Inspection Reports for
Northern Metropolitan Residential Health Care Facility Inc
225 Maple Avenue, Monsey, NY, 10952
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Inspection Report — Mar 9, 2026
Complaint Investigation State
Date: Mar 9, 2026
Visit Reason
State-compiled facility profile showing 3 inspections from 2024 to 2026 with deficiency and complaint history.
Complaint Details
The state logged 49 complaints about this facility; 3 led to on-site inspections. Five citations resulted from those complaints.
Findings
Across three inspections, the facility received a total of 36 citations, including 14 standard health and 22 Life Safety Code citations. Most deficiencies were Level 2 with minor potential harm, and no formal enforcement actions were recorded.
Citations (34)
Facility Assessment: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Antibiotic Stewardship Program: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with pattern Level 2 minor potential harm.
Infection Prevention & Control: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Menus Meet Resident Nds/prep In Adv/followed: Standard Health Citation — quality of care with pattern Level 2 minor potential harm.
Notice Requirements Before Transfer/discharge: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Pain Management: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Resident Rights/exercise Of Rights: Standard Health Citation — quality of care with isolated Level 2 minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with pattern Level 2 minor potential harm.
Aisle, Corridor, Or Ramp Width: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Cooking Facilities: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Corridor - Doors: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Develop Ep Plan, Review And Update Annually: Life Safety Code Citation — NFPA requirements with widespread Level 1 potential for minimal harm.
Egress Doors: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements with pattern Level 2 minor potential harm.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation — NFPA requirements with pattern Level 2 minor potential harm.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements with pattern Level 2 minor potential harm.
Electrical Systems - Other: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Emergency Lighting: Life Safety Code Citation — NFPA requirements with pattern Level 2 minor potential harm.
Exit Signage: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Fire Drills: Life Safety Code Citation — NFPA requirements with pattern Level 2 minor potential harm.
Gas Equipment - Cylinder And Container Storag: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Horizontal Sliding Doors: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Illumination Of Means Of Egress: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Maintenance, Inspection & Testing - Doors: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Physical Environment: Life Safety Code Citation — NFPA requirements with Level 0 no harm potential.
Sprinkler System - Installation: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Stairways And Smokeproof Enclosures: Life Safety Code Citation — NFPA requirements with isolated Level 2 minor potential harm.
Subsistence Needs For Staff And Patients: Life Safety Code Citation — NFPA requirements with widespread Level 1 potential for minimal harm.
Report Facts
Inspections on page: 3
Total citations: 36
Standard Health citations: 14
Life Safety Code citations: 22
Complaints: 49
On-site complaint inspections: 3
Complaint citations issued: 5
Inspections with violations: 2
Inspections without violations: 1
Enforcement actions: 0
Inspection Report — Jul 30, 2024
Annual Inspection CMS
Date: Jul 30, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 7/23/24 to 7/30/24 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including resident dignity related to catheter privacy, environmental cleanliness, notification of resident transfers to the Ombudsman, comprehensive care planning for urinary catheters, pain management, medication storage, food service and menu adherence, food safety and sanitation, infection prevention and control, and antibiotic stewardship.
Citations (10)
F 0550: The facility failed to maintain resident dignity for 2 residents by not ensuring urinary catheters had privacy bags, leaving drainage bags visible to roommates and visitors.
F 0584: The facility did not provide a clean, comfortable, and homelike environment on 1 of 4 units, with stained walls, chipped paint, missing moldings, and dirty floors observed.
F 0623: The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman of resident transfers or discharges for 2 of 4 residents reviewed.
F 0656: The facility did not develop or implement a comprehensive person-centered care plan for 1 resident with an indwelling urinary catheter.
F 0697: The facility failed to provide consistent pain assessment and monitoring of effectiveness of pain medication for 1 of 5 residents reviewed.
F 0761: The facility did not ensure all drugs and biologicals were labeled and stored properly, with expired and resident-specific medications found in medication carts and storage rooms.
F 0803: The facility did not ensure menus were followed for 5 of 32 residents, with multiple instances of missing food items on meal trays.
F 0812: The facility did not ensure food was stored and prepared in accordance with professional food safety standards, including unclean equipment, undated and expired foods, peeling paint, incomplete chemical testing logs, and elevated refrigerator temperatures.
F 0880: The facility failed to maintain an infection prevention and control program, including improper use of personal protective equipment, lack of environmental risk assessment for Legionella, inadequate wound care precautions, and incomplete infection surveillance.
F 0881: The facility did not implement an antibiotic stewardship program that included protocols and real-time monitoring of antibiotic use for 1 resident reviewed.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 5
Residents affected: 5
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in catheter privacy and pain management findings |
| Certified Nurse Aide #16 | Certified Nurse Aide | Named in catheter privacy finding |
| Director of Nursing | Director of Nursing | Named in catheter privacy, care plan, pain management, and antibiotic stewardship findings |
| Registered Nurse Supervisor #4 | Registered Nurse Supervisor | Named in care plan deficiency |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Named in infection prevention wound care deficiency |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in infection prevention PPE deficiency |
| Infection Control Practitioner | Infection Control Practitioner | Named in infection prevention and antibiotic stewardship deficiencies |
| Food Service Director | Food Service Director | Named in food service and food safety deficiencies |
| Administrator | Administrator | Named in food safety and Ombudsman notification deficiencies |
Inspection Report — Nov 16, 2021
Annual Inspection CMS
Date: Nov 16, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with staffing posting requirements and accuracy of staffing information.
Findings
The facility failed to post accurate daily staffing information for licensed and unlicensed nursing staff in a prominent location. Multiple days over a six-month period were missing complete staffing data for various shifts and total nursing hours.
Citations (1)
F 0732: The facility did not post total and actual hours of licensed and unlicensed nursing staff daily as required. Staffing records for multiple days between May and November 2021 were incomplete or missing for day, evening, and night shifts.
Report Facts
Shifts with nursing hours posted: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed about staffing form completion and filing | |
| Director of Nursing | Interviewed regarding staffing omissions and corrective actions |
Inspection Report — Oct 18, 2018
Annual Inspection CMS
Date: Oct 18, 2018
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements related to resident assessments, care planning, and medication management.
Findings
The facility failed to ensure comprehensive assessments addressing psychosocial needs related to dementia care and psychoactive medication use for one resident. Additionally, the facility did not develop or implement a complete care plan to monitor fluid intake for a resident with a 2-liter fluid restriction, resulting in inadequate documentation and monitoring.
Citations (2)
F 0636: The facility did not ensure the comprehensive assessment for one resident addressed psychosocial needs related to dementia care and psychoactive medication use, limiting the development of an appropriate person-centered care plan.
F 0656: The facility failed to develop and implement a complete care plan to ensure a resident with a 2-liter fluid restriction did not consume excess fluids and to monitor hydration status, resulting in lack of fluid intake documentation and monitoring.
Report Facts
Fluid intake documentation: 2000
Urine output documentation: 1170
Urine output documentation: 3100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager/Registered Nurse (RN #1) | Interviewed regarding resident behavioral symptoms and psychiatric evaluation | |
| Social Worker (SW) | Interviewed regarding psychosocial history and medication awareness | |
| Nurse Practitioner (NP) | Interviewed regarding resident's fluid restriction and medical condition | |
| Unit nurse in charge | Interviewed regarding care plan development and fluid restriction monitoring |
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