New Paltz Center For Rehabilitation And Nursing
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
documented oxycodone 5 MG 1 (one) tablet every six (6) hours as needed for pain of 6-10.The narcotic control sheets revealed oxycodone 5 mg tablets were signed out 22 times from 10/19/2025 to 10/28/2025.
There was no documented evidence in the medication administration record that oxycodone 5 mg was administered from 10/19/2025 to 10/28/2025 and that pain was assessed prior to and after the administration of oxycodone11 out of 22 times During an interview on 10/28/2025 at 12:00 PM Licensed Practical Nurse #2 stated documentation on Resident #1's medication administration record was not complete therefore pain assessment was not always done prior to and after the administration of the oxycodone. During an interview on 10/29/2025 at 1:11 PM Licensed Practical Nurse #3 stated Resident #1 was alert, oriented, and demanded as-needed medications. They stated the narcotic book was usually reviewed to determine the last administration time instead of checking the medication administration record.
They stated pain medication that was administered to Resident #1 as requested was not always documented as given on the medication administration record therefore, pain evaluation was not done prior to and after the administration of the oxycodone. During a telephone interview on 10/30/2025 at 11:16 AM Licensed Practical Nurse #5 stated when they signed in the Medication Administration Record that they administered as needed pain medication, the pain evaluation tool automatically populated on the medication administration record for evaluation prior to and after administration. During an interview on October 29, 2025, at 2:00 PM the Director of Nursing stated pain assessment would be documented in the Medication Administration Record when the medication was signed as administered. They stated pain assessment would not be triggered if as needed pain medications were not documented as having been administered. They further stated there was not documented evidence of consistent pain assessment done
before and after Resident #1 and Resident #3 received pain medication.During a follow-up interview on 11/05/2025 at 9:30 AM, Licensed Practical Nurse #3 stated Resident #1 consistently reported a pain level of ten. They stated Resident #1's pain regimen was reviewed frequently with the physician, and the physician conducted in-person evaluations of Resident #1. They stated there was no documentation that Resident #1's pain was consistently monitored or assessed before and after the administration of pain medication. 10 NYCRR 415.12
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
New Paltz Center for Rehabilitation and Nursing
1 Jansen Road New Paltz, NY 12561
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
person.During an interview on 10/28/2025 at 12:00 PM, Licensed Practical Nurse #2 stated documentation
on Resident #1's Medication Administration Record was not complete. They stated they knew they should sign the Medication Administration Record when giving an as needed pain medication but did not always do that as they were busy. During an interview on 10/29/2025 at 1:11 PM, Licensed Practical Nurse #3 stated Resident #1 was alert, oriented, and demanded as-needed medications. They stated pain medication that was administered to Resident #1 as requested was not always documented as given on the Medication Administration Record. They stated the narcotic control sheets were usually reviewed to determine the last administration time instead of checking the Medication Administration Record.During a telephone interview on 10/30/2025 at 11:16 AM Licensed Practical Nurse #5 stated when they administered a controlled medication, they usually signed it out in the narcotic book and then the Medication Administration Record. During an interview on 10/29/2025, at 2:00 PM, the Pharmacy Consultant stated that they did offsite regimen reviews only as that was how the contract with the facility was set up. They stated their review of medications including controlled substances was based solely on
the documentation in the Medication Administration Record. They stated they did not review the narcotic control sheets. They stated the nurses assigned would be responsible for checking to ensure the controlled medications were logged accurately in the Medication Administration Record. They stated they did not
review pain assessments but if they reviewed the Medication Administration Record and identified pain medications were administered often, they may have a concern. They stated if medication administration frequency was not accurate, they would not know to check into it unless it conflicted with the order. During
an interview on 10/29/2025, at 2:00 PM, the Director of Nursing stated when nurses administered narcotics,
they should sign both the narcotics log and the Medication Administration Record. They stated nurses had been educated to sign both. During an interview on 10/30/2025 at 3:15 PM the Director of Nursing stated there was no formal process to check the narcotic control sheets against the Medication Administration Record. They stated the pharmacist worked remotely and did not come to the facility. 10 NYCRR 415.18
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NEW PALTZ CENTER FOR REHABILITATION AND NURSING in NEW PALTZ, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NEW PALTZ, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NEW PALTZ CENTER FOR REHABILITATION AND NURSING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.