Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
9D
0E
0F
Potential for minimal harm
0A
0B
0C
March 25, 2026Complaint inspection · 4 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and interviews during survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice to maintain their highest practicable physical wellbeing. This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, Resident #1 was admitted to the facility with intact skin to the sacrum (a triangular, shield-shaped bone at the base of the spine) and buttocks and subsequently developed moisture associated skin damage (erosion of the skin caused by prolonged exposure to urine, stool, sweat, or wound drainage.) Treatment was not initiated until [DATE] without documented evidence of the effectiveness of treatment between [DATE] and [DATE]. [...]
- G
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on record reviews and interviews during a survey, the facility failed to ensure that medical care for each resident was effectively supervised by a physician. This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, 1) Resident #1 developed Moisture Associated Skin Damage (erosion of the skin caused by prolonged exposure to urine, stool, sweat, or wound drainage) to the sacrum (a triangular, shield-shaped bone at the base of the spine) and bilateral buttocks on 08/12/2025 and treatment was ordered on 08/14/2025 to be completed for 30 days. A Surgical Note by Physician Assistant #1 dated 12/17/2025 indicated wound deterioration. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (ID#2720832), the facility failed to ensure that a designated resident representative was notified of changes in the resident's condition. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, Resident #1 was assessed on 08/14/2025 to have developed moisture associated skin damage (caused by prolonged exposure to moisture from sources such as urine, stool, sweat or wound drainage) to sacrum and bilateral buttocks and treatment was ordered. Resident #1's designated representative was not notified of changes in Resident #1's skin condition.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interviews during the Abbreviated Survey (ID #2720832) the facility failed to ensure the Minimum Data Set assessments accurately reflect each resident's status. This was evident in one (1) out of four (4) residents (Resident #1) sampled. Specifically, 1) Resident 1 was admitted to the facility from the hospital on [DATE] and was identified with Cellulitis (a common, potentially serious bacterial skin infection). The Minimum Data Set, dated [DATE] assessment did not reflect Resident #1's skin condition. 2) the hospital discharged , and Patient Review Instrument dated 12/30/2025, revealed Resident #1 was discharged to the facility with eight wounds to various body areas. A facility admission note dated 01/02/2026 documented Resident #1 had wounds to sacrum, bilateral buttocks, bilateral hips, and gangrene to all toes and bilateral heels. [...]
March 12, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00353123), the facility failed to provide adequate supervision to a resident to prevent accident. This was evident for one (1) of six (6) residents (Resident #3) sampled. Specifically, Certified Nursing Assistant #9 transferred Resident #3 out of bed to the recliner chair by themself at 8:00 AM [DATE]. After breakfast, Certified Nursing Assistant #9 transferred Resident #3 back to bed by themself at 10:51 AM. While Certified Nursing Assistant #9 was in the process of providing morning care to Resident #3 at 10:51 AM, they observed Resident #3 with a discoloration on the left inner thigh. Registered Nurse #2 and Registered Nurse Supervisor #3 assessed Resident #3 who had a bruise on the left inner thigh. An x-ray result dated [DATE] documented an acute fracture of the left hip. [...]
January 27, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey, (NY00368833), the facility did not ensure the residents' right to be free from physical abuse. This was evidence for one out of six residents reviewed (Resident #1). Specifically, on 01/13/2025 at 07:18 PM, Licensed Practical Nurse #1 reported to Registered Nurse Supervisor #1, Certified Nursing Assistant #1 threw a cup of melted ice cream on Resident #1's. Registered Nurse Supervisor #1 assessed Resident #1 and observed a wet stain on the top of Resident #1's clothes.
August 8, 2024Standard inspection, Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 07/31/2024 to 08/07/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident in 1 (Resident #132) of 6 residents reviewed for accidents, out of 38 total sampled residents. [...]
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 07/31/2024 to 08/07/2024, the facility failed to ensure that a Significant Change in Status Assessment was completed within 14 days after a determination had been made in the resident's status from baseline occurred. This was evident in 1 (Resident # 167) of 1 resident reviewed for pressure ulcer / injury out of 35 total sampled residents. Specifically, on 06/30/2024, Resident #167 was identified with an unstageable pressure injury to the sacrum and deep tissue pressure injury to the left heel. The facility did not have a Significant Change in Status Assessment completed after the change in condition was identified.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 07/31/2024 to 08/07/2024, the facility did not ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the Kitchen Task observation. Specifically, 1.) 2 boxes containing 20 (14 ounces) packages of bratwurst in the kitchen refrigerator and the freezer in the emergency food area were stored beyond the best by date, and 2.) potentially hazardous food were not maintained at an acceptable temperature to limit the growth of pathogen.
June 9, 2022Standard inspection · 0 citations
October 9, 2019Standard inspection · 2 citations
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and staff interview conducted during the recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a discharge assessment was not transmitted within 14 days after completion. This was evident for 1 of 1 resident reviewed for the Resident Assessment task. (Resident # 4). The finding is: Resident #4 was discharged from the facility on 06/22/2019. Nursing progress note dated 6/22/19 documented resident was discharged home accompanied by ambulette attendants. Medications were reviewed and discharge instruction was given. Review of the medical record revealed no documented evidence that a discharge MDS assessment had been completed. [...]
- D
Ensure each resident receives an accurate assessment.
Fire safety inspections
5 fire safety citations on file: 3 on August 8, 2024, 1 on June 9, 2022, 1 on October 9, 2019.
Every fire safety citation5 citations
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 8, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · June 9, 2022 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 9, 2019 · Corrected (the home has a date of correction)