Based on observation, record review, and interview during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility did not ensure the resident's ability to safely self-administer medications was clinically appropriate for 5 of 5 residents (Residents #21, #64, #72, #207, and #239) reviewed. Specifically, Residents #21, #64, #72, and #207 had medications that were left in their room, with some being unidentified. Resident #239 was not observed by nursing staff to ensure their controlled substance, which was used to treat narcotic addiction, was taken as prescribed. There was no documented evidence these residents were assessed to determine their ability to safely self-administer medications or had physician orders for self-administration of medication. …
F554 citations in New York
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New York cites F554 more often than its own record predicts
1.42 times the share F554 takes of citations nationally.
Of every deficiency written in New York in 2025, this is the portion that was F554.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New York surveyors wrote
F554 findings written in New York, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure the interdisciplinary team determined a resident's ability to self-administer medications was clinically appropriate for one (1) of one (1) resident (Resident #147) reviewed. Specifically, Resident #147 had expired and/or discontinued medications and used insulin needles in their room.Findings include: The facility policy Self- Administration of Medications dated 01/2025, documented residents had the right to self-administer medications if the interdisciplinary team determined that it is clinically appropriate for the resident to do so. Self-administered medications must be stored in a safe and secure place, which is not accessible by another resident. …
Based 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 of one resident (Resident #361) reviewed. Specifically, Resident #361 had two budesonide-formoterol fumarate dihydrate aerosol inhalers (used for opening airway) in their room and there was no documented evidence of an assessment or a physician order for the resident to safely self-administer medications.Findings include: The facility policy Self-Administering of Medication, revised 11/2025, documented each resident's ability to self-administer medications will be assessed upon admission, with significant changes as defined by the Minimum Data Set and at annual resident… …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.31% | 0.56× |
| 2024 | 0.74% | 1.35× |
| 2025 | 0.81% | 1.42× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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