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
4E
6F
Potential for minimal harm
0A
0B
1C
January 22, 2025Standard inspection, Complaint inspection · 14 citations
- F
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 observations and interviews conducted during the Recertification and Extended survey from 01/14/2025 to 01/22/2025, the facility did not ensure that a safe, clean, comfortable homelike environment was provided. This was evident on all resident units (Unit 6, 4, 3, 2 and 5). Specifically, rooms were not cleaned, walls were discolored and in disrepair, bathrooms were not cleaned, wheelchairs were soiled, window treatments were soiled, window ledges were damaged, and resident's dining areas were in disrepair. This resulted in a finding of Substandard Quality of Care and an Extended Survey was conducted.
- F
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 observation, record review, and interviews conducted during the Recertification and Abbreviated Survey (Complaint #NY00363144) conducted from 01/14/2025 to 01/22/2025, the facility did not ensure that the sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). review of the actual staffing schedules dated from 10/01/2024 to 12/31/2024 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment for Certified Nursing Assistants, 2). the facility Payroll Based Journal (Quarter 1 2024 (October 1 - December 31) also revealed an excessively low weekend staffing, 3). [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, several perishable food items were stored on a food rack in the refrigerator and were not dated, a tray of seasoned chicken with no date was placed on top of thawing chicken, freezer temperatures were outside of acceptable range and food was not stored appropriately, standing water was observed on the floor of the dry storage room, broken floor tiles observed in different areas, and staff were observed not wearing hair restraints while assembling food trays. This was observed during the Kitchen task.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification, Complaint and Extended survey from 01/14/2025 to 01/22/2025 and Extended Survey on 01/22/2025, the facility did not ensure effective and efficient administration of its resources to attain or maintain highest practicable well-being of each resident. Specifically, the facility administration 1) did not provide a safe, clean, comfortable, and homelike environment to the residents; 2) did not sufficiently staff the facility; 3) did not have activities that met the interest or needs for each resident; 4) did not monitor and enhance the quality of care and service by repeating the same deficiencies including F695 Respiratory/Tracheostomy Care, F725 Sufficient Nursing Staff, and F880 Infection Prevention & Control. [...]
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, record review, and staff interviews during the Recertification and Extended Survey from 01/14/2025 to 01/22/2025, the facility did not ensure that it provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evidenced by multiple observations of the outside front entrance, staff bathrooms, elevators and nursing stations.
- E
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on record review and staff interviews during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 185 resident accounts maintained at the facility.
- E
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on interview and record review during a Recertification and Extended survey from 01/14/2025 through 01/22/2025, the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment. Specifically, for 6 of 6 employee files reviewed, the facility did not include effective communications as a mandatory training for direct care staff.
- E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on interview and record review during a Recertification and Extended survey from 01/14/2025 through 01/22/2025, the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment. Specifically, for 6 of 6 employee files reviewed, the facility did not provide mandatory training that outlines and informs staff of the elements and goals of the facility's Quality Assurance Performance Improvement program as part of its Quality Assurance Performance Improvement program.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not ensure that residents' personal funds in excess of $50, for residents whose care was funded by Medicaid, and in general resident funds in excess of $100 were placed in an interest-bearing account. This was evident for 2 (Resident #59 and Resident #56) of 2 resident reviewed for Personal Funds out of 39 sampled residents. Specifically, the Resident Funds Ledgers for Resident #59 and Resident #56 did not reflect that interest was earned and deposited into the accounts.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 01/14/2025 to 1/22/2025, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident. This was evident for 1 (Resident #42) of 1 resident reviewed for Activities out of 37 total sampled residents. Specifically, Resident #42 who had severely impaired cognition, was observed for extended periods of time without meaningful activities, and there was no activity plan to provide activities to the resident while in the dining room.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review and interview conducted during the Recertification survey, from 01/14/2025 to 01/22/2025, the facility did not ensure that a resident that needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. This was evident for 1 (Resident #138) of 3 residents reviewed for Respiratory Care out of a sample of 37 residents. Specifically, Resident #138 did not receive continuous oxygen as per physician orders. The finding is: The facility Policy and procedure titled Oxygen Therapy dated 06/17/24 stated that all residents shall receive oxygen therapy when necessary and in accordance with physician's orders. The policy also stated that nursing staff will set up check and supervise all treatments. [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 01/14/2025 to 01/22/2025, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, the garbage was not properly contained outside of the facility and various types of garbage were observed overflowing around the dumpster. The finding is: The facility policy and procedure titled Waste and Garbage Removal dated 12//05/2024 documented that all garbage is placed in a 35-yard compactor, door closed, and power button pressed. The policy also documented that all cardboard is broken down flat and placed in 7.5 yards dumpster. On 01/16/2025 at 11:50 AM, Dietary Aide #1 was observed taking garbage from the kitchen to the garbage disposal area. The compactor was observed with the door open and two clear garbage bags blocking the opening of the compactor. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 01/14/2025 to 01/22/2025, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Residents #169) of 2 residents reviewed for Tube Feeding out of 37 sampled residents. Specifically, appropriate handwashing was not practiced and Enhanced Barrier Precautions were not maintained during tube feeding administration.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 01/14/2025 to 01/22/2025 the facility did not ensure the daily nurse staffing information included all the required information. Specifically, the daily posting of nurse staffing information did not include the actual number of hours worked by the licensed and unlicensed nursing staff directly responsible for resident care. This was evident during the review of the Staffing Task. The finding is: During multiple observations from 01/14/2025 through 01/22/2025, the nurse staffing information was posted in the lobby near to the security desk. The information that was documented on the form included the facility name, current date, resident census and number of Certified Nursing Assistants, License Practical Nurse, and Registered Nurses on each shift. [...]
February 5, 2024Complaint inspection · 1 citation
- 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 conducted during an Abbreviated Survey (NY00332082), the facility did not ensure that Resident #1 received adequate supervision. This was evident in one of the seven residents sampled (Resident #1). Specifically, on 01/23/24 at 06:24 PM, Resident #1, whose cognition was moderately impaired, left the building for four hours and 21 minutes before staff realized that Resident #1 was missing from the unit. A review of the facility's camera footage showed that Resident #1 exited through the facility's main entrance door on 01/23/24 at 6:24 PM. Security Guard #1 was sitting at the front desk, buzzed the door open, and Resident #1 exited the door.
January 5, 2023Standard inspection · 8 citations
- F
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 conducted during the Recertification and Complaint (NY00293868 and NY00297460) survey from 12/22/22 to 01/05/23, the facility did not ensure there was sufficient nursing staff available to meet the residents' needs considering the number, acuity and diagnoses of the facility's resident population as determined by the Facility Assessment (FA). This was evident during review of Sufficient Staffing. Specifically, 1.) Resident #120's wound care was not administered daily according to Medical Doctor Order (MDO), 2.) during the Resident Council Meeting, Resident #82, #100, and #165 reported there are times when there is no nurse on the unit , and 3.) the actual staffing for Licensed Practical Nurses (LPN) was less than the necessary LPNs as determined by the FA.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 12/22/22 to 1/5/23 the facility did not ensure resident Comprehensive Care Plans (CCP) were reviewed and revised with each assessment and as needed with interventions to reflect the resident's changing needs. This was evident for 2 (Resident #98 and #62) of 39 total sampled residents. Specifically, 1.) multiple CCPs for Resident #98 that were not reviewed and revised upon quarterly Minimum Data Set 3.0 (MDS), and 2.) the CCP related to nutrition and activities of daily living (ADL) were not reviewed and revised for Resident #62.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview conducted during the recertification survey from 12/11/22/ to 12/16/22, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments accurately reflected a resident's status. This was evident for 1 (Resident #16) of 39 total sampled residents. Specifically, the MDS for Resident #16 Preadmission Screening and Resident Review (PASRR) was coded incorrectly.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification and Abbreviated survey (ACTS # NY00297460) from 12/22/22 to 01/05/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #120) of 39 total sampled residents. Specifically, wound care treatments were not performed on Resident #120 in accordance with Medical Doctor Order (MDO).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 12/22/22 to 01/05/22, the facility did not ensure a resident with respiratory care, including tracheotomy care and tracheal suctioning, was provided such care consistent with professional standards of practice. This was evident for 1 (Resident #168) of 1 resident(s) reviewed for respiratory care out of 39 total sampled residents. Specifically, Licensed Practical Nurse (LPN) #7 provided tracheostomy care (TC) to Resident #168 without changing the Velcro straps according to Medical Doctor (MD) order, suctioning the resident, or performing hand hygiene.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification and Complaint survey from 12/22/2022 to 01/05/2023, the facility did not ensure the Director of Nursing (DNS) served as a charge nurse, only when the facility has an average daily occupancy of 60 or fewer residents. Specifically, there was documented evidence the DNS worked as a charge nurse and administered medication to residents when the facility was short of nursing staff.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 12/22/22 to 1/5/23, the facility did not ensure that a resident who is diagnosed with Dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #145) of 1 resident(s) reviewed for Dementia Care of 39 total sampled residents. Specifically, the facility did not develop and implement a person-centered comprehensive care plan (CCP) that included and supported the dementia care needs of Resident #145.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 12/22/22 to 01/05/22, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #168) of 1 resident(s) reviewed for respiratory care out of 39 total sampled residents. Specifically, Licensed Practical Nurse (LPN) #7 placed sterile gauze and saline solution on the resident's bed and did not perform hand hygiene during Resident #168's tracheostomy care (TC).
December 3, 2019Standard inspection · 2 citations
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review and interviews during a Recertification Survey the facility did not ensure that each resident remained free from physical restraints not required to treat the resident's medical symptoms for 2 of 2 residents (Resident #157 and Resident #7) reviewed for Physical Restraints. Specifically, 1) Resident #157, with severely impaired cognition, had a physician's order to use a wheelchair for mobility. The resident was issued a reclining Geri-chair without an evaluation by a qualified health care professional and a physician's order. 2) Resident #7 continued to utilize two half side rails without evaluation and assessment by a qualified healthcare professional to determine the need for the side rails.
- 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 record review and interviews during the Recertification Survey, the facility did not ensure that care was implemented according to each residents' person-centered plan of care for one (Resident #6) of one resident reviewed for Rehabilitation and one (Resident #143) of one resident reviewed for Dialysis. Specifically, 1) Resident #6 had a Physician's order for a floor ambulation program (FAP) with a quad cane. The FAP was not done on [DATE] and [DATE] because the quad cane was not available, and 2) Resident #143 had a Physician's order for the Arterio-Venous (AV) shunt to be monitored every shift for bruit and thrill; however, there was no documented evidence that the bruit and thrill were checked every shift.
Fire safety inspections
10 fire safety citations on file: 6 on January 22, 2025, 3 on January 5, 2023, 1 on December 3, 2019.
Every fire safety citation10 citations
- F
Address subsistence needs for staff and patients.
E 15 · January 22, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · January 22, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · January 22, 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 · January 22, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 22, 2025 · Corrected (the home has a date of correction)
- B
Use approved construction type or materials.
K 161 · January 22, 2025 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · January 5, 2023 · Waiver
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 5, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 5, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 3, 2019 · Corrected (the home has a date of correction)