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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
2F
Potential for minimal harm
0A
1B
0C
December 2, 2025Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (Complaint #2674904), the facility did not ensure that all alleged abuse violations were reported immediately but not later than two (2) hours after the allegation was made to the Administrator of the facility and to the State Survey Agency for one (1) (Resident #1) of three (3) residents reviewed. Specifically, staff did not report an allegation of physical abuse to the Administrator immediately which resulted in delayed reporting to the New York State Department of Health within the required time frames. The finding is: [...]
December 6, 2024Standard inspection · 5 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/06/24, the facility did not ensure the Director of Nursing served as a charge nurse, only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, the Director of Nursing worked as a charge nurse when the facility had a daily average census of greater than 60. The finding is: Review of a facility provided document titled Director of Nursing, last revised 2/2024, revealed the Director of Nursing ensures the health and well-being of our residents by being responsible for oversight and operations of the nursing department and its staff including staffing, training, and development, and management of personnel. [...]
- F
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 interview and record review conducted during the Standard survey completed on 12/6/24, the facility did not employ a qualified professional to furnish a specific service to be provided by the facility and the facility did not have that service furnished to residents by a person or agency outside the facility under an arrangement. Specifically, the facility did not have a dentist on their staff and did not have dental services provided by an outside person or agency under an arrangement. This had the potential to affect 78 of 78 residents. The finding is: The policy titled Dental Care Arrangements dated 6/18/18 documented routine or emergency dental services will be offered onsite on either staff or fee-for-services basis, as administered by or under either the personal or general supervision of a licensed and currently registered Dental consultant. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, record review, and interviews conducted during a Standard survey completed on 12/6/24, the facility did not ensure that all residents received services that provided reasonable accommodations of the resident's needs and preferences for one (Resident #1) of four residents reviewed. Specifically, the call system was not within reach as planned and unable to be used if desired. The finding is: The policy and procedure titled, Call Light/Call Bell/Nurse Call System with a revision date of 9/6/18, documented the Unit Manager/designee will ensure residents will be provided access to a call light when not in a common area of the facility, and the call light will be answered promptly by all nursing staff and unit clerks/designee when a resident signals for assistance. [...]
- 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, interview, and record review conducted during the Standard survey completed on 12/6/24, the facility did not develop a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for one (Resident #18) of three residents reviewed for elopement. Specifically, Resident #18 was assessed as a high risk for elopement and did not have a comprehensive care plan developed with interventions to address their wandering and exit seeking behaviors. The finding is: [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/11/24, the facility did not ensure that services being provided met professional standards of quality for one (Resident #37) of one resident reviewed. Specifically, provider orders were not implemented resulting in a delay in treatment. The finding is: Review of the policy titled Clinics and Consultations (dentist, podiatrist, optometrist, audiologist, other), last revised 03/19, documented designated staff will assist the resident in obtaining outside optometry services as ordered by a physician. The Unit Manager/Charge Nurse contacts the attending physician about the orders or recommendations of the consult. All onsite clinics are recorded in the nursing progress notes, including any recommendations from the medical consultant. [...]
May 3, 2023Standard inspection · 0 citations
December 6, 2021Standard inspection · 1 citation
- B
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/6/21, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) receives the necessary services to maintain grooming and personal hygiene. Specifically, two (Resident #13 and #25) of two residents reviewed for ADL's had long (#13) and dirty fingernails (#13, 25) during multiple observations.
Fire safety inspections
21 fire safety citations on file: 8 on December 6, 2024, 13 on May 3, 2023.
Every fire safety citation21 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 6, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 6, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · December 6, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 6, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · December 6, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · December 6, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 6, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · December 6, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · May 3, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 3, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 3, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · May 3, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 3, 2023 · Corrected (the home has a date of correction)