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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
1H
0I
Potential for more than minimal harm
15D
4E
1F
Potential for minimal harm
0A
4B
0C
July 30, 2026Complaint inspection · 1 citation
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure medical records were complete and readily accessible for three of five residents reviewed (Residents #2, #4 and #5). Specifically, the facility could not readily access medical records maintained in its prior electronic medical record system prior to May 2023 due to transition to a new electronic medical record program for Residents #2, #4, and #5. In addition, the facility could not provide the preadmission screening information for Resident #4.
August 23, 2024Standard inspection, Complaint inspection · 14 citations
- H
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 Survey from 08/18/2024 to 08/23/2024, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (Resident #59 and #71) of two residents reviewed. Specifically, Resident #59 was readmitted from the hospital on [DATE] following surgical treatment of an abscess (a painful, swollen lump filled with pus) and did not have a follow up evaluation as ordered in a timely manner. Resident #71, who had a contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that prevent normal joint movement which is often painful) of the left hand did not have a care plan in place that included measurable goals, interventions, or monitoring which resulted in multiple pressure ulcers and a decrease in range of motion. [...]
- G
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, the facility did not allow a resident the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident for one (Resident #31) of five residents reviewed for accidents. Specifically, Resident #31's side rails that were used to increase their independence and mobility in bed were removed by the facility as considered being a restraint without an appropriate assessment resulting in a fall out of bed with injury. This resulted in actual harm to Resident #31 that was not Immediate Jeopardy and is evidenced by the following: [...]
- F
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for 24 (Residents #1, #5, #22, #25, #27, #28, #37, #49, #58, #59, #61, #69, #73, #76, #79, #82, #83, #84, #85, #100, #109, #110, #161, #311) of 24 residents, the facility did not ensure that the baseline care plan (care plan developed within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident) was completed within the required timeframe and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Residents #73 and #82, the facility could not provide evidence that a baseline care plan was completed within 48 hours of the resident's admission. [...]
- E
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, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00345323) from 08/18/2024 to 08/23/2024, for two (first and second floors) of two resident-use floors, the facility did not ensure a safe, clean, comfortable, and homelike environment. Specifically, there were roof leaks, missing ceiling tiles, and resident care equipment was dirty.
- 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, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for two (Unit One Hall A and Unit Two Hall A) of two medication carts and one (Unit Two) of two medication rooms reviewed. Specifically, medication carts contained expired medications, insulin without an open or expiration date, and one bottle of eye drops without any resident identifiers. Additionally, the medication room contained expired medications. This is evidenced by but not limited to the following: The undated facility policy and procedure, Storage of Medications, included drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. [...]
- 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, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, non-food contact surfaces were dirty, utensils and dishware were dirty, floors were dirty, there was missing grout between floor tiles, a reach-in cooler was dirty, and food items were not stored 6 inches above the floor.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey and complaint investigation (NY00338206) from 08/18/2024 through 08/23/2024, for one (Resident #5) of ten residents, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #5 was observed over several days with debris underneath their fingernails including while eating. This is evidenced by the following: The facility policy Care of Fingernails/Toenails, dated January 2024, documented that nail care included daily cleaning and regular trimming. The policy included to remove dirt from around and under each nail. Resident #5 had diagnoses that included muscle weakness, depression, and arthritis. [...]
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for one (Resident #16) of one resident, the facility did not ensure the resident received treatment and/or assistive devices to maintain hearing. Specifically, Resident #16 was hard of hearing, had a documented request to be seen for hearing aids, and the facility did not arrange for an audiology (hearing) evaluation. This is evidenced by the following: Resident #16 had diagnoses including diabetes, depression, and bilateral hearing loss. The Minimum Data Set Resident Assessment, dated 07/03/2024, included the resident was cognitively intact, was able to hear with minimal difficulty, and did not have hearing aids. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey and complaint investigations (NY00338206 and NY00337318) from 08/18/2024 to 08/23/2024, the facility did not ensure that appropriate treatment and services were provided to prevent urinary tract infections for a resident with an indwelling urinary catheter (tube inserted into the bladder to drain urine into a drainage bag) for one (Resident #25) of one resident reviewed. Specifically, Resident #25 had a history of urinary tract infections and was observed on multiple occasions with their urinary catheter drainage bag, catheter drainage port, and catheter tubing lying directly on the floor without a barrier, and with the drainage bag completely full of urine resulting in a backup of urine in the tubing. This is evidenced by the following: [...]
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for one (Resident #59) of one resident reviewed for tube feedings (nutrition administered via a tube inserted directly into the stomach via the abdomen due to the residents' inability to consume food and drink by mouth), the facility did not provide appropriate treatment and services to prevent potential complications. Specifically, there was no documented evidence that Resident #59's total daily intake of tube feedings was being monitored to ensure their nutritional needs were being met, physician's orders regarding administration of the tube feedings while consuming food were unclear, and free water flushes and nutritional supplements were not administered as ordered by the physician. This is evidenced by the following: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 08/19/2024 to 08/23/2024, for one (Resident #85) of three residents, the facility did not ensure residents who needed respiratory care were provided such care consistent with professional standards of practice. Specifically, Resident #85 was observed wearing oxygen via a nasal cannula (a device that delivers oxygen through a person's nose), did not have a physician order in place for oxygen use via a nasal cannula, and there was no documentation in the Medication Administration and Treatment Administration Records that reflected the use of oxygen via nasal cannula each shift. This is evidenced by the following: The facility policy Oxygen Administration. dated January 2024, included to verify and review a physician's order for oxygen administration. [...]
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, interviews, and records review conducted during a Recertification Survey and complaint investigation (NY00345323) from 08/18/2024 to 08/23/2024, for one of one kitchen, the facility did not ensure there was an effective pest control program. Specifically, small brown flies and fruit flies were present and untreated.
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for six (#52, #312, #313, #314, #315, and #317) of seven residents reviewed, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries at the termination of their Medicare coverage. Specifically, the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to Residents #314 and #315 and did not provide a Notice of Medicare Non-Coverage (NOMNC) to Residents #52, #312, #313, #317, and/or their representatives informing them of their appeal rights and/or their liability for services. This is evidenced by but not limited to the following: [...]
- B
Post nurse staffing information every day.
Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 08/18/2024 to 08/23/2024, the facility did not ensure the nurse staffing information was posted daily and included the required information. Specifically, the facility did not post the accurate nurse staffing data on 08/18/2024, 08/20/2024, 08/21/2024 or 08/22/2024, as required per the regulations. This is evidenced by the following: During an observation on 08/18/2024 at 8:30 PM, the daily nurse staffing information was not visibly posted. During observations on 08/20/2024 at approximately 11:15 AM, 08/21/2024 at 10:29 AM, and 08/22/2024 at 9:04 AM, the posted daily nurse staffing information was dated 08/19/2024. During an interview on 08/21/2024 at 10:29 AM, Receptionist #1 stated Scheduler #1 was responsible for printing the daily nurse staffing information. [...]
March 28, 2024Complaint inspection · 1 citation
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on interviews and record reviews conducted during the Abbreviated Survey, (complaint #NY00336027) and completed [DATE], it was determined that the facility could not ensure there were adequate number of personnel in the facility to provide basic life support, including cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart and/or lungs cease functioning). Specifically, the facility did not maintain an updated list of staff who were currently certified in cardiopulmonary resuscitation and could not provide evidence that a cardiopulmonary resuscitation certified staff member was in the facility at all times to provide basic life support when needed. This is evidenced by the following: [...]
October 3, 2023Complaint 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 interviews and record review conducted during an Abbreviated Survey (NY00302380 and NY00321005) 8/3/23 to 10/3/23, the facility did not ensure the resident's right to be free from abuse for three (Residents #3, #4, and #5) of six residents reviewed for abuse. Specifically, staff reported potential abusive behavior towards all three residents by one staff member (Registered Nurse (RN) #1). This is evidenced by the following: The facility policy, Abuse Prohibition Program, dated January 2023, documented that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, and/or theft/misappropriation of resident property are thoroughly investigated by facility management. [...]
June 10, 2022Standard inspection · 4 citations
- 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, interview and record review conducted during a Recertification Survey completed on 6/10/22, it was determined that for one (Resident #43) of five residents reviewed, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, Resident #43's Comprehensive Care Plan (CCP) was not individualized with goals and interventions to address use of psychotropic medications. This is evidenced by: Resident #43 had diagnoses that included Alzheimer's dementia with behaviors, depression, and adult failure to thrive. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 6/10/22, it was determined that for one (Resident #36) of two residents reviewed the facility did not ensure that the resident received care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and that the resident received the necessary treatment to promote healing of a pressure ulcer, prevent infection and prevent new ulcers from developing. [...]
- 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 reviews conducted during the Recertification Survey and complaint investigation (#NY00296839), completed on 6/10/22, it was determined that the facility did not ensure the resident's environment was free from accident hazards for one (Resident #32) of three residents reviewed. Specifically, Resident #32, who had severe impairment of cognitive function, was able to exit the facility unsupervised due to a door alarm failure. Additionally, the residents care plan was not revised following actual exit seeking behavior and an elopement. This was evidenced by the following: Resident #32 had diagnoses that included Alzheimer's disease, dementia, and a history of repeated falls. [...]
- B
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review and interviews conducted during the Recertification Survey completed 6/7/22 to 6/10/22, it was determined that for one (Resident #47) of one resident reviewed for hospitalizations, the facility did not ensure a written notification, which specifies the duration of the bed-hold policy, was provided to the resident and/or the resident representative at the time of transfer to the hospital. Specifically, Resident #47 was transferred to the hospital and the facility could not provide evidence that a written notice of information regarding the facility's bed-hold policy (including bed reserve policy) was provided to the resident or the resident's representative per the regulation. This was evidenced by the following: [...]
November 1, 2019Standard inspection · 5 citations
- 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 observations and interviews conducted during the Recertification Survey, it was determined that for two of two residential living units the facility did not provide housekeeping services that are necessary to maintain sanitary, orderly, and comfortable conditions. This is evidenced by the following: During an observation on 10/30/19 at 4:07 p.m., in the small dining room (TV room) on the first floor six of six recliners had worn bald spots in the fabric and there was no nap left to some areas of the fabric. The recliners were, stained, discolored, and smelled of urine. The finish on the vinyl upright chair was worn through to a lighter color. The fabric was worn on the red cloth chair and all four of the chair legs were scuffed with lighter colored wood visible below the dark brown top stain. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #9) of one resident reviewed for abuse and for one (Resident #13) of five residents reviewed for accidents, the facility did not report resident-to-resident incidents to the State Survey Agency as required. This is evidenced by the following: Review of the facility policy and procedure, Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting, dated December 2016, revealed that alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately to the facility Administrator and to other officials, including the New York State Department of Health. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for hydration, the facility did not have a system in place to ensure that daily fluid intakes were consistently or timely monitored or followed physician orders. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, chronic kidney disease, and a history of urinary tract infections. The Minimum Data Set Assessment, dated 10/12/19, revealed the resident had severely impaired cognition, required set up help for eating, and used a diuretic daily. The Certified Nursing Assistant (CNA) Care Plan, dated 6/12/19, directs to set up and supervise at meals, encourage and assist if needed. [...]
- D
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on observations and an interview conducted during the Recertification Survey, it was determined that the carbon monoxide detection was not provided in compliance with Federal, State, and Local Laws and Professional Standards. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection (adopted by New York State), requires carbon monoxide detection in all areas with fuel burning/gas operated equipment. Specifically, carbon monoxide detection was not installed in the basement levels of Buildings 906 and 918 where there was fuel burning equipment. This is evidenced by the following: Observations conducted between 10/28/19 and 10/29/19 revealed there was no carbon monoxide detection installed within the facility on floor one and the basement. [...]
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #35) of one resident reviewed for hospitalization, the facility did not ensure that the resident's representative was provided with a written transfer/discharge notice. This is evidenced by the following: Resident #35 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia, pneumonia, and dementia. The Minimum Data Set Assessment, dated 9/5/19, revealed the resident's cognitive skills for daily decision making were severely impaired. A nursing progress note, dated 10/24/19, revealed the resident was having trouble breathing and at 11:00 a.m., the resident was transferred to the hospital for evaluation and treatment. [...]
Fire safety inspections
16 fire safety citations on file: 8 on August 23, 2024, 3 on June 10, 2022, 5 on November 1, 2019.
Every fire safety citation16 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · August 23, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 23, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 23, 2024 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 23, 2024 · Corrected (the home has a date of correction)
- C
Create arrangements with other facilities to receive patients.
E 25 · August 23, 2024 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · August 23, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 10, 2022 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · June 10, 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 · June 10, 2022 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · November 1, 2019 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 1, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 1, 2019 · Corrected (the home has a date of correction)
- C
Have an enclosure around a vertical opening shaft.
K 311 · November 1, 2019 · Corrected (the home has a date of correction)
- C
Have a properly installed and maintained dumbwaiter or escalator.
K 532 · November 1, 2019 · Corrected (the home has a date of correction)