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Complaint Investigation

Isabella Geriatric Center Inc

December 23, 2025 · New York, NY · 515 Audubon Avenue
Citations 2
CMS Rating 2/5
Beds 705
Provider ID 335100
Healthcare Facility
Isabella Geriatric Center Inc
New York, NY  ·  View full profile →
Inspection Summary

Isabella Geriatric Center Inc in NEW YORK, NY — inspection on December 23, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

During an interview on 12/15/2025 at 10:42 AM, the Director of Nursing stated Resident #1 was admitted on [DATE] and the admitting nurse should have initiated a new care plan for at risk for constipation.

The Director of Nursing stated that the registered nurses, head nurses, and registered nurse supervisors are responsible for completing the care plans. 10 NYCRR 415.11(c)(1)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Isabella Geriatric Center Inc

515 Audubon Avenue New York, NY 10040

SUMMARY STATEMENT OF DEFICIENCIES

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The findings are: The facility policy titled ‘Consultations' dated 10/2021 documented after consultation is completed, the nurse reviews recommendations and contacts attending physician to report recommendations or changes in treatment plan. Resident #1 was admitted to facility with diagnoses including chronic pulmonary embolism ( a blood clot that blocks and stops blood flow to an artery in the lung), coronary heart disease, moderate pericardial effusion (refers to collection of excess fluid in the pericardial sac surrounding the heart) and small cell carcinoma of the Lung complicated by superior vena cava syndrome (occurs when blood flow through the heart blood vessel is obstructed, often due to tumors or blood clots, leading to symptoms like swelling and difficulty breathing).The Minimum Data Set, dated [DATE], documented Resident #1 had moderately impaired cognition.A review of a Hematology/Oncology consult dated 09/10/2025, documented Resident #1 was seen by the oncologist on 09/10/2025, and the oncologist recommended to stop cyclobenzaprine (muscle relaxant), consider reducing olanzapine ten (10) milligram to five (5) milligram if tolerated and to start Dexamethasone (anti-inflammatory) four (4) milligrams. A Physician's order dated 09/19/2025 revealed Olanzapine ten (10) milligram was changed to five (5) milligrams and Dexamethasone four (4) milligrams were ordered.A review of the nursing progress notes from 09/10/2025 to 09/19/2025, revealed no documented evidence Medical Doctor #1 was notified of the oncologist's recommendations.

During an interview on 12/09/2025, Resident #1's adult child #1 stated that they accompanied Resident #1 to an oncology appointment on 09/10/2025 and that the oncologist made some recommendations that the facility did not carry out timely. Resident #1's adult child stated that on 09/19/2025 they accompanied Resident #1 to another oncologist appointment and the oncologist asked them why Resident #1 did not receive the Dexamethasone they prescribed on 09/10/2025. Resident #1's adult child stated that the oncologist called the facility on 09/19/2025 and spoke to them about the medication that was recommended.

During an interview on 12/11/2025 at 10:40 AM, Licensed Practical Nurse #2 stated they received the oncology consult dated 09/10/2025, but that they had just looked at the consultation.

Licensed Practical Nurse #2 stated that they notified the nursing supervisor (unsure of name), but was do not recall notifying the Medical Doctor.

During an interview on 12/11/2025 at 12:14 PM, Registered Nurse Supervisor #1 stated they were not aware of the oncologist recommendations of 09/10/2025.

Registered Nurse Supervisor #1 stated that the unit nurses are responsible for reviewing the consults when a resident returned from their appointments.

Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #2 should have notified Medical Doctor #1 of the oncologist's recommendations.

During an interview on 12/11/2025 at 1:02 PM, Medical Doctor #1 stated they received a call from a facility nurse (unsure of name) on 09/19/2025 stating that the oncologist had recommendations on 09/10/2025 that was not prescribed.

Medical Doctor #1 stated that they gave a telephone order on 09/19/2025 for the medication (Dexamethasone) that was ordered by the oncologist on 09/10/2025.

Medical Doctor #1 stated they reviewed the oncology consult on 09/22/2025 when they visited the facility. 10 NYCRR 415.12

Facility ID:

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 YORK, 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 Isabella Geriatric Center Inc or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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