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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
2L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
8E
2F
Potential for minimal harm
0A
0B
1C
August 1, 2025Standard inspection · 8 citations
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/28/2025-8/1/2025 the facility did not ensure sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 2 of 3 resident units (Units 1 and 3). Specifically, Unit 1's and 3's meal trays were consistently delivered after the posted scheduled mealtimes and concerns were identified with the effectiveness of meal preparation and other food and nutrition services. Deficiencies related to food and nutrition services were identified in F 809 Frequency of Meals/Snacks at Bedtime; F 812 Food Procurement, Store/Prepare/Serve; and F 814 Dispose of Garbage and Refuse Properly.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00385403) surveys conducted 7/28/2025-8/1/2025, the facility did not ensure residents had the right to a dignified existence for 2 of 3 units (First and Third Floors) reviewed. Specifically, the First floor meals were served more than 30 minutes late; the Third floor meals were served more than 30 minutes late, and dining table residents were not served together. Additionally, deficiencies were identified in sufficient dietary support personnel to safely and effectively carry out the functions of the food and nutrition service (F802) that led to an undignified dining experience.
- 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 conducted 7/28/2025-8/1/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in one (1) out of one (1) main kitchen. Specifically, the main kitchen was unclean, had damaged freezer storage equipment, improperly stored utensils, and improper storage of food products.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not ensure garbage and refuse was disposed of properly in one (1) of one (1) main kitchen. Specifically, the main kitchen garbage and refuse areas were not maintained to prevent attraction and harborage of pests.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not ensure as needed orders for psychotropic drugs were limited to 14 days for one (1) of five (5) residents (Resident #14) reviewed. Specifically, Resident #14 had a physician order for as needed Ativan (anti-anxiety medication) that was not reevaluated for appropriateness or discontinuation after 14 days.
- D
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently both during day-to-day operations and emergencies. The facility did not review and update the facility assessment as necessary. Specifically, the facility assessment did not accurately reflect the clinical nutrition staff and department heads.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of six (6) residents (Resident #4) reviewed. Specifically, during Resident #4's wound dressing treatment Licensed Practical Nurse #8 did not perform hand hygiene when changing from contaminated to clean gloves.
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on observations and interviews during the recertification survey conducted 7/28/2025 - 8/1/2025, the facility did not ensure one qualified individual, who was not the Director of Nursing, was responsible for the facility's Infection Prevention Control Program. Specifically, the Assistant Director of Nursing was not qualified based on education, training, experience or certification to assume the role of Infection Preventionist and the Director of Nursing assumed those duties.
September 30, 2024Complaint inspection · 3 citations
- L
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 abbreviated survey (NY00354300) the facility failed to ensure residents remained as free of accident hazards as possible for 7 of 55 residents (Residents #1, #4, #5, #6, #7, #8 and #9) reviewed. Specifically, Resident #1 who had severely impaired cognition, had a contour mattress and right side bed rail (assist rail) and was not assessed for appropriate alternatives to the bed rail, was not assessed for entrapment risk, did not have the risks and benefits of a bed rail reviewed, and there was no informed consent from the resident's representative before installation of the bed rail. Subsequently, the resident was found with their body out of the bed and their head wedged between the bed rail and the mattress and was pronounced deceased . [...]
- L
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interviews during the abbreviated survey (NY00354300), the facility failed to ensure correct installation, use, and maintenance of bed rails to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for 55 of 55 residents (Residents #1-#16 and #18-#56) reviewed. Specifically, Resident #1 had a contour mattress and a right side bed rail. The facility did not inspect and regularly check the mattress and bed rail for areas of possible entrapment. Additionally, the facility did not evaluate alternatives to bed rails, review the risks and benefits of bed rails with the resident or resident representative or obtain informed consent prior to the installation of bed rails for Resident #1 and all 54 residents with bed rails (Refer to F689). [...]
- F
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Inspectors wroteBased on observation, record review, and interviews during abbreviated surveys (NY00354147 and NY00354300), it was determined the facility and governing body failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F 689 Accident Hazards and F 700 Bedrails. Specifically, the facility's governing body did not establish and implement policies regarding the management and operation of the facility. Subsequently, there were outdated and a lack of operational policies and equipment to ensure resident safety.
August 22, 2024Standard inspection, Complaint inspection · 10 citations
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review and interviews during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not make prompt efforts to resolve resident grievances for 3 of 8 anonymous residents and for 5 additional grievances (Residents #38 [2 grievances], #47, #79, and #94) reviewed. Specifically, 3 residents from the Resident Council meeting stated their grievances were not always acted upon or resolved and they were not provided with a reason why. Additionally, there were five grievances that did not have documented resolution.
- 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 interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 4 of 8 residents (Resident #3, #58, #74, and #93) reviewed. Specifically, Resident #93's comprehensive care plan did not include pain management and hospice services; Resident #47's comprehensive care plan did not include the use of antipsychotic medications; Resident #74's comprehensive care plan did not include self-medication administration or diabetes; and Resident #3's comprehensive care plan did not include ordered interventions for edema (swelling).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY0032236) surveys conducted 8/19/2024-8/22/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 or 2 meal test tray (the 8/20/2024 and 8/21/2024 lunch meals) reviewed; for 8 of 8 anonymous residents present at the Resident Council meeting, and for 6 additional residents (Residents #3, #35, #36, #44, #63, and #74) interviewed during initial screening. Specifically, the 8/20/2024 and 8/21/2024 lunch meals were not served at palatable and appetizing temperatures and were not flavorful. Additionally, 8 anonymous residents at the Resident Council meeting and Residents #3, #35, #36, #44, #63, and #74 stated the food was cold and unappetizing.
- 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 interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen. Specifically, in the main kitchen potentially hazardous foods were not cooled properly, there were several unclean areas, and the food storage areas contained unprotected food products.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #74) reviewed. Specifically, Resident #74 was observed with medications stored in an unlocked drawer of their dresser, and there was no documented evidence the interdisciplinary team had assessed the resident's ability to safely self-administer medication.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #71) reviewed. Specifically, Resident #71's call bell was not in reach as care planned.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00322036) surveys conducted 8/19/2024-8/22/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 2 of 3 residents (Residents #6 and #71) reviewed. Specifically, Residents #6 and #71 were not assisted with toileting as planned.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 1 resident (Resident #3) reviewed. Specifically, Resident #3 did not have their elastic compression bandage (ACE wrap) applied as ordered.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 2 residents (Resident #31 and #58) reviewed. Specifically, Resident #31 did not have a pillow between their left arm and body for pressure relief as care planned, and Resident #58 did not have pressure relief for their heels as planned.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection for 1 of 2 residents (Resident #31) reviewed. Specifically, Resident #31's wound care was completed without appropriate hand hygiene, clean supplies, and precautions to prevent contamination of the wound. Additionally, three infection control policies were not reviewed annually as required.
April 10, 2024Complaint inspection · 2 citations
- E
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 the abbreviated survey (NY00329178), the facility did not ensure adequate supervision was provided to prevent accidents for 1 of 7 residents reviewed (Resident #5). Specifically, Resident #5 experienced increased anxiety and aggressive behaviors towards Residents #4, 6, 7, 8, 9, and 10 and the facility did not ensure adequate supervision was provided to prevent behaviors directed towards others.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review during the abbreviated survey (NY00329178), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated or reported to the New York State Department of Health timely when required for 3 of 10 residents (Resident #6, 9 and 10) reviewed. Specifically, Residents #5 and 6 had physical altercations that were not thoroughly investigated and altercations involving Residents #5, 6, and 9 were not reported to the New York State Department of Health as required.
September 1, 2022Standard inspection · 2 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review during the recertification survey conducted 8/29/22-9/1/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 3 residents (Residents #54 and 76) reviewed. Specifically, Resident #54 received an altered consistency diet, had a significant weight loss, did not receive assistance at meals as care planned, and was not reassessed by clinical nutrition staff to address weight loss. Resident #76 had a significant weight loss, was not reassessed by clinical nutrition staff, and had further significant weight loss.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview during the recertification survey conducted 8/29/22-9/1/22, the facility failed to post on a daily basis, at the beginning of each shift, in a prominent place readily accessible to residents and visitors, nurse staffing information including the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. Specifically, the facility did not post nurse staffing information in an accessible place for residents and visitors as required.
Fire safety inspections
25 fire safety citations on file: 10 on August 1, 2025, 12 on August 22, 2024, 3 on September 1, 2022.
Every fire safety citation25 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 1, 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 · August 1, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 1, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 1, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 1, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 1, 2025 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · August 1, 2025 · Corrected (the home has a date of correction)
- D
Install a two-hour-resistant firewall separation.
K 133 · August 1, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 1, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 1, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 22, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 22, 2024 · 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 · August 22, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 22, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 22, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 22, 2024 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 22, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 1, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · September 1, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 1, 2022 · Corrected (the home has a date of correction)