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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
0E
0F
Potential for minimal harm
0A
0B
0C
May 16, 2025Standard inspection · 1 citation
- 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 conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that all drugs and biological were stored in accordance with currently accepted professional principles. This was evident in 1 (Unit C) of 2 units observed. Specifically, expired medications were stored in Unit C medication cabinet.
January 23, 2024Standard inspection · 5 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure a resident's right to receive services with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #15) of 21 total sampled residents. Specifically, Resident #15 was prevented from using their room's bathroom due to the door being locked.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 01/16/2024 to 01/23/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit C) of 3 units. Specifically, resident rooms had loose wires and dusty, dirty equipment, and the floor dining room had dirty window shades.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident in 1 (Resident #30) of 18 total sampled residents. Specifically, Resident #30 fall resulting in spinal fracture was not reported to the New York State Department of Health.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not services provided met professional standards of quality. This was evident for 1 (Resident #16) 18 total sampled residents. Specifically, the nurse did not inform Physician #1 of Resident #16's high fingerstick blood sugar readings in accordance with Physician's Orders.
- 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 observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #16) 18 total sampled residents. Specifically, Physician #1 did not address Resident #16's consistently high blood glucose levels.
February 16, 2022Standard inspection · 4 citations
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on observation, record review and interview conducted during the Recertification/Complaint Survey, the facility did not ensure that a Significant Change (MDS) Minimum Data Set assessment was completed for a resident within 14 days of determining the status change was significant. Specifically, a resident who had a change in Activity of Daily Living (ADL), in more than 2 care areas did not have a significant change assessment initiated within 14 days. This was evident for 1 of 1 resident reviewed for ADL decline, out of a sample of 23 residents. (Resident #14).
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interviews, during the Recertification/Complaint Survey, the facility did not ensure that Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a resident's Discharge Assessments were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for 1 of the 2 residents reviewed for Resident Assessment, out of a sample of 23 residents. (Resident #2). The CMS RAI Version 3.0 Manual (Dated October 2017) was referenced. Chapter 5 titled Submission and Correction of the MDS Assessments was reviewed. The MDS completion date must be no later than 14 days after the ARD for all non-admission, OBRA, and PPS assessments. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review and staff interviews during the recertification survey , the facility did not ensure that each resident's drug regimen must be free from unnecessary drugs when used in the presence of adverse consequences which indicate the dose should be reduced or discontinued. This was evident in 1 of 1 resident reviewed for change in condition in a sample of 16. (Resident #39) The finding is : The facility policy titled, Laboratory (LAB) and Diagnostic Test Results with effective date of 1/2016 documents, Assessment and Recognition: The physician will identify and order diagnostic test and lab testing based on diagnostic and monitoring needs. The staff will process test requisition and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. [...]
- 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 and interviews conducted during the recertification and abbreviated survey, the facility did not ensure that drugs and biological's were stored under proper temperature. Specifically an eye drop that was supposed to be kept refrigerated before opening was found sitting in the cart top drawer unopened. This was evident during the facility Medication Storage Task on 1 of 3 units. (Unit A-first floor)
Fire safety inspections
16 fire safety citations on file: 14 on May 16, 2025, 1 on January 23, 2024, 1 on February 16, 2022.
Every fire safety citation16 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 16, 2025 · 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 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 16, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 16, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 16, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · May 16, 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 · May 16, 2025 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · May 16, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · January 23, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 16, 2022 · Corrected (the home has a date of correction)