Masonic Care Community of New York

Inspectors wroteBased on observations and interviews, the facility failed to ensure each resident had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States to include sending and receiving mail and to receive letters, packages, and other materials delivered to the facility for all 296 of 296 residents residing in the facility. Specifically, mail was not delivered to residents promptly to include Saturdays.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intake 2722137) the facility failed to ensure routine and emergency drugs and biologicals were provided to two (2) of two (2) residents (Residents #14 and #247) reviewed. Specifically, three (3) doses of Resident #14's alprazolam (used to treat anxiety) were not administered due to the medication not being available from pharmacy; and Resident #247 was not administered five different medications (diltiazem, methimazole, nadolol, hydralazine, and lisinopril) between February 2026 and March 2026 due to the medications not being available from pharmacy.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care and the right to participate in social and community activities for two (2) of two (2) residents (Residents #133 and #281) reviewed and for 13 of 13 anonymous residents present at the resident group meeting. Specifically, Residents #133 and #281 and 13 anonymous residents present at the resident group meeting expressed their displeasure with not being able to go outside on facility grounds without supervision.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for five (5) of eleven (11) medication carts ([NAME], [NAME], Westchester, Manhattan, and Placid Neighborhoods) reviewed. Specifically, the Placid Neighborhood narcotic box contained 30 morphine (opiate) syringes and 57 lorazepam (anti-anxiety) syringes belonging to a deceased resident; the Manhattan Neighborhood medication cart contained one (1) morphine syringe without a resident's name on the label; the Westchester Neighborhood medication cart contained three (3) pre-poured medication cups; the [NAME] Neighborhood medication cart contained expired eye drops and a nasal spray that was not labeled with an open date; and the [NAME] Neighborhood medication cart had expired and undated nasal sprays.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) test trays (the 03/30/2026 lunch meal and the 04/01/2026 lunch meal), 13 of 13 anonymous residents during a resident meeting, and one (1) resident (Resident #11) reviewed. Specifically, food was not served at palatable and appetizing temperatures during lunch meals on 03/30/2026 and 04/01/2026; 13 anonymous residents during a resident council and Resident #11 stated the food was cold. Additionally, multiple meal trays were observed sitting for 30-60 minutes prior to resident consumption; and the facility did not have a procedure in place to ensure food was properly re-heated on the resident units to the required temperatures.

Inspectors wroteBased on observations and interviews, the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one (1) of one (1) main kitchen. Specifically, the main kitchen had unlabeled/undated prepared and leftover food; and dishwashing machine temperatures were not monitored routinely.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life for three (3) of three (3) residents (Residents #30, #190, and #288) reviewed. Specifically, staff stood over Residents #30, #190, and #288 while assisting them with feeding.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #299) reviewed. Specifically, Resident #299 had a large bottle of acetaminophen (pain reliever), a tube of Neosporin (antibiotic ointment), a bottle of antacids, loperamide gel capsule (antidiarrhea medication), and a medication cup with several different pills in their room. There was no documented evidence of assessments and/or physician orders for the resident to safely self-administer medications.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for two (2) of two (2) residents (Residents #77 and #16) reviewed. Specifically, Resident #77's person-centered comprehensive care plan did not include the use of oxygen; and Resident #16's person-centered comprehensive care plan did not include the use of psychotropic (used to treat mood/ behaviors) medications.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and promote healing of pressure ulcers for two (2) of five (5) residents (Residents #16 and #304) reviewed. Specifically, Resident #16's and Resident #304's pressure relieving interventions were not implemented as planned; and Resident #16 had conflicting wound care orders signed off as completed and wound care recommendations by the wound care provider were not implemented.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #4) reviewed. Specifically, Resident #4's hung tube feeding was not dated during multiple observations.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #312) reviewed. Specifically, Food Service Worker #2 entered Resident #312's room, who was on enteric precautions (measures to prevent the spread of pathogens transmitted through feces), without donning personal protective equipment or performing hand hygiene upon exit.

Inspectors wroteBased on observations, record review, and interviews conducted during the abbreviated (iQIES incident #2607732) survey, the facility failed to ensure residents received adequate supervision to prevent accidents for two (2) of five (5,) residents (Residents #1 and #3) reviewed for accidents. Specifically, Resident #1 was at risk for elopement and exited the facility undetected on 09/03/2025 and 10/25/2025; and Resident #3 left the facility grounds on 07/25/2025, undetected, on their motorized scooter and was found two (2) hours later at a fast-food restaurant approximately four (4) miles away. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #1 and #3 and placed all 59 residents with exit-seeking behaviors at risk for serious harm, serious injury, serious impairment, or death. [...]

Inspectors wroteBased on record review and interviews during the recertification survey conducted 5/13/2024 -5/17/2024, 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.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 2 of 6 residents (Residents #96 and #155) reviewed. Specifically, Resident #96 was observed with prescribed eye drops and nasal sprays at their bedside and there was no documented evidence the resident had an assessment or order to self-administer the medications. Additionally, Resident #155 was observed with prescribed eye drops at their bedside and did not have an assessment or order to self-administer the medications.

Inspectors wroteBased on record review and interview during the recertification survey conducted 5/13/2024 - 5/17/2024, the facility did not ensure a comprehensive, person-centered care plan was developed and implemented to meet a resident's medical and nursing needs for 1 of 5 residents (Resident #170) reviewed. Specifically, Resident #170 did not have a comprehensive, person-centered care plan that included anticoagulant (blood thinner) therapy.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/13/2024-5/17/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #106) reviewed. Specifically, Resident #106 was ordered to have bilateral heel float boots on 4/29/2024 and did not receive the left boot until 5/12/2024. The undated facility policy Skin Assessment for Admissions or Change of Condition: Skin Prevention Protocol documented there were three categories for a resident's skin that required physician orders and care plan interventions: high risk, moderate risk, and a skin tear. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, or obtain informed consent prior to the installation of bed rails for 1 of 1 residents (Resident #40) reviewed. Specifically, for Resident #40, there was no documented evidence of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 5/13/2024 - 5/17/2024 the facility did not ensure that residents were free of any significant medication errors for 1 of 1 residents (Resident #28) reviewed. Specifically, Resident #28 did not receive four consecutive doses of carbidopa - levodopa (brand name Rytary, used to treat Parkinson's Disease) on 5/11/2024 -5/12/2024 as physician ordered.

Inspectors wroteBased on observation and interview during the recertification surveys conducted 5/13/2024-5/17/2024 the facility did not ensure an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment was established and maintained to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #15) reviewed. Specifically, Resident #15 had a urinary catheter bag resting on the floor without a barrier for multiple days of survey.

Inspectors wroteBased on observation and interview during the recertification survey conducted 12/1/21-12/7/21, the facility failed to ensure each resident received drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 7 of 16 residents reviewed. Specifically, Residents #3, 53, 91, 92, 185, 232, and 258 on the Saranac Unit were not offered hot beverages or an equivalent substitution. This is evidenced by: The facility policy Diet and Menus Food Preferences dated 10/1/2017, documented providing preferred food and fluids enhanced and maintained the resident's quality of life and nutritional status. The Residence Aide (RA) job description revised 3/2008 documented the RA preformed a variety of activities and services necessary to meet the needs and comforts of the residents including meal service. [...]

Inspectors wroteBased on observation and interview during the recertification survey conducted 12/1/21-12/7/21, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for 2 of 18 nursing units (Buffalo and Amherst) and 1 of 1 (Resident #88) resident reviewed. Specifically, the Buffalo Unit dining room had a missing section of flooring material and there were sections of floor in Buffalo Unit resident room D101 and in Amherst Unit resident room D201 that were uneven and potential tripping hazards. Resident #88 was observed on multiple days in a soiled Broda (type of geriatric positioning chair) chair.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 12/1/21 through 12/7/21, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents (Resident #187) reviewed. Specifically, Resident #187 was care planned for the use of an extra-large (XL) mechanical lift sling (used when transferring a resident from surface to surface) and staff transferred the resident using a large size sling. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00257278) surveys conducted from 12/1/21-12/7/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident # 164 and #78) reviewed. Specifically, Resident #164 had a fall from a mechanical lift and a complete and thorough investigation was not completed.

Inspectors wroteBased on observation and interview during the recertification and abbreviated surveys (NY00275746) conducted 12/1/21-12/7/21, the facility failed to post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent place readily accessible to residents and visitors for 5 of 5 days reviewed. Specifically, the facility did not post the most current, daily resident census and nurse staffing information as required.

Inspectors wroteBased on record review and interview during the recertification survey conducted from 12/1/21- 12/7/21, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents reviewed (Resident #240). Specifically, Resident #240's blood pressure medication was administered, and the resident's blood pressure was not obtained prior to administration per physician ordered parameters.

Inspectors wroteBased on observation and interview during the recertification survey conducted 12/1/21-12/8/21 the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 9 medication carts (Forestport and [NAME] households) reviewed. Specifically, the Forestport medication cart had stock medications that were expired or outdated beyond the manufacturer expiration date and the [NAME] medication cart had resident insulin pens that were not labeled with an opened date.

Inspectors wroteBased on record review, observation and interview during the recertification survey conducted from 12/1/21-12/7/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen and two resident unit kitchenettes (Buffalo and [NAME] Units) reviewed. Specifically, there were dented cans of food in the main kitchen dry storage room; and the Buffalo Unit and [NAME] Unit kitchenette refrigerators contained undated and unlabeled foods