Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Tolstoy Foundation Rehabilitation And Nrsg Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not initiate or update care plans for a resident at high risk for falls who later experienced a fall, and for two residents involved in a physical altercation, despite existing care plans for abuse. Staff interviews confirmed that care plans were not revised to reflect these incidents or to implement new interventions as required.
A resident with cognitive impairment physically struck their roommate, who had multiple medical conditions, during a verbal altercation. Both residents had care plans addressing abuse risk and cognitive issues, but the incident still occurred, indicating a failure to protect residents from abuse as required by facility policy.
A resident with moderate cognitive impairment and mobility limitations was found with floor mats propped upright against their bed, secured by night tables, preventing movement out of bed. This setup, implemented by a CNA who believed it would prevent falls, constituted a physical restraint without a physician order or documented medical need, contrary to facility policy. Staff interviews confirmed the mats should have been placed flat on the floor, and the incident was identified during a federal survey.
The facility did not promptly report suspected abuse incidents or submit required investigation results to the state health department for two residents. In one case, a resident was physically restrained with floor mats and furniture, and in another, a resident reported being struck by a roommate. Both incidents were not reported or concluded within the required timeframes.
A resident with significant medical needs experienced a witnessed fall while attempting an independent transfer, despite prior instructions to seek assistance. The required accident/incident report was incomplete, lacking an investigative summary, staff statements, and documentation of family notification, contrary to facility policy. The RN involved cited short staffing and multiple duties as reasons for not completing the investigation.
A resident with severe cognitive impairment and multiple pressure ulcers did not have their care plan updated to reflect the development and progression of a sacral/buttocks pressure ulcer. The care plan only addressed a heel ulcer, omitting documentation of the additional wound, its measurements, treatments, and physician findings, despite regular wound care assessments and communication. Nursing leadership confirmed that care plan updates were expected but not completed as required.
A resident admitted with significant comorbidities was found to have a Stage 2 pressure ulcer during the admission skin check, but the physician was not notified and no treatment orders were obtained, contrary to facility policy. Nursing staff and the DON confirmed this oversight, resulting in a failure to provide necessary care and services for the pressure ulcer.
A resident with severe cognitive impairment was reportedly abused by a CNA, who was witnessed punching the resident in the head. Despite the lack of physical evidence and the resident's inability to communicate, the facility terminated the CNA to ensure safety. The incident highlighted a deficiency in the facility's abuse prevention measures, as there was no documented risk for abuse care plan for the resident.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with severe cognitive impairment. A visitor reported seeing a CNA physically assault the resident, but the facility did not obtain a written statement from the CNA or assess other residents under their care. Despite assessments by medical staff, the investigation lacked comprehensive documentation, leading to an unsubstantiated conclusion.
The facility did not complete annual performance appraisals for its Certified Nurse Aides, as required. During a survey, it was discovered that appraisals were not documented for five aides, with the most recent appraisals dating back several years. The Director of Human Resources confirmed that the Nursing Department had not completed the necessary appraisals, despite a recent initiative to update them.
The facility failed to maintain an effective infection control program, with deficiencies in linen handling, water management, and contact precautions for a resident with C. Diff. Clean linens were transported uncovered, and staff did not practice proper hand hygiene. The facility lacked a current Water Management Plan, and staff were not educated on Legionella prevention. Additionally, appropriate contact precautions were not implemented for a resident with C. Diff, with staff observed not wearing required PPE and inadequate signage and PPE availability.
The facility did not ensure proper documentation of COVID-19 vaccination status for three staff members, as identified during a recertification survey. The Assistant DON acknowledged efforts to encourage vaccination, but many staff were resistant, and records from HR did not show screening or offering of the vaccine.
A resident developed an unstageable sacral pressure ulcer, but the facility failed to notify the resident's family as required by the care plan. Despite documentation of the ulcer and treatment recommendations, there was no record of family notification, which was confirmed by the Assistant Director of Nursing.
A resident with multiple diagnoses reported an incident of sexual abuse during a shower to the facility Administrator. The Director of Nursing was informed and began an investigation but failed to report the allegation to the New York State Department of Health within the required two-hour timeframe, mistakenly believing they had 24 hours to do so.
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet needs in ADLs and specific medical conditions. Interviews revealed confusion among staff regarding responsibility for care plan initiation and updates, contributing to the deficiencies identified.
The facility did not ensure that certified nurse aides received the required training in dementia care and abuse prevention. Documentation for two nurse aides was missing, and the MDS Nurse/Staff Educator confirmed the inability to locate the necessary records.
Two residents with severe cognitive impairments were not provided a dignified dining experience. A CNA stood over one resident while assisting with meals, contrary to facility policy, and another resident was inappropriately referred to as a "feeder". Despite being advised to sit, a CNA stood over the second resident during meals, citing a lack of chairs.
A facility failed to ensure a resident's right to formulate advance directives, as there was no physician's order for such directives. The resident, with moderately impaired cognition and serious medical conditions, had a MOLST form signed by the resident but not by a physician, leading to conflicting instructions regarding life-sustaining treatments. Staff interviews revealed a lack of awareness and proper documentation of the resident's advance directives.
The facility failed to provide written notification to two residents and their representatives about hospital transfers, and did not notify the Ombudsman. Both residents had intact cognition and were transferred without documented notice. The Director of Social Work confirmed the absence of required notices in the residents' files.
The facility failed to notify two residents or their representatives in writing about the bed hold policy during hospital transfers. Despite having intact cognition, these residents, with conditions such as diabetes and hypertension, were transferred without receiving the required notification. The Director of Social Work confirmed the absence of documentation, indicating that the responsibility lay with the nurse on duty after hours and an administrative staff person during business hours.
A resident's MDS 3.0 admission assessment was not completed within the required 14 days, as it was submitted late by the facility's MDS/Discharge Planning Coordinator. The resident, with conditions including diabetes and dementia, was admitted, but the assessment was delayed beyond the mandated timeframe.
The facility failed to ensure that PASRR assessments were signed and included digital IDs for three residents before admission. Interviews revealed confusion over responsibility for verifying these documents, with the Director of Admissions or Outreach Coordinator expected to ensure completion.
A newly admitted resident with an unstageable pressure ulcer and other conditions did not have a baseline care plan developed within 48 hours, as required by facility policy and CMS regulations. The omission was due to staffing issues, with the RN on duty unable to complete the plan due to time constraints.
The facility's designated Infection Preventionist, the Assistant DON, did not complete the required specialized training in infection prevention and control before assuming the role. The IP had outstanding training modules, including Antibiotic Stewardship and Occupational Health, and only completed the necessary training after the survey began.
Failure to Develop and Update Comprehensive Care Plans After Clinical Events
Penalty
Summary
A deficiency was identified in the facility's development and implementation of comprehensive, person-centered care plans for residents. Specifically, for three residents reviewed, the facility failed to initiate or update care plans in response to significant clinical findings and incidents. One resident, admitted with multiple diagnoses including diabetes mellitus and end stage renal disease, was assessed as high risk for falls upon admission, but there was no documented evidence that a fall risk care plan was initiated. This resident later experienced a fall when attempting to self-transfer from bed to chair. Another incident involved two residents who were roommates. One resident reported being struck by the other following a verbal disagreement. Although both residents had existing care plans noting potential for abuse, there was no documentation that these care plans were updated to reflect the incident or that new interventions were implemented. The resident who was struck was relocated for safety, but the care plan documentation did not reflect this event or any subsequent changes in interventions. Interviews with facility staff, including registered nurses and directors of nursing, confirmed that care plans should be initiated or updated when assessments trigger specific care areas or after incidents occur. However, in these cases, the required updates and documentation were not completed as per facility policy and regulatory requirements. The lack of timely and appropriate care plan development and revision was observed through record reviews and staff interviews during the survey.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident reported being physically struck by their roommate during a verbal altercation. The incident involved one resident propelling their wheelchair to the other side of the shared room and striking the other resident twice on the left chest and neck area. Documentation showed that both residents had care plans addressing potential for abuse and impaired cognitive function, with interventions such as monitoring behaviors and assessing needs. Despite these plans, the altercation occurred, and the incident was reported as required by facility policy. The resident who was struck had diagnoses including atrial fibrillation, hypotension, and cardiomegaly, and was cognitively intact but required assistance with daily activities. The other resident had acute kidney failure, hypotension, hyperlipidemia, and moderate cognitive impairment, with a history of impaired thought processes. The facility's policies required immediate reporting and individualized monitoring for residents at risk of altercations, but the event still took place, indicating a failure to protect the resident from abuse as required.
Improper Use of Physical Restraint with Upright Floor Mats
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and multiple medical diagnoses, including metabolic encephalopathy and muscle weakness, was found in bed with floor mats propped upright against the bed and held in place by two wooden night tables. This arrangement prevented the resident from moving out of bed, effectively acting as a physical restraint. The resident required moderate assistance for bed mobility and was dependent for transfers and toileting, with no documented physician order for restraints or side rails in use. The facility's Restraint-Free Environment policy states that restraints are only to be used for the safety and well-being of residents and only after all alternatives have been tried unsuccessfully, and never for staff convenience or fall prevention. Despite this, a Certified Nurse Aide was responsible for placing the mats in this manner, believing it would prevent the resident from rolling out of bed and ensure safety. The incident was discovered during a federal survey, and interviews revealed that the mats were intentionally positioned upright and secured, rather than being placed flat on the floor as intended. Further investigation showed that the resident was bedridden, required a two-person assist for transfers, and had difficulty bearing weight. Staff interviews confirmed that the mats should not have been positioned upright, as this constituted a restraint. There was no evidence of physical harm to the resident, but the use of the mats in this way was not in accordance with facility policy or regulatory requirements, and there was no documented medical need or order for such a restraint.
Failure to Timely Report Suspected Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse and the results of related investigations to the New York State Department of Health for two out of three residents reviewed for abuse. In the first instance, a resident with diagnoses including metabolic encephalopathy, depression, and muscle weakness was found in bed with floor mats propped up against the bed and held in place by two wooden night tables, preventing the resident from exiting. The responsible certified nurse aide believed this would prevent the resident from rolling out of bed. Although the facility's investigation did not substantiate a breach in quality of care, the use of mats in this manner constituted a physical restraint. The incident was not reported to the Department of Health until the following day, and the 5-day investigative conclusion was not submitted until over a year later. In the second instance, a cognitively intact resident reported being struck twice on the chest/neck area by their roommate following a verbal disagreement. The incident was unwitnessed, and a full body and skin assessment revealed no injuries. However, the 5-day investigative conclusion for this incident was not submitted to the Department of Health until six days after the event. The facility's policy required immediate reporting of suspected abuse and submission of investigative results within five business days, but these requirements were not met in either case.
Incomplete Investigation Following Resident Fall
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following a fall involving a resident with multiple diagnoses, including diabetes mellitus, end stage renal disease, and benign neoplasm of the duodenum. The resident, who was cognitively intact but required maximal assistance with transfers and had upper extremity impairments, experienced a witnessed fall while attempting to transfer independently from bed to chair, despite prior instructions to seek assistance. The accident/incident report for this event was incomplete, lacking an investigative summary and staff statements, and there was no documentation that the resident's representative was notified of the fall. According to facility policy, an investigation should be initiated for any outward event, such as a fall, and should include staff interviews and statements from those present during the incident. However, the Registered Nurse who witnessed the fall did not complete the required incident report or obtain statements from Certified Nurse Aides, citing short staffing and multiple responsibilities as reasons. The only documentation provided was a progress note, and the Assistant Director of Nursing confirmed that only the top portion of the report was completed, with no explanation for the omission.
Failure to Update Care Plan for Pressure Ulcer Progression
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed, updated, and revised for one resident with significant skin integrity issues. Specifically, the resident, who had severe cognitive impairment, hemiparesis, and was dependent for all care, developed a Stage 2 pressure ulcer to the sacrum and bilateral buttocks while in the facility, in addition to a Stage 4 pressure ulcer present on admission. The care plan in place only addressed a Stage 4 pressure ulcer on the left heel and did not include documentation of the sacral/buttocks ulcer, its measurements, treatments ordered, or updates on wound progression and physician findings, despite these being reported to the facility. Interviews with nursing leadership revealed that wound care physician notes were received weekly, and it was the expectation that nursing staff would update the care plan with any changes in wound status or treatment orders. However, the care plan was not updated to reflect the presence or progression of the sacral/buttocks ulcer, nor were physician findings consistently documented. The responsibility for updating care plans was described as belonging to unit managers, but this was not carried out as required by facility policy and regulatory standards.
Failure to Notify Physician and Obtain Treatment Orders for Pressure Ulcer on Admission
Penalty
Summary
A deficiency was identified when a resident admitted with multiple diagnoses, including diabetes mellitus and end stage renal disease, was found to have a Stage 2 pressure ulcer in the intergluteal medial cleft during the admission skin check. The ulcer measured 5 cm x 4 cm, showed no signs of infection, and the resident denied pain. Despite facility policy requiring that the physician be notified of any wounds or pressure ulcers at the time of assessment and that treatment orders be obtained, there was no documented evidence that the physician was informed of the pressure ulcer or that any treatment orders were obtained upon admission. Interviews with nursing staff and the Director of Nursing confirmed that the standard protocol was not followed in this case. The responsible RN stated that they did not receive a treatment order from the physician for the pressure injury, describing this as an oversight. The DON further clarified that while there are standing orders for different wound stages, the physician must be notified to determine the appropriate protocol. The lack of physician notification and absence of treatment orders for the pressure ulcer constituted a failure to provide necessary care and services consistent with professional standards of practice.
Resident Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident where a Certified Nurse Assistant (CNA) was reported to have physically abused a resident. A visitor witnessed the CNA punching the resident in the head while in the resident's room. The resident, who had severe cognitive impairment due to dementia, was unable to communicate details of the incident. The facility's abuse policy, revised in January 2024, mandates that all residents be free from abuse, including physical abuse such as hitting and slapping. The resident involved in the incident had a documented history of severe cognitive impairment and required maximal assistance with daily activities. Despite this, there was no documented evidence of a risk for abuse care plan in place for the resident. The facility conducted an investigation following the report of abuse, but was unable to substantiate the allegation due to the lack of physical evidence and the resident's inability to articulate the incident. However, the facility decided to terminate the CNA involved, citing the severity of the allegations and the need to ensure resident safety. Interviews with facility staff, including the Administrator and Medical Director, revealed that the CNA left the facility shortly after the incident and did not provide a statement. The Medical Director and Attending Physician examined the resident and found no physical injuries. The Administrator acknowledged the credibility of the witness and expressed belief that the CNA did abuse the resident. Despite the lack of physical evidence, the facility took the precautionary step of terminating the CNA to maintain a high standard of care and safety.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving a resident with severe cognitive impairment. A visitor reported witnessing a Certified Nurse Assistant (CNA) physically assaulting the resident by punching them in the head. Despite the severity of the allegation, the facility did not obtain a written statement from the accused CNA, nor did they interview or assess other residents under the CNA's care to rule out further abuse. The resident involved in the incident had a history of Alzheimer's, diabetes, and muscle weakness, and was severely cognitively impaired, as indicated by a Brief Interview for Mental Status score of 0. The facility's investigation included assessments by the Medical Director, nursing supervisor, and Director of Nursing, but there was no documented evidence of a comprehensive medical assessment by a physician or nurse practitioner. The investigation concluded without substantiating the abuse allegation, despite a credible witness account, due to the lack of physical evidence and the resident's inability to communicate details of the incident. Interviews with facility staff revealed inconsistencies and gaps in the documentation of the incident. The Administrator acknowledged the credibility of the witness but noted the absence of a statement from the CNA. Licensed Practical Nurses involved in the post-incident care of the resident did not document their assessments, and the Director of Nursing admitted to not documenting the skin check. The facility's failure to follow its abuse policy and ensure comprehensive documentation and investigation of the incident led to the deficiency.
Deficiency in Certified Nurse Aide Performance Appraisals
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months, as required. During a recertification survey conducted from May 28, 2024, to June 4, 2024, it was found that performance appraisals were not documented for five certified nurse aides. Interviews with the Director of Human Resources revealed that a project to update performance appraisals had begun about a month prior, but the Nursing Department had not completed appraisals for any nurse aides. Upon request, the Director of Human Resources was unable to provide recent performance appraisals for the selected staff members, with the most recent appraisals dating back several years, and one staff member having no documentation of any appraisal.
Infection Control Deficiencies in Linen Handling, Water Management, and C. Diff Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the recertification survey. Firstly, clean linens were transported throughout the facility without being covered, which is against infection control protocols. Maintenance staff were unaware of the requirement to cover linen carts, despite the Director of Maintenance acknowledging that staff had been previously instructed to do so. Additionally, a Certified Nurse Aide was observed handling dirty linens and then making a resident's bed without changing gloves, indicating a lapse in hand hygiene practices. The facility also lacked a current Water Management Plan, which is essential for preventing Legionella infections. The Director of Maintenance was unable to articulate a plan or next steps in the event of positive test results for Legionella, and the Assistant Director of Nursing admitted that the Director of Maintenance had not been educated on the Legionella Plan upon hiring. This lack of a comprehensive water management strategy poses a risk of Legionella growth and spread within the facility's water systems. Furthermore, the facility failed to implement appropriate contact precautions for a resident with a confirmed Clostridium Difficile infection. Despite a physician's order for contact isolation, the resident was observed outside their room without proper signage or personal protective equipment (PPE) available for staff. Multiple staff members, including a Certified Nurse Aide and the Director of Rehabilitation, were observed not wearing the required PPE while interacting with the resident. The Director of Nursing acknowledged the oversight in signage and PPE availability, and the Assistant Director of Nursing was unsure why the contact isolation sign was not posted, despite attending daily clinical meetings discussing residents on precautions.
Deficiency in COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to ensure that each staff member was screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks, and potential side effects associated with the vaccine. This deficiency was identified during a recertification survey conducted from May 28 to June 4, 2024, where it was found that there was no documented evidence of immunization records for three out of ten staff members reviewed for COVID-19 vaccines. Specifically, the facility lacked documentation of screening, education offering, or current COVID-19 vaccination status for these staff members. During an interview, the Assistant Director of Nursing acknowledged the issue, stating that efforts had been made to encourage staff to receive the COVID-19 vaccine, but many employees were resistant. They also mentioned that vaccine records were obtained from Human Resources and reviewed upon hire, but they were unaware that the records for these employees did not show they were screened, offered, or given an opportunity to decline the COVID-19 vaccine.
Failure to Notify Family of Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident's representative was immediately notified of the development of an unstageable sacral pressure ulcer. This deficiency was identified during a recertification and abbreviated survey, where it was found that the representative of a resident with a history of urinary tract infection, metabolic encephalopathy, and brain tumor was not informed about the pressure ulcer. The resident, who was admitted with modified independence for decision-making and required assistance with daily living activities, did not have a pressure ulcer documented upon admission. The care plan for the resident, which included an intervention to inform the resident or family of any new skin breakdown, was not followed. On 12/5/2022, a nurse's note documented a sheer injury to the sacrum, and a subsequent physician consultant wound note on 12/7/2022 described the ulcer as unstageable. Despite these developments, there was no documentation that the family was notified of the pressure ulcer. The Assistant Director of Nursing confirmed the lack of documentation regarding family notification.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the New York State Department of Health within the required two-hour timeframe. The incident involved a resident with diagnoses including amyotrophic lateral sclerosis, cerebrovascular accident, dementia, reflux, and hypertension, who had intact cognition and was dependent on staff for activities of daily living. The resident reported to the facility Administrator that during a previous shower, three women forcibly removed their clothes, dragged them down the hallway naked, and one of the women squeezed their genitals multiple times. This allegation was made known to the Administrator on 5/6/24. The Director of Nursing was informed of the allegation on the same day by the Administrator and began an investigation by reviewing the previous three showers and obtaining staff statements. However, the report to the New York State Department of Health was not submitted until the following day, 5/7/24, at 13:39 PM. The Director of Nursing admitted to not being aware of the two-hour reporting requirement, mistakenly believing they had 24 hours to report the incident. This oversight resulted in a failure to comply with the mandated reporting timeframe for allegations of abuse.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for four residents, leading to deficiencies in meeting their needs. Resident #42, who required varying levels of assistance with activities of daily living (ADLs), did not have an active care plan outlining these needs. Interviews with staff revealed confusion and lack of clarity regarding responsibility for initiating and updating care plans, with multiple staff members pointing to others as responsible for the oversight. Resident #229, admitted with a seizure disorder and other conditions, also lacked a care plan addressing ADLs and seizure management. Staff interviews indicated that care plans should be initiated upon admission, but there was a disconnect between policy and practice, as evidenced by the absence of a care plan for this resident. The Director of Nursing acknowledged the expectation for care plans to address all resident needs, including specific diagnoses and medication management. Resident #70, who experienced an alleged abuse incident, did not have a care plan addressing ADLs or abuse prevention. Despite the incident being reported, there was no follow-up in terms of care planning to prevent future occurrences or address the resident's needs. Similarly, Resident #327, who required assistance with ADLs, did not have a documented care plan, and family members reported inadequate care. Staff interviews highlighted a lack of awareness and responsibility for ensuring care plans were in place, contributing to the deficiencies identified.
Deficiency in Nurse Aide Training Documentation
Penalty
Summary
The facility failed to ensure that certified nurse aides received the required 12 hours of training and annual in-services on dementia care management and resident abuse prevention. During a recertification survey, it was found that the facility could not provide evidence of mandatory training for two of the five nurse aides reviewed. Specifically, the training documentation for Staff #8 and Staff #11 was missing. The MDS Nurse/Staff Educator, responsible for maintaining these records, confirmed the inability to locate the 'Mandatory In-Service Sign-Off Sheets' for these staff members.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents during a recertification survey. Resident #328, who has severe cognitive impairment and requires extensive assistance with eating due to conditions such as dementia and Parkinson's disease, was observed being assisted with their meal by a certified nurse aide who stood over them instead of sitting. This action was contrary to the facility's feeding program policy, which aims to promote residents' self-esteem and well-being. The staff member acknowledged knowing the correct protocol but did not follow it during the observation. Similarly, Resident #46, who also has severe cognitive impairment and requires moderate assistance with eating, was addressed inappropriately as a "feeder" by a certified nurse aide. Additionally, this resident was fed by another aide who stood over them during meals, despite being advised to sit by a licensed practical nurse. The aide cited a lack of available chairs as the reason for standing. These actions were inconsistent with the facility's policy and compromised the residents' right to a dignified dining experience.
Failure to Ensure Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate advance directives, as evidenced by the lack of a physician's order for such directives. Resident #334, who was admitted with diagnoses including anemia, malignant neoplasm of the prostate, and occlusion and stenosis of precerebral arteries, had moderately impaired cognition. During a record review, it was found that there were no advance directives in the electronic medical records or a hard copy of Medical Orders for Life Sustaining Treatment (MOLST) for the resident. Interviews with staff revealed that in the event of a medical emergency, the facility would contact the family and physician and send the resident out for evaluation. A review of the resident's MOLST form showed it was signed by the resident but not by a physician, and it included conflicting instructions regarding CPR and other life-sustaining treatments. A physician's order indicated the resident was Full Code, but there was no evidence the physician was aware of the resident's other advance directives. The Director of Social Services acknowledged the need for a physician's signature on the MOLST form.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as well as failing to notify the Ombudsman, for two residents. Resident #18, who had diagnoses including diabetes mellitus, chronic kidney disease stage 3, and protein calorie malnutrition, was transferred to the hospital on 3/19/24. Despite having intact cognition, there was no documentation that Resident #18 or their representative received a written notice of the transfer, nor was there evidence that the Ombudsman was notified. The Director of Social Work confirmed that no notice of transfer was found in the resident's file, and it was noted that the responsibility for completing the form varied depending on the time of transfer. Similarly, Resident #24, with diagnoses including diabetes mellitus, hemiplegia and hemiparesis affecting the right side, and hypertension, was transferred to the hospital on 4/1/24. The resident also had intact cognition, yet there was no documentation of written notification to the resident or their representative, nor was there a record of notification to the Ombudsman. The Director of Social Work acknowledged the absence of the notice in the resident's file. The facility's policy, revised in February 2018, mandates issuing a valid notice of discharge/transfer to residents, their representatives, and the Ombudsman, which was not adhered to in these cases.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during hospital transfers, as required by regulations. This deficiency was identified during a recertification survey conducted from May 28, 2024, to June 4, 2024, affecting two out of three residents reviewed for hospitalization. Specifically, the facility could not provide evidence of written notification for Residents #18 and #24, who were transferred to the hospital with the anticipation of return. Resident #18, who had diagnoses including diabetes mellitus, chronic kidney disease stage 3, and protein-calorie malnutrition, was transferred to the hospital on March 19, 2024. Despite having intact cognition, there was no documentation that the resident or their representative received a written notice of the bed hold policy. Similarly, Resident #24, with diagnoses including diabetes mellitus, hemiplegia, and hypertension, was transferred to the hospital on April 1, 2024, and also did not receive the required notification. Interviews with the Director of Social Work confirmed the absence of these notifications, attributing the responsibility to the nurse on duty after hours and an administrative staff person during business hours.
Delayed MDS Assessment for Resident
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) 3.0 comprehensive assessment for a resident in a timely manner, as required by federal and state regulations. Specifically, the MDS admission assessment for a resident with diagnoses including diabetes, hypertension, and dementia was not completed within the mandated 14 calendar days from the date of admission. The resident was admitted on January 7, 2024, and the assessment was scheduled for January 9, 2024, but was not completed until January 24, 2024, exceeding the required timeframe. The facility's policy, revised in January 2024, mandates that the Resident Assessment Instrument (RAI) be used to ensure optimal care planning and quality of care, with the assessment coordinator responsible for timely completion. During an interview, the MDS/Discharge Planning Coordinator acknowledged the delay, stating that the admission assessment was submitted late. This deficiency was identified during a recertification survey conducted from May 28, 2024, through June 4, 2024.
Deficiency in PASRR Documentation
Penalty
Summary
The facility failed to ensure that each resident's Pre-Admission Screening and Resident Review (PASRR) assessment was signed and included the required digital ID prior to admission. This deficiency was identified during a recertification survey, where it was found that three out of twenty-five residents reviewed did not have the necessary documentation. Specifically, the electronic medical records for these residents lacked evidence of a signed and digitally identified PASRR assessment, which is required to assess for mental illness, dementia, and intellectual disabilities. Interviews conducted during the survey revealed a lack of clarity regarding responsibility for ensuring the completion and documentation of PASRR assessments. The Director of Social Work was unaware of who was responsible for verifying the signatures and digital IDs. The facility Administrator indicated that the Director of Admissions or the Outreach Coordinator should ensure the completion of these assessments before admission. However, the Outreach Coordinator, who was temporarily filling in for the Director of Admissions, confirmed that they were responsible for this task during the interim period.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours of admission, as required by their policy and CMS regulations. The resident, who was admitted with diagnoses including an unstageable pressure ulcer, local skin infection, and darkened skin, did not have a baseline care plan documented in their electronic record. This omission was identified during a recertification survey. Interviews with facility staff revealed that the baseline care plan was not completed due to staffing issues. The Assistant Director of Nursing acknowledged the absence of the care plan and stated that it should have been completed by a Registered Nurse within the first 48 hours. A Registered Nurse Supervisor admitted to not completing the care plan, citing a lack of time as they were the only RN on the floor at the time.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), who was the Assistant Director of Nursing, completed specialized training in infection prevention and control before assuming the role. During the recertification survey, it was found that the IP had not completed the necessary training modules, including those on Antibiotic Stewardship and Occupational Health, until after the survey had commenced. The IP had been in the role since March 2024 but only completed the required Centers for Disease Control training course and presented the certificate on 5/29/24, after the survey began on 5/28/24.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 755 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Valley Cottage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nyack Ridge Rehabilitation And Nursing Center | 0.8 mi | — | 1 | 0 |
| Northern Manor Geriatric Center Inc | 4.3 mi | — | 0 | 0 |
| Tarrytown Hall Care Center | 4.7 mi | — | 0 | 0 |
| Cedar Manor Nursing & Rehabilitation Center | 4.8 mi | — | 2 | 0 |
| Briarcliff Manor Center For Rehab And Nursing Care | 4.9 mi | — | 0 | 0 |
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