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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
27D
2E
0F
Potential for minimal harm
0A
0B
0C
December 9, 2025Complaint inspection · 1 citation
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on record review and interviews during an Abbreviated Survey (2625704), the facility did not ensure that each resident's clinical condition demonstrated the need for an indwelling urinary catheter in the absence of clinical indications for use and did not document the provision of counseling to assist the resident in understanding the clinical implications and risks associated with the use of a urinary catheter for one (Resident #1) of one resident reviewed for urinary catheter. Specifically, Resident #1 received a urinary catheter insertion after the resident requested a catheter due to urinary incontinence. There was no documented clinical indication for the catheter and there was no documented education regarding clinical implications and risks. [...]
November 19, 2025Standard inspection, Complaint inspection · 8 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, and staff interviews, during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not maintain equipment for respiratory care, such as oxygen equipment, in accordance with federal, state, and local laws and regulations. This was identified for two (2) (Resident #200 and Resident#142) of five (5) residents reviewed for Respiratory Care. Specifically, during an observation on 09/14/2025, the oxygen tubing for Resident #142's and Resident #200's oxygen concentrator and nebulizer machines were not changed since 08/25/2025.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial Kitchen tour and during the Dining Task observation of the lunch meal on 09/14/2025. Specifically, 1) several frozen food items in the walk-in freezer were stored undated and with open packaging; and 2) the facility did not monitor the temperature of cold food items.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review and interviews during the Recertification and Abbreviated Survey (2569298), initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that each resident had the right to make choices about aspects of their life in the facility that are significant to them. This was identified for one (Resident #78) of four Residents reviewed for Abuse. Specifically, Resident #78 wanted a shower on their scheduled shower day; however, Certified Nursing Assistant #6 gave a bed bath against the resident's wishes. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 09/14/2025 and completed 09/18/2025, the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice. This was identified for one (1) (Resident #225) of two (2) residents reviewed for Skin Conditions. Specifically, Resident #225 was identified with two skin tears to the left forearm on 09/11/2025. Registered Nurse #5 applied the treatment to the skin tears; however, there was no documented evidence of the skin assessment and physician orders for the wound care treatment until 09/16/2025. [...]
- 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 during the Recertification and Abbreviated Survey (# 2569298) initiated on 09/14/2025 to 09/18/2025, the facility did not ensure each resident received adequate supervision and assistance devices to prevent Accidents. This was identified for one (1) (Resident #78) of five (5) residents reviewed for Accidents. Specifically, Resident #78 was assessed to require two-person assistance for bath/shower and bed mobility as per their plan of care. Certified Nursing Assistant #6 provided a bed bath to Resident #78 by themselves, without assistance from another staff member. [...]
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that nurse staff posting data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, the facility entrance lobby was observed on 09/14/2025 at 09:00 AM with the Daily Staff Posting dated 09/12/2025. There were no Daily Staff Postings for 09/13/2025. The finding is:During an observation on 09/14/2025 at 09:00 AM, a Daily Staff Posting dated 09/12/2025 was observed near the facility reception area. During an interview on 09/14/2025 at 01:29 PM, the Registered Nurse Supervisor #3 stated they were responsible for posting the Daily Staff Posting sheet at the front desk reception area. [...]
- 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 observation, record review, and interviews during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that the attending Physician acted upon a consultant Pharmacist's drug regimen review recommendation regarding the use of a as-needed (PRN) psychotropic medication for one (1) (Resident #12) of five (5) residents reviewed for unnecessary medications. Specifically, the consultant Pharmacist recommended to consider having a stop date for Xanax ([NAME]-anxiety) medication that was ordered as needed (PRN) basis by the resident's Physician. A decision to agree or disagree to the recommendation was not documented by the Physician. The physician orders did not document a stop date on physician orders and continued prescribing Xanax on an as needed basis. [...]
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey on 09/14/2025 and completed on 09/18/2025, the facility did not ensure call bells were within reach for each resident at their bedside. This was identified for one (Resident #201) of one resident reviewed for call systems. Specifically, on multiple occasions, the call bell was not within Resident #201's reach while in bed. The finding is:The facility's policy titled Call Light, last reviewed 09/05/2025, documented every call light shall be attached to the resident's bed within easy reach of the resident. Resident #201 was admitted with diagnoses including Ogilvie syndrome (acute dilatation of the colon in the absence of any mechanical obstruction in severely ill patients), Intellectual Disabilities, and a history of Falls. [...]
August 8, 2024Standard inspection, Complaint inspection · 13 citations
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00339563) initiated on [DATE] and completed on [DATE], the facility did not ensure each resident transferred to the hospital and discharged from the facility had documentation in the medical record of the attempts made by the facility to meet the needs of the resident before the resident was discharged to the hospital. This was identified for one (Resident #413) of three residents reviewed for death and the facility did not ensure each resident had documentation from a Physician of the necessity to transfer or discharge the resident. This was identified for two (Resident #413 and #414) of three residents reviewed for death. [...]
- 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 the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a person-centered care plan for each resident that includes measurable objectives and timeframes to meet each resident's medical and nursing needs was implemented as identified in the comprehensive assessment. This was identified for one (Resident #71) of five residents reviewed for Respiratory Care. Specifically, Resident #71 had a physician's order to drain fluids from the abdominal cavity on the 7:00 PM - 7:00 AM shift via a Peritoneal (abdominal) Pleurex catheter (a thin, flexible tube that is inserted into the abdominal cavity to drain fluid) due to the diagnosis of Ascitis (a condition where fluid builds up in the abdomen between the lining of the abdomen and the abdominal organs). [...]
- 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 observation, record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #116) of two residents reviewed for Communication. Specifically, Resident #116's comprehensive care plan for Communication documented that the resident was hard of hearing in the left ear. The comprehensive care plan was not updated to indicate the resident used a hearing aid and preferred keeping the hearing aid at the bedside. The finding is: [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene. This was identified for one (Resident #5) of five residents reviewed for pressure ulcers and one (Resident #132) of two residents reviewed for activities of daily living. Specifically, 1) on 8/7/2024, Resident #5's fingernails on both hands were observed to be long and dirty, with a brown substance under the nails and 2) on 8/2/2024, Resident #132's right palm was observed with dark crusty flakes and a musty odor was detected coming from their right hand.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wrote2) The facility's policy and procedure titled, Air Mattress last revised in 10/2023 documented that the selection of the air mattress will be based on the individual's specific needs, including mobility levels, weight, and any pre-existing medical condition. The Wound Care Coordinator will conduct a monthly audit of the resident's weight and assessment of the staff's knowledge of operating the equipment. The operation manual for the low air loss alternating pressure relief air mattress documented instructions that included determining the patient's weight and setting the control knob to that weight setting on the control unit. -Resident #94 was admitted with diagnoses including End Stage Renal Disease, Acute Respiratory Failure, and Type 2 Diabetes. [...]
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease of range of motion. This was identified for one (Resident #132) of three residents reviewed for positioning and mobility. Specifically, Resident #132 had a physician's order for right hand Therapy Carrot (a nonsurgical device that helps position contracted hands) to be worn at all times. On 8/1/2024 and 8/2/2024 the resident was observed not wearing the right-hand Therapy Carrot as ordered by the Physician. The finding is: [...]
- 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 staff interviews during the Recertification Survey initiated on 8/01/2024 and completed on 8/08/2024, the facility did not ensure that each resident's receives adequate supervision and the resident's environment remained as free of accident hazards as possible to prevent accidents. This was identified for one (Resident #28) of seven residents reviewed for accidents. Specifically, Resident #28 was observed on 8/1/2024 with an Albuterol inhaler on their overbed table. There was no staff present in the vicinity. Additionally, Resident #28 did not have a physician's order for the use of the Albuterol inhaler or an order to self-administer medications. The finding is: Resident #28 was admitted to the facility with diagnoses including Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/01/2024, and completed on 8/08/2024 the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for two (Resident #42 and Resident #71) of five residents reviewed for Respiratory Care. Specifically, 1) Resident #42 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 and 8/7/2024. 2) Resident #71 had a physician's order for oxygen to be administered at 2 liters per minute via a nasal cannula. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 at 10:30 AM and 2:34 PM. This is a repeat deficiency.
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not ensure that outside professional services were furnished timely. This was identified for one (Resident #222) of one resident reviewed for Dignity and for one (Resident #150) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #222 was readmitted from the hospital on 7/13/2024 with a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). The hospital discharging physician recommended a follow-up with a Neurosurgeon within a week. The recommended consult was not completed as of 8/7/2024 when it was brought to the facility's attention by the Surveyor. 2) Resident #150 was admitted to the facility in November 2023. [...]
- 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 during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure medical records for each resident were complete and accurately documented. This was identified for one (Resident #90) of three residents reviewed for Choices. Specifically, Resident #90 had a physician's order for a finger stick blood glucose monitoring every morning. The Medication Administration Record did not include the finger stick blood glucose level results and the Vital Signs record had inconsistent documentation of the finger stick blood glucose level results. The finding is: The policy titled Blood Glucose Monitoring dated 7/2013 documented findings (of finger stick blood glucose levels) shall be documented in the medical chart. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of infections was maintained. This was identified for one (Resident #6) of five residents reviewed for Pressure Ulcers. Specifically, during a dressing change observation of Resident #6's sacral wound, Registered Nurse #15 did not change their gloves and did not wash their hands after cleansing the sacral wound and before applying the treatment. The finding is: The facility's Hand Washing Protocol dated 11/2017 documented to perform hand hygiene before and after each resident/patient contact. [...]
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, interviews, and record review during the recertification Survey and Abbreviated Survey (NY 00332930) initiated on 8/01/2024 and completed on 8/08/2024, the facility did not provide a safe, functional, sanitary, and comfortable environment. This was identified for two (Resident #131, Resident #5) of three residents reviewed for Environment. Specifically, the toilets that were mounted to the walls in Resident #131 and Resident #5's bathroom did not have appropriate support and reinforcement. The toilets were observed with wooden blocks underneath the toilet to provide support and reinforcement.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not provide each resident access to personal and medical records pertaining to themselves, upon an oral or written request, in the form and format requested by the individual. This was identified for one (Resident #222) of one resident reviewed for Dignity. Specifically, Resident #222 was readmitted to the facility from the hospital on 7/13/2024 and requested a copy of their hospital Discharge Summary, which was received by the facility upon the resident's return from the hospital. The facility did not make the requested discharge summary available to Resident #222 within the required timeframe. The finding is: [...]
December 16, 2022Standard inspection · 7 citations
- 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 interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00292215) initiated on 12/12/2022 and completed on 12/16/2022, the facility did not develop and implement a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was identified for one (Resident #399) of one resident reviewed for Tube Feeding. Specifically, Resident #399 was admitted to the facility on [DATE] and the baseline care plan developed for the Gastrostomy (G) tube did not include use of an abdominal binder. A baseline care plan for the use of the abdominal binder was not developed until 3/3/2022. The finding is: The policy titled: [...]
- 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 the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was identified for one (Resident #105) of three residents reviewed for Choices. Specifically, Resident #105 had documented Physician's Orders on 6/6/2022, 8/16/2022, and 10/22/2022 to have a bilateral breast mammogram which was never completed. The finding is: The facility's policy titled: Laboratory, Radiology and Other Diagnostic Services, last revised in August 2018, documented to provide, or obtain radiology and other diagnostic services only when ordered by a medical provider. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2) The facility policy entitled, Laboratory, Radiology and other diagnostic services, dated 8/2018 documented that the facility will provide radiology services only when ordered by a medical provider. The licensed nurse must ensure to pick up orders made by the Physician/Physician extenders. A stat order must be transcribed as soon as the nurse is made aware of the request. The licensed nurse will ensure to properly fill out the requisition form and must call the appropriate service provider immediately. A follow up call must be made by the licensed nurse to the appropriate service provider to ensure that stat order was received and acknowledged. The licensed nurse must document in the medical record any communication made with the appropriate provider. Resident #186 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure and Non-Alzheimer's Dementia. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that a resident who needs respiratory care, is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #57) of four residents reviewed for Respiratory Care. Specifically, Resident #57 had a diagnosis of Chronic Obstructive Pulmonary Disease and was observed receiving four liters of oxygen via a nasal cannula without a Physician's order. The finding is: Resident #57 was admitted with diagnoses that include Pneumonia, Chronic Obstructive Pulmonary Disease and Congested Heart Failure. [...]
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that Radiology services to meet the resident's needs were provided timely as ordered by a Physician. This was identified for one (Resident #105) of three residents reviewed for Choices. Specifically, 1) Resident #105 had documented Physician's Orders dated 6/6/2022, 8/16/2022, and 10/22/2022 to have a bilateral breast mammogram which was never completed; and 2) as a result of the mammogram not being completed, a Physician's order for bilateral breast ultrasound due to breast pain and to rule out breast mass was obtained on 10/27/2022. The bilateral breast ultrasound was not performed until 5 days later on 11/1/2022.
- D
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record review and interview during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that radiology services were obtained only when ordered by a Physician, Physician Assistant, or Nurse Practitioner. This was identified for one (Resident #186) of six residents reviewed for respiratory care. Specifically, Resident #186 received radiology services of an abdominal and chest x-ray without a Physician/Physician Assistant/Nurse Practitioner's order. The finding is: The facility policy entitled Laboratory, Radiology, and other diagnostic services dated 8/2018 documented that the facility will provide radiology services only when ordered by a medical provider. The licensed nurse must ensure to pick up orders made by the Physician/Physician extenders. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and interviews during the Recertification initiated on 12/12/2022 and completed on 12/16/22 the facility failed to maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and COVID-19 infection. This was identified on 1 of 5 units. Specifically, 1) On the Legrange Unit, a Transmission Based Precautions (TBP) sign was not observed for a resident who was COVID-19 positive; 2) a Certified Nursing Assistant (CNA #5) did not utilize appropriate Personal Protective Equipment (PPE) when entering a COVID-19 positive resident's room and did not discard all of the used PPE prior to leaving the COVID-19 positive resident's room. The finding is: [...]
Fire safety inspections
6 fire safety citations on file: 1 on November 19, 2025, 4 on August 8, 2024, 1 on December 16, 2022.
Every fire safety citation6 citations
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 19, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · December 16, 2022 · Corrected (the home has a date of correction)