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
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
10E
1F
Potential for minimal harm
0A
0B
0C
May 26, 2026Standard inspection, Complaint inspection · 10 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 observations and interviews the facility failed to ensure that food was stored in accordance with professional standards for safe food handling and storage practice. Specifically, food items stored in the walk-in freezer, walk-in refrigerator, nutritional refrigerator, cook's freezer and dry storage room were observed open to air, undated, and/or without expiration dates.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a dignified experience for three (3) of four (4) residents (Residents #45, #118 and #145) reviewed for dignity. Specifically, 1) Licensed Practical Nurse # 10 was observed standing over Residents #118 and #145, who were seated at opposite ends of the dining table, while assisting them with eating. Additionally, Licensed Practical Nurse #10 provided other residents water and set up assistance while assisting Resident #118 and Resident #145 with eating and 2) Certified Nurse Aide #9 referred to Resident #45 as a feeder in the presence of other residents during the 05/18/2026 lunch service.
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview conducted during the survey, the facility failed to ensure Minimum Data Set assessments were completed and/or submitted timely for eight (8) of 8 residents reviewed for Minimum Data Set Resident assessments (Residents # 38, #53, #69, #77, #85, #112, #126, and #13).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two (2) of three (3) residents (Resident #112 and #182) reviewed for change in condition. Specifically, 1) Resident #112 received their daily 9 AM medications at approximately 2:30 PM on 04/13/2026 including the medications Isosorbide Mononitrate and Valsartan (blood pressure pills) for hypertension, Torsemide (water pill) for congestive heart failure, Trelegy Ellipta (inhaler) and Albuterol nebulizer medicine for asthma and 2)for Resident #182 with a history of urinary tract infection and reported complaints of urinary tract symptoms, urine was not collected timely for urinalysis/culture as per the 11/29/2024 physician order. [...]
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that residents consistently received necessary treatment and services to prevent and promote healing of pressure ulcers for three (3) of six (6) residents (Residents #s 81, 33 and 55) reviewed for pressure ulcers. Specifically, 1) heel offloading was not implemented as per physician order for Resident #81 with documented pressure ulcers to both heels, 2) heel offloading was not implemented as per physician order for Resident #33 who was assessed to be at risk for pressure ulcers, and 3) the use of heel booties was not implemented as per physician orders for Resident #55 who was assessed to be at risk for pressure ulcers and had observed redness to both heels.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections was implemented for one (1) of five (5) residents (Resident #7) reviewed for infection control. Specifically, enhanced barrier precautions were not implemented as per physician order for Resident #7 when Certified Nurse Aide #19 was observed turning and repositioning, feeding, and changing a soiled gown and Licensed Practical Nurse #16 was observed providing pressure ulcer wound care and repositioning assistance without wearing an isolation gown.
- 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 the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for one (1) of five (5) residents (Resident #33) reviewed for activities of daily living. Specifically, on multiple occasions from 05/18/2026-05/19/2026 Resident #33 was observed unkempt, unshaven and wearing the same clothing.
- 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 observation, record review, and interviews, the facility failed to ensure that needed services, care, and equipment were provided to ensure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for one (1) of five (5) residents (Resident #55) reviewed for position and mobility. Specifically, the use of a left-hand palm guard was not implemented as per physician order and the comprehensive care plan for Resident #55.
- D
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, the facility failed to ensure they implemented interventions correctly and consistently including adequate supervision consistent with the Resident's needs, goals, care plan, and physician's orders to prevent accidents for one (1) of five (5) residents (Resident #112) reviewed for accidents. Specifically, there was no documented evidence that every one-hour monitoring when in bed was implemented as per physician order prior to an 8/25/2025 fall, no documented evidence that Resident #112 was always kept in a supervised area when awake as per comprehensive care plan prior to an 8/31/2025 fall, and no documented evidence that Resident #112 was out of bed to their wheelchair on the 11:00 PM to 7:00 AM shift as per comprehensive care plan prior to a 03/27/2026 fall. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview the facility did not ensure each resident received necessary respiratory care in accordance with professional standards of practice for one (1) of two (2) residents (Resident # 10) reviewed for respiratory care. Specifically, Resident #10 with a physician order for oxygen administration via nasal cannula at two (2) to three (3) liters per minute as needed was administered continuous oxygen at two (2) and/or four (4) liters per minute. Additionally, there was no documented evidence in the administration record to indicate Resident #10 was receiving oxygen.
December 22, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and interviews during an abbreviated survey (2686442) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for one (1) out of three (3) residents (Resident #1) reviewed for consultations. Specifically, Resident #1 had a gastroenterology consult on 08/07/2025 and was recommended to start on the Linzess (a medication for chronic constipation). Licensed Practical Nurse #1 received Resident #1 at the facility following the consultation and documented there were no recommendations. There was no documented evidence that Resident #1 was ever ordered the Linzess (a medication for chronic constipation).
- 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 record review and interviews during an abbreviated survey (2686442) the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for 1 out of 3 residents (Resident #1) reviewed for consultations. Specifically, Resident #1, who had a known history of chronic constipation, had a gastrointestinal consultation on 08/07/2025 and was ordered to start on the medication Linzess (a medication for chronic constipation). Nurse Practitioner #2 saw Resident #1 on 08/17/2025 and documented they reviewed the consultation services, but there was no documented evidence of the medication being ordered for the resident. The facility also did not have the consultation documentation on the resident's record or available for review.
October 11, 2024Standard inspection, Complaint inspection · 13 citations
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00329183) from 10/3/2024 to 10/11/2024, the facility did not ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain their highest practicable wellbeing in accordance with the facility assessment. This was evident on 2 (5th Floor and 4th Floor) of 4 resident units. Specifically, 6 of 6 Certified Nursing Assistant personnel files contained no evidence of practical competency in basic nursing skills and activities of daily living, and 4 of 4 licensed nursing personnel files did not contain competency assessments of medication management.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00329183) from 10/3/2024 to 10/11/2024, the facility did not ensure a performance review of every nurse aide at least once every 12 months, and regular in-service education based on the outcome of these reviews. This was evident on 1 (5th Floor) of 4 resident units. Specifically, 6 of 6 Certified Nursing Assistant personnel files contained no evidence of performance evaluations and inservice based on the results of performance evaluations.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY00329183) from 10/03/24 to 10/11/24, the facility did not ensure residents were free of significant medication errors for 2 (Resident #202 and #96) of 9 residents reviewed for Medication Administration. Specifically, 1) Resident #202 was administered Lasix (diuretic) 20 milligrams and Losartan (antihypertensive) 100 milligrams without a physician's order, which resulted in the need for blood pressure monitoring every 30 minutes and intravenous fluids. 2) Resident #96 was about to receive a 4 milligram dose of Tizanidine (muscle relaxant) instead of the physician ordered 2 milligram dose during a medication observation that was stopped by the surveyor.
- E
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 observations, record review, and interviews conducted during the Recertification Survey from 10/03/24 to 10/11/24, the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice for 2 (Residents #12 and #96) of 8 residents reviewed for Medication Administration; and Medication and Treatment carts were observed unlocked. Specifically, 1.) Resident #12 was found with physicians ordered ipratropium nasal spray and an albuterol sulfate inhaler in their room on their bedside table. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 10/03/24 to 10/11/24, the facility did not ensure that infection control prevention practices and procedures were maintained by 3 of 4 nurses (Registered Nurse #3 and Licensed Practical Nurse #2 and Licensed Practical Nurse #1) during the medication administration observation. Specifically, 1) Registered Nurse #3 did not practice hand hygiene or sanitize vital signs equipment between residents, and touched a resident's eye lid with the eye dropper during administration. 2) Licensed Practical Nurse #2 did not practice hand hygiene or wipe down the blood pressure cuff prior to doing the resident's blood pressure and before placing it back into the vital signs machine basket. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 10/3/2024 to 10/11/2024, the facility did not ensure residents were treated with respect and dignity. Specifically, several nursing staff on the Dementia unit were observed without identification badges.
- D
Give residents a notice of rights, rules, services and charges.
Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted from 10/3/24 - 10/10/24, the facility did not ensure residents were informed during their stay of their rights and rules and regulations governing resident conduct and responsibilities. Specifically, the facility did not ensure resident rights were provided or reviewed during monthly Resident Council meetings.
- 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 observations, record review, and interviews conducted during the Recertification Survey from 10/03/24 to 10/11/24, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #96 ) reviewed for self-administration of medications. Specifically, the facility did not develop a care plan to address Resident #96 carrying and self-administering their albuterol sulfate aerosol inhaler.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 10/3/2024 to 10/11/2024, the facility did not ensure a resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This was evident for 1 (Resident #107) of 33 sampled residents. Specifically, Resident #107 exhibited behavior without any non-pharmacological intervention or staff interaction to address their behaviors.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 10/3/2024 to 10/11/2024, the facility did not ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #24) of 33 total sampled residents. Specifically, Resident #24 was observed sitting in the floor dayroom on multiple occasions without being engaged in meaningful activities.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 10/03/24 to 10/11/24, the facility did not ensure that it provided or obtained emergency dental services to meet the needs of each resident for 1 (Resident #56) of 2 residents reviewed for Dental Services. Specifically, Resident #56 was evaluated by the Dentist for a fractured front tooth on 7/25/24 and given a referral to have the tooth extracted. The facility did not schedule the appointment with the oral surgeon until 10/10/2024.
- D
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 interview conducted during the recertification survey from 10/3/24 through 10/11/24 the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, 1. Foods stored in nutrition and storage refrigerators were not labeled and dated. 2. Storage refrigerator meat was observed with Jello on the same shelf; and 3. staff were observed touching unsanitary surfaces and equipment with gloved hands, then preparing food without changing their gloves.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, record review and interview conducted during the recertification survey on 10/03/24 through 10/11/24 the facility did not ensure proper disposal of garbage and refuse. Specifically, the dumpsters/compactors on the exterior of the building was not maintained in a sanitary condition to prevent the harborage and feeding of pests.
March 8, 2022Standard inspection · 0 citations
Fire safety inspections
19 fire safety citations on file: 4 on May 26, 2026, 6 on October 11, 2024, 9 on March 8, 2022.
Every fire safety citation19 citations
- 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 · May 26, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 26, 2026 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 26, 2026 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 26, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 11, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 11, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 11, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 8, 2022 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · March 8, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 8, 2022 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · March 8, 2022 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 8, 2022 · 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 · March 8, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 8, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 8, 2022 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 8, 2022 · Corrected (the home has a date of correction)