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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
29D
4E
0F
Potential for minimal harm
0A
1B
1C
November 19, 2025Standard inspection, Complaint inspection · 12 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on one (1) (Unit 2) of six (6) resident units reviewed for the Sufficient Nursing Staffing Task. Specifically, the Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Three (3) 2025 (April 1st- June 30th) indicated that the facility had excessively low weekend staffing. Additionally, two (2) (Resident #4 and #214) out of nine (9) residents in the Resident Council Task reported complaints about short staffing; [...]
- D
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 Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #5) of one (1) resident reviewed for Dignity. Specifically, on 09/11/2025, Resident #5 was observed in bed sleeping with a clear plastic bag tied to their bed rail, visible from the hallway. The plastic bag was filled with soiled briefs, smeared feces, and used tissues. There was no staff within the vicinity of Resident #5's room. The finding is:The facility's policy titled Dignity, last revised on 09/04/2025, documented that residents are treated with dignity and respect at all times. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure the Minimum Data Set (MDS) assessment was completed to accurately reflect each resident's status. This was identified for one (1) (Resident #6) of five (5) residents reviewed for Nutrition and for one (1) (Resident #7) of two (2) residents reviewed for Urinary Catheter or UTI (Urinary Tract Infection). Specifically, 1) Resident #6 had a significant weight loss, which was not identified in the 5-Day Minimum Data Set assessment dated [DATE], and 2) Resident #7's bladder and bowel function related to the use of an indwelling catheter was not accurately reflected in the quarterly Minimum Data Set assessment dated [DATE].
- 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 during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical and nursing needs. This was identified for one (1) resident (Resident #1) of three (3) residents reviewed for Respiratory Care and for one (1) (Resident #80) of one (1) resident reviewed for Insulin. Specifically, 1) Resident #1 had a Physician Order for Oxygen continuously at two (2) liters per minute. During observations on 09/11/2025, Resident #1 was receiving oxygen at five (5) liters per minute, and on 09/12/2025, the resident was receiving oxygen at three (3) liters per minute. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain grooming and personal hygiene. This was identified for one (1) (Resident #131) of two (2) residents reviewed for Activities of Daily Living. Specifically, Resident #131, who had severely impaired cognition and required staff assistance with Activities of Daily Living, was not dressed and assisted out of bed until after 2:00 PM. The assigned Certified Nursing Assistant #2 did not provide morning care to Resident #131 because they were providing care to the other residents on their assignment. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (1) (Resident #27) of three (3) residents reviewed for Hydration. Specifically, Resident #27 was observed on 9/11/2025 at 10:53 AM with a peripheral intravenous catheter (a short flexible tube inserted into a peripheral vein to deliver fluids, medications, and blood products directly into a patient's bloodstream) to the left forearm covered with a transparent dressing that was dated 08/28/2025. Additionally, there was no Physician's order to flush the intravenous catheter and monitor the area. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (1) (Resident #240) of five (5) residents reviewed for Nutrition. Specifically, Dietitian #2 recommended Resident #240 to receive a liquid nutritional supplement of Two Cal HN (protein and calorie-dense supplement) twice daily for additional calories and protein; however, the supplement was never ordered. The finding is: [...]
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (2609906) initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure the medical care of each resident was supervised by a Physician. This was identified for one (1) (Resident #246) of three (3) residents reviewed for Hospitalization. Specifically, Resident #246's Physician indicated in multiple progress notes that the resident's Foley urinary catheter should be flushed with normal saline. However, there was no physician's order written for flushing the catheter, and no documented evidence that the catheter was flushed by the nursing staff. The finding is:The undated facility policy titled Foley Catheter Care and Privacy documented the catheter should be monitored for patency (free flowing). [...]
- D
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 observation, record review, and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #5) of five (5) residents reviewed for Accident Hazards. Specifically, a tube of unlabeled Lidocaine and Prilocaine (local anesthetic that numbs tissue) cream 2.5 percent was observed on Resident #5's overbed table. There was no Nursing staff in the vicinity of Resident #5 's room. Resident #5 was not assessed to self-administer their medications. The finding is:The facility's policy titled Medication Labeling Storage Policy, last revised on 06/19/2025, documented that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interviews, during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that each resident's medical record was in accordance with accepted professional standards and practices and was complete and accurately documented. This was identified for one (1) (Resident #7) of two residents reviewed for Urinary Catheter. Specifically, Resident #7's Foley Catheter was removed on 06/11/2025 for a voiding trial (an assessment to see if the resident can effectively urinate after a catheter is removed); however, the Physician's order, comprehensive care plan, and nursing assistant instruction (Kardex report) continued to document that Resident #7 required Foley Catheter care until September 2025. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for two (2) (Resident #99 and #238) of four (4) residents observed during Medication Administration. Specifically, during the medication administration observation, Licensed Practical Nurse #5 did not perform hand hygiene after administering medications for Resident #238 and before preparing the medications to administer to Resident #99. The finding is:Resident #238 was admitted to the facility with diagnoses including Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Diabetes. [...]
- C
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that residents and their representatives had a full understanding of arbitration agreements. This was identified for four (Residents #14, #24, #15, and #131) of the four residents reviewed for the Arbitration task. Specifically, interviews with Residents #14, #24, #15, and a representative for Resident #131 all stated they were not aware that they had accepted an arbitration agreement and did not have a full understanding of the agreement. The finding is:The facility's policy titled Binding Arbitration, dated 11/05/2024, documented residents or representatives are informed of the nature and implications of any proposed binding arbitration agreement so as to make informed decisions on whether to enter into such agreements. [...]
April 21, 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, interviews and record review during an abbreviated survey conducted on 3/19/2025 through 04/21/2025 for case number NY00375018 the facility failed to protect each resident's right to be free from physical abuse. This was identified for one (Resident #1) of three residents reviewed for physical abuse. Specifically, video surveillance showed Licensed Practical Nurse #1 pointing their right finger at Resident #1's face. Licensed Practical Nurse #1 reaches forward with both hands, places them at Resident #1's neck, and pushes them backwards in their wheelchair. The incident was discovered when a staff member was reported as injured by Resident #1.
September 27, 2024Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interviews and record review during an abbreviated survey conducted on 9/3/24 through 9/27/24, the facility did not ensure that the alleged violations involving abuse, including injuries of unknown source, neglect, or mistreatment were reported within 24 hours to the New York State Department of Health. This was identified for two (Resident #1 and Resident #2) of three resident records reviewed for Abuse. 1) Specifically, Resident #1 was observed with areas of bruises to their forehead and area above their right eye. The cause of this injury was unknown. 2) Resident #2 was pushed by another resident and fell to the ground hitting their head on 08/06/2024 and neither (Resident #1 and Resident #2) incidents were not reported to the New York State Department of Health as required.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interviews and record review during an abbreviated survey conducted on 9/3/24 through 9/18/24, the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment, including an injury of unknown origin were thoroughly investigated. This was identified for 2 of 3 residents reviewed for abuse. Specifically, 1) Resident # 1 was observed with an injury of unknown origin to the right side of their face and eyebrow area on 9/1/24. 2) Resident #2 was pushed by another resident and fell to the ground hitting their head on 08/06/2024. There is no documented evidence that the facility did a thorough investigation of the incidents to identify the root cause of the injury and to rule out Abuse, Neglect, and Mistreatment. This is a repeat deficiency.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews and record review during an abbreviated survey conducted on 9/25/24 through 9/27/24, the facility did not ensure that care was provided in accordance with professional standards and by individuals qualified to do so. Specifically, the facility had a Licensed Practical Nurse serving in the capacity of Unit Manager completing assessments for 17 out of 17 reviewed records following accidents and falls on their unit. This Licensed Practical Nurse placed their name on the form in the space titled Registered Nurse Supervisor and signed their name and title on the completed document which is out of the scope of practice for a Licensed Practical Nurse.
May 7, 2024Standard inspection, Complaint inspection · 12 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00337626) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that all incidents including the injury of unknown origin were thoroughly investigated. This was identified for two (Resident #530 and Resident #140) of six residents reviewed for Accidents and for one (Resident #133) of three residents reviewed for Abuse. Specifically, 1) on 2/16/2024 Resident #530 was found on the floor and sustained a hematoma (bruising) to the forehead and skin tears on both arms. The facility did not thoroughly investigate the incident to identify the root cause and to rule out Abuse, Neglect, and Mistreatment. Additionally, the facility did not ensure that the investigation summary of the incident was completed within 5 days as required. [...]
- E
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 review, and interviews during the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024, 1) the facility did not ensure that 1) medications were administered within one hour of the ordered administration time on two (Unit 2 [NAME] and Unit 1 West) of four units during unit observations, and 2) the drug records were in order and accounted for all controlled drugs on one (Unit [NAME] 1) of six units observed during the medication storage task. Specifically, 1) on 4/29/2024 on Unit 2 [NAME] in the Glengariff building, three residents (Resident #126, #131, and #32) did not get their 9:00 AM medications within one hour of the physician-ordered administration time; [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Extended Survey (NY 00321997) initiated on 4/29/2024 and completed on 5/7/2024 the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. This was identified for two (Resident #151 and Resident #82) of three residents reviewed for Abuse. Specifically, Resident #151 and Resident #82 were involved in a resident-to-resident altercation on 8/11/2023, in which Resident #151 was allegedly pushed by Resident #82 and fell to the floor. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interviews and record review during the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that preadmission screening for individuals with a mental disorder and individuals with intellectual disability was conducted prior to their admission to the facility. This was identified for one (Resident #18) of 40 residents reviewed for Pre-admission Screening and Resident Review (a federal requirement to ensure that residents were not inappropriately placed in a skilled nursing facility). Specifically, Resident # 18 was admitted [DATE], the Level 1 Pre-admission Screening and Resident Review (PASARR) screening was not completed by the facility staff until 7/16/2023, two days after the resident's admission to the facility. 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 interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Resident #531) of six residents reviewed for Accidents. Specifically, Resident #531 was not assessed to safely self-administer their medications. On [DATE] an inhaler (handheld devices that allow you to breathe medicine in through your mouth, directly to your lungs) was observed in Resident #531's room with no staff member present. The inhaler did not have a label that indicated the resident's name or direction for the administration. Additionally, Resident #531 did not have a Physician's order for the use of the inhaler. The finding is: [...]
- 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 initiated on 4/29/2024 and completed on 5/7/2024 the facility did not ensure that the medication regimen review recommendations that were approved by the physician were implemented. This was identified for one (Resident #24) of five residents reviewed for unnecessary medications. Specifically, on 3/12/2024 the consultant Pharmacist recommended the addition of a calcium supplement to Resident #24's medication regimen. The resident's Physician approved the recommendation made by the consultant Pharmacist; however, there was no physician's order written for the calcium supplement and the resident did not receive the recommended supplement. The finding is: [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that each resident's drug regimen was free from unnecessary medication. This was identified for one (Resident #166) of five residents reviewed for Unnecessary Medications. Specifically, on 2/20/2024 and again on 3/12/2024, Resident #166's Physician agreed to discontinue Oxybutynin (medication to treat bladder overactivity) and Benadryl (anti-allergy medication) as per the recommendations made by the consultant Pharmacist because the medications were no longer medically required. Resident #166 continued to receive Oxybutynin Extended Release 5 milligrams from 2/20/2024 to 5/5/2024 and received Benadryl Allergy oral tablet 25 milligrams on 3/22/2024, 3/29/2024, 5/4/2024 and 5/5/2024. The finding is: [...]
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on record review and interviews during the Recertification and Abbreviated (NY 00331067) Survey initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure each resident received routine dental services to meet the needs of each resident. This was identified for one (Resident #127) of one resident reviewed for Dental Services. Specifically, Resident #127 had a dental consult completed on 3/18/2024. The dental consult documented recommendations for a dental follow-up visit in one week with medical clearance for tooth extraction. There was no documented evidence that the recommendations made by the Dentist were addressed until 5/7/2024. The finding is: The facility's Dental Services policy last revised in December 2023, documented to provide residents with routine and emergency dental services. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00337626) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not immediately notify the resident's Designated Representative when there was a significant change in the resident's physical status. This was identified for one (Resident #140) of one resident reviewed for Notification of Change. Specifically, on 3/17/2024 Resident #140 fell and hit their head on a radiator and was identified to have sustained a scalp laceration. Subsequently, the resident was transferred to the hospital for evaluation on 3/17/2024. There was no documented evidence that the resident's designated representative was notified of the resident's fall and the resident's transfer to the hospital until 3/19/2024. The finding is: [...]
- 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 the Recertification Survey and Extended Survey (NY 00337759) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that a physician wrote, signed, and dated a progress note at each visit. This was identified for one (Resident #126) of two residents reviewed for Hospitalization. Specifically, on 3/17/2024 Resident #126 reported experiencing stroke-like symptoms. Physician #1 examined the resident but did not document the examination findings in the resident's medical record. Subsequently, the resident was transferred to the hospital after the resident's family activated emergency medical services and was diagnosed with a possible acute Cerebral Vascular Insufficiency. The finding is: [...]
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview, and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY 00339556) initiated on [DATE] completed on [DATE], the facility did not ensure that all residents were provided medically-related social services to attain or maintain the highest practicable well-being. This was identified for one (Resident #380) of one Resident reviewed for Hospice and End of Life. Specifically, Resident #380 was admitted to the facility with a deteriorating health condition due to a diagnosis of Cancer. On [DATE] (Saturday) upon request of Resident #380's designated representative the Physician wrote an order to obtain a Hospice service referral. The facility's Social Worker or designee was not available to request the physician-ordered Hospice service referral until Monday ([DATE]). [...]
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00339556) initiated on [DATE] and completed on [DATE], the facility did not ensure that all residents were assisted with the provision of Hospice services when a resident requested a transfer. This was identified for one (Resident #380) of one Resident reviewed for Hospice and End of Life. Specifically, Resident #380's designated representative requested Hospice services on [DATE] and a referral was not provided until [DATE]. Resident #380 expired on [DATE] shortly after the referral to the Hospice services was made. The finding is: The facility Comfort Care and Palliative Care policy and procedure revised on 12/2023 documented it is the policy of the facility to respect the wishes of the residents and their designated representatives regarding end-of-life decisions. [...]
August 9, 2022Standard inspection · 7 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, and interviews, conducted during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022, the facility did not ensure that the facility's medication error rates are not five percent or greater. This was identified for 15 of 25 opportunities during a medication pass observation resulting in a 60% medication error rate. Specifically, 1) Resident #109 did not receive the Physician ordered 9 AM medications until 12:20 PM. 2) Resident #433 did not receive the Physician ordered 9 AM medications until 12:50 PM. 3) Resident # 150 did not receive the Physician ordered 9 AM medications until 1 PM.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey and abbreviated survey (NY 00297469 and NY 00290555) initiated on 8/02/2022 completed on 8/9/2022 the facility did not ensure that for each resident the resident's representative or physician were notified immediately when there was a change in condition. This was identified for 1 (Resident #432) of 3 residents reviewed for change of condition and one (Resident #483) of 2 residents reviewed for hospitalization. Specifically, 1) Resident #432 developed an infection and required Intravenous (IV) antibiotics; however, the resident's representative was not notified of initiation of the IV antibiotic therapy for the resident. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #83) of 6 residents reviewed for Pressure Ulcers; and 2 of 10 Resident Council attendees (Resident #127 and Resident #118) who complained of not receiving wound care treatments consistently. Specifically, 1) Resident #83 was identified with an open area to the left lateral Malleolus (outer ankle) on 7/15/2022. There was no assessment or treatment provided until six days later on 7/21/2022; however, the assessment did not include the size, depth, or type of wound until 7/27/2022 when the resident was seen by the wound care Physician. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022, the facility did not ensure that all residents received adequate supervision to prevent Accidents. This was identified for one (Resident #7) of five residents reviewed for Accidents. Specifically, Resident #7, who required extensive assistance of one person for personal hygiene, was observed shaving themselves with a razor without supervision. The finding is: The Facility's Hazardous Area, Devices and Equipment Policy dated 4/24/2022, documented all hazardous devices in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards. A hazard is defined as anything in the environment that has the potential to cause injury or illness. [...]
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated survey (NY00280683) initiated on 8/2/2022 and completed on 8/9/2022 the facility did not promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's order. This was identified for 1 (Resident #582) of 3 residents reviewed for change in condition. Specifically, Resident #582 had Urine Analysis and Culture and Sensitivity (UA and CS) report results that were outside of clinical reference ranges; however, there was no documented evidence that these results were reviewed either by the physician or the nursing staff prior to the resident being sent to the hospital. [...]
- 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 interview during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022, the facility did not ensure that the facility assessment included what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility assessment did not include the overall number of facility staff needed to ensure that a sufficient number of qualified nursing staff are available to meet each resident's needs. The finding is: The facility assessment dated [DATE] documented that the staffing plan was based on the resident population and their needs for care/support. The staffing plan portion of the facility assessment documented that the number of hours in a two-week period for licensed nurses providing direct care was 4,040 and 8,184 hours for nurse aides. [...]
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022 the facility did not ensure that completed Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days as required. This was identified for 3 (Resident #1, #2, and #3) of 3 residents reviewed for the Resident Assessment Facility Task. Specifically, Resident #1's Medicare 5-day MDS assessment was not electronically transmitted to CMS until 19 days after completion of the assessment; Resident #2's Significant Change in Status MDS assessment was not electronically submitted to CMS until 32 days after completion of the assessment; Resident #3's Admission/5-day MDS assessment was not electronically submitted to CMS until 21 days after completion of the assessment.
Fire safety inspections
22 fire safety citations on file: 2 on November 19, 2025, 2 on May 7, 2024, 18 on August 9, 2022.
Every fire safety citation22 citations
- F
Use approved construction type or materials.
K 161 · November 19, 2025 · Not yet corrected
- E
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · November 19, 2025 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · May 7, 2024 · Waiver
- 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 7, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · August 9, 2022 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 9, 2022 · Corrected (the home has a date of correction)
- F
Have properly sized and located compartments to protect residents from smoke.
K 371 · August 9, 2022 · Waiver
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 9, 2022 · Corrected (the home has a date of correction)
- E
Provide at least two remote exits on each floor or fire section of the building.
K 252 · August 9, 2022 · Waiver
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · August 9, 2022 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · August 9, 2022 · Waiver
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 9, 2022 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 9, 2022 · Corrected (the home has a date of correction)
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · August 9, 2022 · Waiver
- D
Have properly spaced exits within rooms.
K 261 · August 9, 2022 · Waiver
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 9, 2022 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · August 9, 2022 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · August 9, 2022 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · August 9, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 9, 2022 · Corrected (the home has a date of correction)
- C
Provide primary/alternate means for communication.
E 32 · August 9, 2022 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · August 9, 2022 · Corrected (the home has a date of correction)