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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
25D
4E
1F
Potential for minimal harm
0A
0B
0C
August 4, 2025Standard inspection · 7 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 07/28/2025 to 08/04/2025, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #38) of 1 resident reviewed for Dignity out of 37 total sampled residents. Specifically, the Infection Control Preventionist was observed using profane language when speaking to Resident #38.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a safe, clean, comfortable, and homelike environment was provided to the residents, and maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided to the residents. This was evident on 1 (Unit 5) of 5 units. Specifically, on Rooms 501, 505, 507, 509, and 517, and the general residents' bathroom were observed with air conditioners with dirty and rusty grill covers, mismatched chipped paint in the residents' room, hole in the wall and unclean discolored bathroom heater.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification and Complaint survey from 07/28/2025 to 08/04/2025, the facility did not ensure that a Comprehensive Care Plan for each resident was developed and implemented consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing and mental psychosocial needs that are identified in the comprehensive assessment. This was evident for 1 (Resident #82) of 1 resident reviewed for Hospice and End of Life out of 37 sampled residents. Specifically, there was no care plan created that addressed comfort care for Resident #82.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey from 07/28/2025 to 08/04/2025, the facility did not ensure that each resident's Comprehensive Care Plans were reviewed and revised. This was evident for 1 resident reviewed for Dignity out of 37 sampled residents. Specifically, there was no documented evidence that the Comprehensive Care Plans for Mood State, Cognitive Loss/Dementia, Wandering/Elopement, Behavioral Symptoms (Verbally Abusive Behavior), and Behavioral Symptoms were reviewed and revised for Resident #38 after their last quarterly Minimum Data Set assessment was completed.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1 Based on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that services provided or arranged by the facility as outlined by the Comprehensive Care Plan meet professional standards of quality including current evidence-based practice. This was evident for 1 (Resident #14) of 5 residents reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review out of 37 sampled residents. Specifically, Licensed Nurses did not inform the Physician or the Physician Assistant when a resident with diagnosis of Diabetes Mellitus had elevated blood glucose readings, of inconsistent blood glucose monitoring as per Physician's order of four times a day and of Resident's refusal of treatment as ordered by the Physician. The finding is: [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview conducted during the Recertification survey, the facility did not ensure that each resident received treatment and care in accordance with goals for care and professional standards of practice. This was evident for 1 (Resident #6) of 4 residents reviewed for Limited Range of Motion out of 38 sampled residents. Specifically, Resident #6, who had a history of limited neck flexion, and a Physician's order for cervical brace to be worn at all times except for skin check, hygiene, and exercise was observed on several occasions without them.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that the Physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #14) of 5 resident reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review out of 37 sampled residents. Specifically, there was no documented evidence the Physician addressed Resident #14's consistently high blood sugars and non-compliance with diabetic management.
February 12, 2025Complaint inspection · 1 citation
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (NY00339419 and NY00342391), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). This was evident in three (3) out of five (5) residents sampled (Residents #1, Resident #2 and Resident #3). Specifically, on 04/11/2024 at 12:50 PM, Registered Nurse #1 documented while monitoring residents at the start of their shift 7:00 AM to 3:00 PM, Resident #1 complained of pain in their private area and stated they think someone might have touched their private area because it hurts. [...]
July 26, 2023Standard inspection · 12 citations
- F
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 interviews conducted during the recertification survey from 7/19/2023 to 7/24/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during Kitchen observation. Specifically, cold sandwiches and milks were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation and staff interviews conducted during the Recertification and Abbreviated Survey from 7/19/23 to 7/26/23, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced dignity. Specifically, a resident was observed on more than one occasion with no clothes on. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 35 residents. (Resident # 45)
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteResident #168 Based on observations, interviews and record review conducted during the recertification and complaint survey from 7/19/23 to 7/24/23, the facility did not ensure that each resident has the right to make choices about aspects of life that are significant to the resident. This was evident for one (Resident #168) of six residents reviewed for Activities of Daily Living. Specifically, Resident #168 was was not asked about bathing preferences when their shower schedule was created, and they were informed about their shower schedule.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, and staff interviews during the Recertification and abbreviated survey conducted from 7/19/23 to 7/26/25, the facility did not ensure that residents' privacy and confidentiality were maintained. This was evident for 1 of 1 resident reviewed for Privacy out of a total sample of 35 residents (Resident # 15). Specifically, Resident #15's privacy curtain was missing and left the resident exposed to everybody entering the room.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification survey from 07/19/2023 to 07/26/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 1 (2nd Floor) of 5 Units. Specifically, resident rooms were observed with mismatched paint and dry wall patches, clutter including multiple cardboard boxes and food containers, rusty and cracked light fixtures, ripped fall mats, ripped leather on a resident's recliner, and ripped and dirty privacy curtains.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure Minimum Data Set (MDS) 3.0 assessment was completed within 14 days of admission. This was evident for Resident #157 reviewed for Resident Assessment out of 38 total sampled residents. Specifically, Resident #157's admission MDS was not completed within 14 days of their admission to the facility.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 07/19/2023 to 07/26/2023, the facility did not ensure the resident and their representatives were provided with a written summary of the baseline care plan (BCP). This was evident for 2 (Resident #43 and #387) of 38 total sampled residents. Specifically, 1) Resident #43's representative was to provide with a copy of the BCP and, 2) Resident #387 was not provided with a copy of their BCP.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 7/19/2023 to 7/24/2023, the facility did not ensure an effective discharge planning process was developed and implemented. This was evident for 1 (Resident #82) of 3 residents reviewed for Discharge out of 38 total sampled residents. Specifically, documents needed for discharge planning were not submitted to another facility per Resident #82's request.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 07/19/2023 to 07/26/2023, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for Resident #95 reviewed for Activities out of 38 total sampled residents. Specifically, Resident #95 was not provided with television (TV) stations in their preferred language.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review and interview conducted during the recertification and abbreviated survey, the facility did not ensure a Physician order on oxygen tubing was followed to prevent the transmission of infectious disease. This was evident for 1 (Resident #14) of 2 residents reviewed for Respiratory Care out of a total sample of 35 residents. Specifically, Resident #14's oxygen tubing was not changed in accordance with Physician Order (PO).
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, record review and interviews conducted during a recertification survey from 7/19/2024 to 7/24/2024, the facility did not ensure that all drugs and biologicals were labeled in accordance with professional standards. This was evident for 2 (2nd and 3rd Floor) of 3 medication rooms. Specifically, 1) two boxes of expired flu vaccines were observed in the 3rd Floor medication room, and 2) one box of expired covid vaccines was observed in the 2nd Floor medication room.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 7/19/2023 to 7/24/2023, the facility did not ensure garbage and refuse was disposed of properly. This was evident during kitchen observation. Specifically, the garbage compactor door was observed ajar, and multiple flies were observed flying on top of garbage inside the compactor.
May 20, 2021Standard inspection · 10 citations
- E
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on record review and staff interviews conducted during the Recertification and Abbreviated survey the facility did not ensure a surety bond was purchased to provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 100 of 134 residents who maintained personal funds accounts at the facility. The finding is: On 05/20/2021 the facility submitted a document titled Midway Nursing Home Disbursement Worksheet dated 05/19/2021 which showed a total balance of resident's funds in the amount of $327,083,00. The facility presented a surety bond dated 12/20/2020 to 12/20/2021 in the amount of $140,000. [...]
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review and staff interviews conducted during a Recertification and Abbreviated survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, 1). a care plan was not created for a resident with a diagnosis of Human Immunodeficiency Virus, and 2). A care plan was not implemented for a resident on fluid restrictions. This was evident for 1 of 3 residents reviewed for Nutrition and 1 of 2 residents reviewed for Respiratory Care and of out of a sample of 27 residents (Resident #7 and Resident #34).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record reviews and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, 1). Physician's order were not implemented for a resident receiving oral chemotherapy anti-hypertensive medications with special order requirements and monitoring and 2). fluid restriction for a resident with edema was not implemented. This was evident for 1 of 3 residents reviewed for Activities of Daily Living and 1 of 2 residents reviewed for Respiratory Care out of a sample of 27 residents. (Resident # 114 and Resident #34).
- D
Ensure each resident receives an accurate assessment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interviews and record reviews during the Recertification and Abbreviated survey, the facility did not ensure each resident or resident representative was given the opportunity to participate in the review and revision of the care plan. Specifically, a resident was not invited to participate in their care plan meeting. This was evident for 1 of 1 resident reviewed for Care Plan out of a sample of 27 residents. (Resident #71).
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that the facility review the resident's total program of care, including medications, and treatments, at each visit. Specifically, there was no documented evidence of medical follow-up for a resident admitted with a diagnosis of Human Immunodeficiency Virus (HIV). This was evidenced for 1 of 3 residents reviewed for Nutrition out of a sample of 27 residents (Resident # 7). The finding is: The facility policy dated March 1, 2021 titled Physician Services documented that it is the policy of Midway Nursing Home to provide Physician Services in accordance with State and Federal Regulations. The policy also documented that the physician will review the resident's total program of care, including medications and treatments, at each visit. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification and Abbreviated survey, the facility did not ensure timely identification and removal from current medication supply of medications for disposition. Specifically, an opened bottle of medication was observed in the medication cart past the expiration date. This was evident on 1 of 5 units reviewed for Medication Storage (Unit 3). The facility policy and procedure titled Expired Medication dated 3/20/2015 documented all medication carts, cabinets and refrigerators will be routinely checked by nursing personnel. All expired medications will be removed and discarded. The procedure included on a weekly basis, 11-7 nurse will check all above-mentioned areas for any expired medications. Same will be discarded. [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and staff interview during the Recertification and Abbreviated survey, the facility did not ensure medication and biologicals drugs were stored and labeled in accordance with currently accepted professional principles. Specifically, 1). the facility did not ensure the multidose medications were properly labeled with opening date and resident name on the bottle and vial, and 2). insulin pens were not stored in a manner to prevent cross-contamination. This was evident on 1 of 5 units reviewed during the Medication Storage and Labeling Task.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, record review and staff interview conducted during a Recertification and Abbreviated survey, the facility did not ensure that special eating equipment and utensils were provided for residents who need them. Specifically, during a lunch meal a resident was not provided with an insulated mug with lid that was ordered. This was observed during the Dining Observation Task for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 27 residents (Resident #45). The finding is: The facility policy titled Adaptive Feeding Service Program dated February 2019 documented that it is the policy of Midway Nursing Home that residents will be evaluated as needed and will receive necessary adaptive devices for meals to ensure completion of meals and to enhance their quality of life and to reach their highest level of independence. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated survey, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented. Specifically, the physician frequently documented an incorrect gender and age of residents in the clinical records. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 27 residents. (Residents #5 and 74).
Fire safety inspections
10 fire safety citations on file: 3 on August 4, 2025, 6 on July 26, 2023, 1 on May 20, 2021.
Every fire safety citation10 citations
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 4, 2025 · deficient, provider has
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 4, 2025 · deficient, provider has
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 4, 2025 · deficient, provider has
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 26, 2023 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · July 26, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · May 20, 2021 · Corrected (the home has a date of correction)