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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
16D
6E
2F
Potential for minimal harm
0A
0B
0C
December 12, 2025Standard inspection · 7 citations
- F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, record reviews and interviews during a recertification survey, the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, the facility did not document nursing unit narcotics were counted by two (2) licensed staff members and signed as appropriately done on the facility provided narcotic record sheets. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, and interviews during a recertification survey, the facility did not maintain an infection control program in accordance with professional standards of care. Specifically, a) for Resident #7, the licensed practical nurse removed a dressing without wearing gloves and b) the facility did not ensure signage and supplies for transmission-based precautions were readily available and visible. [...]
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, time frames for the different steps in the process. Specifically, the facility policy, titled Medication Therapy, did not identify time frames for the steps in the process. This is evidenced by: The facility policy titled, Medication Therapy, reviewed 01/2025, stated the Consultant Pharmacist would review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected, and the Medical Director and Consultant Pharmacist would collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. [...]
- E
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 staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Specifically, the automatic dishwashing machine was not operating within the manufacturer's instructions, sanitizing solution concentration could not be verified, and surfaces, equipment, and floors required cleaning or repair. This is evidenced by: During observations on 09/21/2025 at 10:56 AM: The automatic dishwashing machine final rinse was 197 degrees Fahrenheit at 7 (seven) pounds per square inch of water pressure; the dishwashing machine data plate states that the water pressure is to be between 15 and 25 pounds per square inch. The facility did not have a chemical test kit with graduations above 400 parts per million; [...]
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpster was heavily soiled below the side door and was not rodent proof. This is evidenced by: During observations on 09/21/2025 at 12:02 PM, the right dumpster was heavily soiled below the side door and was missing a drain hole plug and was not rodent proof. During an interview on 09/21/2025 at 12:07 PM, Assistant Food Service Manager #1 stated that they would speak with the maintenance department about having the dumpster cleaned and a drain hole plug installed. New York Codes, Rules, and Regulations Title 10 S415.14(h)
- 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 observations, record review, and interviews conducted during the recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident and in response to current interventions for two (2) (Resident #'s 11 and 20) of 19 reviewed. Specifically, Resident #11's Comprehensive Care Plan for Anticoagulants was not resolved after the resident's order for Plavix was discontinued in 2023 and Resident #20's Comprehensive Care Plan was not reviewed or revised to include the resident's diagnosis of constipation and treatment/orders for constipation. This is evidenced by: [...]
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure food brought for residents by family or visitors was stored safely and in a way that is either separate or easily distinguishable from facility food on one (1) of two (2) resident units. Specifically, resident food was not properly labeled, and the facility did not have a policy to assist residents in accessing food brought in to them. This is evidenced by: During observations on the North Wing kitchenette on 09/21/2025 at 11:39 AM, deli chicken salad was not labeled with a resident name, and two (2) homemade sandwiches were not labeled. During an interview on 09/21/2025 at 11:46 AM, Assistant Food Service Manager #1 stated that the homemade sandwiches were likely for a resident, and food brought to residents should be labeled with the resident name and dated. [...]
October 27, 2025Complaint inspection · 4 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Case #2635234), the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (2) of four (4) residents (Resident #1 and 3) reviewed for falls. Specifically, [a.] Resident #1 had severe cognitive impairment and had five (5) unwitnessed falls from [DATE] to [DATE]. The facility failed to develop appropriate interventions to mitigate falls when it was known that the resident was self-transferring. On [DATE] at 11:30 PM, Resident #1 was found on the floor unresponsive, unclothed and cold to the touch by Certified Nurse Aide #1. [...]
- G
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review and interview conducted during an abbreviated survey (Case #2635234), the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) of four (4) residents (Resident #1) reviewed. Specifically, on [DATE] at 11:30 PM, Resident #1 was found unresponsive with an oxygen saturation of 73 percent (normal 95 to100 percent) and signs of respiratory distress. Emergency Medical Services documented 'extreme' wheezing in all lung fields and a clinical impression of pneumonia (an infection in one or both lungs). The resident was admitted to the hospital with septic shock (a progression from sepsis that causes a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review conducted during the abbreviated survey (Case # 2635234), the facility did not thoroughly investigate accidents for 1 (one) of 4 (four) residents reviewed for accidents. Specifically, on 9/28/2025 at 11:30 PM, Resident #1 was found in their room on the floor next to their bed. Resident #1 was unresponsive except to painful stimuli and had uncontrollable shaking. Resident #1 was left for an undetermined amount of time without providing care. Subsequently, when assessing Resident #1's vital signs (key indicators of the body's essential physiological functions including temperature, heart rate, breathing rate, and blood pressure), Resident #1's body temperature was too low to be read by a thermometer. The facility did not have documented evidence of a thorough investigation to rule out if Resident #1 was abused and/or neglected. [...]
- 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 record review and interviews during an abbreviated survey (Case # 2635234), the facility did not ensure the development and implementation of a person-centered care plan that included measurable objectives and timeframes to meet the resident's needs for 2 (two) (Resident #s 1 and 3) of 4 (four) residents reviewed. Specifically, the facility did not ensure it developed, implemented, monitored, and evaluated appropriate person-centered care plan interventions to mitigate falls for Resident #'s 1 and 3, who had multiple unwitnessed falls in their rooms related to self-ambulation. This is evidenced by: Cross-referenced to F689: [...]
February 3, 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 (Case #NY00357658), the facility did not ensure it protected the resident's right to be free from abuse and neglect for 1 (Resident #1) of 3 residents reviewed. Specifically, Registered Nurse #1 forcefully removed Resident #1 from the floor after the resident became unsteady and fell to the floor. Registered Nurse #1 did not assess the resident for injury prior to getting the resident up and ambulating them to their room. This is evidenced by: The Facility's Abuse Policy Prevention program updated on 10/20/2024 documented the following: Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. [...]
May 31, 2024Complaint inspection · 2 citations
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00326640), the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used for excessive duration and without adequate indication for 1 (Resident #10) of 1 resident reviewed. Specifically, Resident #10 was administered Atarax (an antihistamine used to treat anxiety, nausea, vomiting, itching and skin rash without obtaining a physician's order. This is evidenced by: Resident #10 was admitted to the facility with the diagnoses of hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), cerebral infarction (stroke), and depression. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interviews and record review conducted during an abbreviated survey (Case #NY00316477), the facility did not ensure residents were free from significant medication errors for 1 (Resident #3) of 1 resident reviewed. Specifically, the facility did not ensure significant medications were accurately transcribed from Hospital Discharge instructions for Resident #3. Subsequently, Resident #3 did not receive orders for respiratory nebulizer treatments from 5/11/2023 to 5/13/2023 and was re-admitted to the hospital on [DATE] for respiratory distress. This is evidenced by: Resident #3 Resident #3 was admitted to the facility with diagnosis of metabolic encephalopathy (A problem in the brain caused by a chemical imbalance in the blood), acute and chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body. [...]
May 22, 2023Standard inspection · 6 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview during the recertification survey and an abbreviated survey (Case #NY00316948) dated 05/15/23 through 05/22/23, the facility failed to protect the resident's right to be free from neglect for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, on 04/16/2023 Certified Nurse Aide (CNA) #2 did not use two staff for bed mobility as documented in Resident #23's Comprehensive Care Plan (CCP) . Subsequently, on 4/16/2023 Resident #23 rolled out of bed onto the floor sustaining a fracture of their left elbow and a gash requiring stitches on their left elbow. This resulted in actual harm that is not immediate jeopardy for Resident #23. This was evidenced by: Resident #23 was admitted to the facility with diagnoses of multiple sclerosis, Chronic Obstructive Pulmonary Disorder (COPD), and diabetes. [...]
- E
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 during the recertification survey dated 05/15/23 through 05/22/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean and homelike environment on two (2) of 2 resident units. Specifically, on the South Wing Unit, the floors were soiled with dirt and a black build-up where the door frame meets the floor and along the wall in the dining room, corridor, ice machine area, Beauty Shop, and in resident room #'s 102, 104, 108, and #116; the floor was soiled with dust and dirt below the chests of drawers in room #'s 205, 222, and #226; the radiators were soiled with food drips in room #'s 215, 222, and #226; the radiator cover was falling off in room [ROOM NUMBER]; and the ½ size oxygen tanks in the oxygen tank storage area were dusty. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interviews during the recertification survey dated 05/15/23 through 05/22/23, the facility did not prepare or serve food in accordance with professional standards for food service safety. Specifically, the test papers used to check the concentration of the chemical used to manually sanitize food equipment were expired (expiration dates 12/15/2022 and 04/01/2023). The food temperature thermometer being used by cook #1 was found out of calibration when checked by the standard ice-bath method (temperature registered less than the lowest graduation on the thermometer scale). [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews, and record review during the recertification survey and an abbreviated survey (Case #NY00316948), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, for Resident #23, the facility did not report that Resident #23 sustained a fractured elbow and a laceration on their left elbow requiring sutures when on 04/16/2023, the facility did not ensure that a staff member utilized 2 persons for bed mobility as documented both in their Comprehensive Care Plan (CCP) revised on 2/2/2023 and [NAME] dated 4/16/2023. This was evidenced by: Please refer to F600. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews during the recertification survey and an abbreviated survey (Case #NY00316948), the facility did not prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, for Resident #23, the facility did not ensure to prevent further potential abuse, neglect, exploitation, or mistreatment when the facility did not remove a staff member from resident care on 4/16/2023 when the staff member did not follow Resident #23's Comprehensive Care Plan (CCP) revised on 2/2/2023 and [NAME] dated 4/16/2023 that documented the resident required 2 persons for bed mobility. This resulted in a a fracture and a laceration requiring sutures to the resident's left elbow from a fall out of bed. [...]
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interviews during the recertification survey conducted from 5/15/2023 through 5/22/2023, the facility did not ensure drug regimen irregularities were reported by the pharmacist to the attending physician for 1 (Resident #67) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #67, the facility did not ensure an irregularity in the monitoring orders for Alendronate (used to prevent and treat certain types of bone loss (osteoporosis) in adults) was documented and reported to the physician by the consultant pharmacist on 5/2/2023. This was evidenced by: Resident #67 Resident #67 was admitted to the facility with the diagnoses of cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), and depression. [...]
July 12, 2021Standard inspection · 7 citations
- 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 interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 7 (Resident #'s 4, 20, 23, 29, 40, 66, and #170) of 17 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #4, the facility did not ensure an intervention on the CCP for an indwelling catheter to maintain the urine collection bag below the level of the resident's bladder was implemented; [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review during a recertification survey, the facility did not ensure a follow up screen was developed based on a resident change of condition for one (Resident #66) of sixteen residents reviewed. Specifically, for Resident #66, whose pre-admission screen dated 3/05/2021 was checked no for the section for Danger to Self or Others, the facility did not ensure to perform a follow up screen when the resident exhibited violent behaviors at the facility. This was evidenced by: Resident #66 Resident #66 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (CVA), schizoaffective disorder and encephalopathy. The Minimum Data Set (MDS-an assessment tool) dated 6/20/2021 documented the resident had severe cognitive impairment. The resident usually understood others and could usually be understood by others. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 2 (Resident #'s 40 and #42) of 2 residents reviewed for Activities of Daily Living (ADLs). Specifically, for Resident #'s 40 and #42, the facility did not ensure the residents, who were unable to carry out activities of daily living, received a weekly shower to maintain good personal hygiene. This is evidenced by: The Policy and Procedure (P&P) titled Shower/Tub Bath last revised 1/2021, documented the purpose of this procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. The P&P documented the following information should be recorded on the resident's ADL record: [...]
- 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 interview during a recertification survey and abbreviated survey (Case #NY00278577) the facility did not ensure residents received adequate supervision and assistive devices to prevent avoidable accidents for 1 (one) (Resident #38) of (1) one resident reviewed. Specifically, for Resident #38, the facility did not implement a care planned intervention for a 2 person assist required while using an assistive device to be used in the transferring of the resident from the wheelchair to the bed to reduce the resident's risk of falls. This resulted in a fall from the bed on 6/27/2021 with an injury, requiring a transfer to the hospital. This is evidenced by: Resident #38 Resident #38 was admitted to the facility with diagnosis of end stage renal disease (ESRD), morbid obesity and spondylopathy (disorder of the vertebrae). [...]
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed, maintained, and implemented for the monthly medication regimen review (MRR) process that addressed the time frames for the different steps in the process. Specifically, the facility did not ensure step #6 included time frames for the physician and staff to address medication related complications that require urgent action to protect the residents from harm. This is evidenced by: On 7/6/2021the facility provided a policy titled: Medication Therapy/Drug Regiment Review, with a revised date of 1/2021. The policy provided did not include timeframes for notifying the physician for clinically significant effects. Step #6 (medication follow up) of the policy documented the following: [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review during a recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, for 2 (Resident #'s 29 and 40) of 6 residents reviewed for unnecessary medications. Specifically, for Resident #29, the facility did not ensure an as needed blood pressure medication was administered when the resident's blood pressure was higher than the physician ordered parameter and for Resident #40, the facility did not ensure blood pressures were obtained prior to administering a blood pressure medication that included a physician ordered parameter. This is evidenced by: [...]
- D
Report COVID19 data to residents and families.
Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure residents and were informed by 5:00 PM the next calendar day following the occurrence of a single confirmed infection of COVID-19 for 3 (Resident #'s 13, 16, and #30) of 3 residents reviewed for notification. Specifically, the facility did not ensure Resident #'s 13, 16 and #30 were provided with verbal or written notification by 5:00 PM the next calendar day after a resident tested positive for COVID-19 on 7/2/2021. This is evidenced by: The Center of Medicare and Medicaid Services (CMS) guidance titled, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (Ref: [...]
Fire safety inspections
13 fire safety citations on file: 7 on December 12, 2025, 3 on May 22, 2023, 3 on July 12, 2021.
Every fire safety citation13 citations
- F
Establish staff and initial training requirements.
E 37 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 12, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 12, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 12, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 12, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 22, 2023 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 22, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · May 22, 2023 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · July 12, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 12, 2021 · 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 12, 2021 · Corrected (the home has a date of correction)