that staff review the resident care guide before delivering care and document any care not given, reporting it to the nurse. Despite these policies, the nursing staff failed to document accurately that the resident only had one heel float boot and did not take steps to obtain the second boot in a timely manner. The resident's care plan, which included interventions for high-risk skin breakdown, was not followed as ordered, leading to a delay in the provision of the necessary heel float boot. This failure was observed and documented by multiple staff members, including Licensed Practical Nurses and Registered Nurse Unit Managers, who acknowledged the oversight but did not take immediate corrective action. The delay in providing the left heel float boot resulted in the resident developing additional skin issues, including a yellow, sloughing dry scab on the left heel, a small yellow fluid-filled blister on the left great toe, and fresh blood draining from the skin between the toes. The facility's failure to follow the physician's order and provide the necessary equipment in a timely manner contributed to the resident's deteriorating skin condition. Interviews with various staff members, including the Nurse Practitioner and Assistant Director of Nursing, confirmed that the delay in obtaining the heel float boot was a significant issue that should have been addressed promptly to prevent further skin breakdown.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from bed rails prior to their installation, did not review the risks and benefits of bed rails with the resident or their representative, and did not obtain informed consent before installing the bed rails. Specifically, for Resident #40, there was no documented evidence of a bed rail assessment, no informed consent, and no physician orders for the use of bed rails. The resident had diagnoses including polyneuropathy, vascular dementia, and morbid obesity, and was dependent on assistance for various movements and transfers. Despite these needs, the required assessments and consents were not completed before the bed rails were installed and used. The facility's policy required these steps to be taken to ensure the safety and appropriateness of bed rail use, but these procedures were not followed in this case. The resident was observed on multiple occasions with half bed rails up on both sides of the bed, and staff interviews revealed a lack of clarity and adherence to the policy regarding bed rail assessments, documentation, and consent. Staff members, including a Certified Nurse Aide, Registered Nurse Unit Manager, Assistant Director of Nursing, and Director of Physical Therapy, provided inconsistent information about the procedures and documentation required for bed rail use. This inconsistency contributed to the failure to properly assess and document the use of bed rails for Resident #40, leading to a deficiency in the facility's compliance with safety regulations.
Failure to Administer Parkinson's Medication
Penalty
Summary
The facility did not ensure that a resident was free from significant medication errors, specifically failing to administer four consecutive doses of carbidopa-levodopa to a resident with Parkinson's Disease. The resident was admitted with diagnoses including Parkinson's Disease and required the medication to manage symptoms such as tremors and movement difficulties. The medication was not administered on four occasions due to it being unavailable, and the nursing staff failed to notify the medical team as required by the facility's policy. The Medication Administration Record documented that the carbidopa-levodopa was not given on 5/11/2024 at 6:00 PM, and on 5/12/2024 at 8:00 AM, 1:00 PM, and 6:00 PM. Progress notes indicated that the pharmacy was contacted multiple times, but the medication was not delivered in time. The nursing staff, including LPNs and RNs, were aware of the missed doses but did not follow the protocol to notify the medical team, which could have provided alternative instructions or medications. Interviews with the nursing staff and the physician revealed that the medical team was not informed about the missed doses, which could have led to worsening symptoms for the resident. The facility's policy required that the Nurse Manager/Supervisor explore alternative methods for obtaining the medication and notify the medical team if a resident missed a dose. However, this protocol was not followed, resulting in the resident missing critical doses of their Parkinson's Disease medication.
Infection Control Deficiency: Catheter Care
Penalty
Summary
The facility did not ensure an infection prevention and control program was properly maintained, leading to a deficiency in the care of a resident with a urinary catheter. Specifically, the resident's catheter drainage bag was observed resting on the floor without a barrier on multiple occasions during the survey. The facility's policy stated that the drainage bag should never touch the floor, yet observations on several days showed the bag on the bare floor, posing an infection risk. The resident had a history of urinary tract infections and was on long-term antibiotics for prevention, making proper catheter care crucial. Interviews with staff revealed that they were aware of the policy requiring the drainage bag to be covered and off the floor, but failed to consistently implement it. Certified Nurse Aide and Licensed Practical Nurse both acknowledged the infection risk associated with the drainage bag touching the floor. The Registered Nurse Infection Preventionist confirmed that catheter drainage bags should be off the floor and in a privacy bag to prevent contamination. Despite yearly infection control training, the staff did not adhere to the established protocols, resulting in the observed deficiency.
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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.
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Nursing homes near Utica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oneida Center For Rehabilitation And Nursing | 2.9 mi | — | 0 | 0 |
| Charles T Sitrin Health Care Center Inc | 3.2 mi | — | 0 | 0 |
| The Pines At Utica Center For Nursing And Rehab | 3.5 mi | — | 1 | 0 |
| The Grand Rehabilitation And Nursing At Utica | 3.6 mi | — | 0 | 0 |
| Mvhs Rehabilitation And Nursing Center | 4.5 mi | — | 0 | 0 |
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