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 33 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
8E
0F
Potential for minimal harm
0A
0B
0C
August 14, 2025Complaint inspection · 1 citation
- J
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interviews during the abbreviated survey (IQIES #2572456), the facility failed to establish consistent mechanisms for documenting and communicating a resident's choice regarding advance directives to the staff responsible for the resident's care for one (1) of three (3) residents, Resident #1. Specifically, Resident #1 was found without a pulse and without respirations, and staff did not initiate cardiopulmonary resuscitation (emergency procedure performed when someone's breathing or heartbeat has stopped) per the resident's wishes documented on their Medical Orders for Life Sustaining Treatment, resulting in the resident's death. Additionally, the facility failed to ensure there was a process for verification of medical orders related to residents' advance directives. [...]
August 12, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview during the abbreviated survey (NY00323539/IQIES 652830), the facility did not ensure residents with pressure ulcers or at risk of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #3). Specifically: Resident #3 developed a new pressure ulcer that was not assessed and was not treated timely. Two weeks after the wound developed, the facility investigated the pressure ulcer and concluded the wound was not assessed, there was no treatment order implemented, and was not documented.
May 2, 2025Standard inspection, Complaint inspection · 11 citations
- 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, record review, and interviews during the recertification and abbreviated (NY00370054) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for three (3) of three (3) nursing units (Units A, B, and C) reviewed. Specifically, water temperatures were not maintained at comfortable levels on Units A, B, and C between 2/4/2025-4/1/2025.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00370054 and NY00327240) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of three (3) meals reviewed (dinner meal on 4/28/2025, and lunch meals on 4/29/2025 and 5/1/2025). Specifically, food was not served at palatable and appetizing temperatures and was not palatable. Additionally, five (5) anonymous residents during a resident council meeting and five (5) residents (Resident #31, 53, 59, 60, and 306) interviewed stated the food did not taste good, was bland, lacked flavor, and was cold.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025 - 5/2/2025, the facility did not ensure suitable, nourishing alternative meals and snacks were provided to residents who preferred to eat at non-traditional times or outside of scheduled meal service times for two (2) of three (3) nursing units (Units B and C). Specifically, residents did not have snack items available on nursing units B or C and were not offered anything to eat or drink when meal trays were not available at the scheduled and posted times. Additionally, meals were not served according to the posted mealtimes for all units.
- 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 and abbreviated (NY00327240) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for three (3) of three (3) residents (Residents #31, #52, and #88) reviewed. Specifically, staff stood over Residents #52 and #88 while assisting them to eat; and Resident #31 was placed at a table that was above the level of their chin. Additionally, residents were referred to as feeders, and staff assisted residents with feeding while conversing amongst themselves and not including the residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00365859) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for four (4) of six (6) residents (Residents #24, #37, #60, and #68) reviewed. Specifically, Residents #24 and #60 did not receive toileting assistance when they were wet; Resident #37 was not provided with oral hygiene or shaving: and Resident #68 was not provided with oral hygiene.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure residents received respiratory care consistent with professional standards of practice for one (1) of one (1) resident (Resident #88) reviewed. Specifically, Resident #88 did not receive oxygen therapy as ordered, their portable oxygen tank was not replaced when it was empty, and their care plan did not include the need for oxygen therapy.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure that a resident who required dialysis (a process that filters blood when kidneys do not function normally) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #77) reviewed. Specifically, Resident #77 received hemodialysis and there was no documented evidence of ongoing communication and collaboration with the dialysis facility.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not review risks and benefits of bed rails, obtain informed consent, or remove enabler bars after physical therapy deemed them contraindicated for use for one (1) of one (1) resident (Resident #31) reviewed. Specifically, Resident #31 had enabler bars (used to assist with bed mobility) on both sides of their bed after a physical therapy assessment documented enabler bars were contraindicated for the resident; there was no documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure each resident received food that accommodated resident preferences for two (2) of two (2) residents (Residents #60 and #31) reviewed. Specifically, Resident #31 was missing food items at meals; Resident #60 was missing soda listed on their meal ticket and received hot chocolate instead.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen and one (1) of three (3) dining room refrigerators and ice machines (B-wing) reviewed. Specifically, the B-Wing dining room refrigerator was not clean; the B-Wing dining room ice machine was not working; the main kitchen dry storage room floor was not cleanable; the main kitchen hand wash sink was leaking onto the floor; and the main kitchen walk-in freezer door did not close properly due to ice buildup.
- 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 record review and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the Facility Assessment, Medicare/Medicaid Application (CMS-671), Facility Survey Report (DOH-1550), New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325), Equipment Inventory Form, Legionella policies and procedures, and a list of employees whose date of hire was 4 months or less that was requested by the New York State Department of Health (NYS DOH) surveillance team in a timely manner as required.
January 7, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview during the abbreviated survey (NY00347901), the facility did not ensure residents with pressure ulcers or at risk of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 3 residents (Residents #1 and 3) reviewed. Specifically: -Resident #1 developed new pressure ulcers and there was no documented evidence that recommended treatment orders obtained or implemented timely and no documented evidence diagnostic tests were ordered or obtained timely. -Resident #2 developed a Stage 3 pressure ulcer on their coccyx and there was no documented evidence the registered dietitian reassessed the resident's nutritional needs. [...]
September 3, 2024Complaint inspection · 2 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 record reviews and interviews during the abbreviated survey (NY00341925) the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 exhibited frequent exit-seeking behaviors, there were no documented interventions to address their behaviors, the resident exited the building and was found in the parking lot.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews and interviews during the abbreviated survey (NY00341925) the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 exhibited frequent exit-seeking behaviors, was not supervised, had no care planned interventions in place, and exited the building to the parking lot.
March 4, 2024Complaint inspection · 1 citation
- J
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 record review, and interview during the abbreviated survey (NY00333772), the facility failed to administer cardiopulmonary resuscitation to 1 of 3 residents (Resident #1) who was found without a pulse and wished to be resuscitated. Specifically, on [DATE], Resident #1 was found without a pulse and without respirations, and staff did not initiate cardiopulmonary resuscitation (chest compressions) per the resident's wishes documented on their Medical Orders for Life Sustaining Treatment. Staff asked the resident's spouse (who was not the resident's decision maker ) if they wanted staff to initiate cardiopulmonary resuscitation and the spouse declined. The facility's failure to administer cardiopulmonary resuscitation, per the resident's wishes, placed all 108 residents in the facility who had Advance Directives in place at risk. [...]
August 18, 2023Standard inspection · 10 citations
- 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 observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 3 resident units (B Unit and C unit). Specifically, B Unit and C Unit had damaged walls and floors.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 7 residents (Residents #38, 51, 69, 75, and 105) reviewed. Specifically, Resident #38 was not ambulated or assisted with toileting as planned; Resident #75 was observed wearing a hospital gown and was exposed and visible from the hallway, their ADLs were not completed timely, and they did not have a hand splint and heel booties applied as ordered; Resident #105 was not provided oral care as planned; Resident #51 was not assisted with shaving; and Resident #69 was not turned and positioned or provided incontinence care as care planned.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00311963) surveys conducted 8/10/2023-8/18/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, and at an appetizing temperature for 3 of 3 meals reviewed (8/10/2023 dinner meal, 8/10/2023 supper meal, and 8/11/2023 breakfast meal). Specifically, food was not served at palatable and appetizing temperatures.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure each resident received at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plans of care for 3 of 3 nursing units (Unit A, Unit B, and Unit C) observed. Specifically, resident meal trays were served up to 2 hour and 29 minutes after the scheduled mealtimes on Units A, B, and C.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 3 of 3 resident units (A Unit, B Unit, and C Unit) and two isolated areas (the physical therapy space and the main kitchen). Specifically, fruit flies were observed on Units A, B, C, in the physical therapy space, and in the main kitchen.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents were treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of quality of life for 2 of 3 residents (Residents #103 and 108) reviewed. Specifically, Resident # 103 was observed with their urinary drainage bag uncovered and visible to staff and visitors; Resident #108 was observed with hair on their face and chin.
- 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 observation, record review, and interview during the recertification survey conducted 8/10/2023 to 8/18/2023, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 5 residents (Residents #101) reviewed. Specifically, Resident #101 had a history of suicide attempts and was planned to have safety checks every 15 minutes and not have access to items that could cause potential harm. Multiple hazardous items were observed in the resident's room and there was no documented evidence 15 minute safety checks were consistently completed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/10/2023 - 8/18/2023, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #38) reviewed. Specifically, Resident #38 had an unlabeled topical medication (antifungal powder) in their room and shared bathroom, the medication was not ordered by a physician, and was applied by unlicensed staff.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 1 of 1 resident (Resident #7) reviewed. Specifically, Resident #7 was not wearing their right hand splint/brace (a device to help prevent contractures) as planned.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 of 1 resident (Resident #63) reviewed. Specifically, Resident #63 received hemodialysis (HD, a process that filters blood when kidneys do not function normally) and there was no documented evidence of ongoing assessments and plans for monitoring of the HD access sites.
May 24, 2021Standard inspection · 6 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey completed on 5/24/21 the facility did not make prompt efforts to resolve grievances the resident may have for 1 of 2 residents (Resident #74) reviewed. Specifically, Resident #74 reported a missing shirt and the facility did actively work toward resolution to locate the missing item. This is evidenced by: The 2/2021 revised Resident Complaint and Grievance Process policy documents the policy is to support, encourage, and promote the resident's rights including the right to an easy to use and responsive grievance and suggestion procedure without fear of reprisal. The Director of Social Work is the facility's Grievance Officer. All verbal or written suggestions or grievances will be directed to the Grievance Officer for coordination and initial investigation. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review during a recertification survey and abbreviated survey (NY00252289) completed on 5/24/21, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #146) reviewed. Specifically, Resident #146 was not assessed timely by a qualified professional after falling and complaining of pain and was sent to the hospital with a fractured femur (thigh bone) approximately 6 hours after the fall.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review and interviews during a recertification survey completed on 5/24/21, the facility did not ensure a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents (Resident #95) reviewed. Specifically, Resident #95 was observed without a towel in their left elbow crease to promote elbow extension as planned and did not have range of motion (ROM) interventions documented.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview conducted during the recertification survey completed on 5/24/21, the facility did not ensure the storage, preparation, distribution and service of food was in accordance with professional standards for food service safety for 2 isolated areas in the main kitchen (the walk-in cooler and the dry storage room). Specifically, the walk-in cooler floor was soiled and unclean and there was a large amount of ice buildup inside the cooler side of the door to the adjoining freezer. Additionally, the floor of the dry storage room beside the walk-in cooler was soiled with sticky spills, food packaging and products under the shelving.
- 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 record review and interviews conducted during the recertification survey ending 5/24/21, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 2 of 2 residents (Residents #34 and #56) reviewed. Specifically, Residents #34 and #56 did not have determination of medical decision-making capacity or a concurring determination of capacity completed prior to implementing advance directives to withhold life sustaining treatment as required by New York State law.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review, and interview during the recertification survey concluded on 5/24/21, the facility did not maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen (the main kitchen) reviewed. Specifically, there were fruit flies observed within the main kitchen.
Fire safety inspections
25 fire safety citations on file: 17 on May 2, 2025, 5 on August 18, 2023, 3 on May 24, 2021.
Every fire safety citation25 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 2, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 2, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 2, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 2, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · May 2, 2025 · Corrected (the home has a date of correction)
- E
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 2, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 2, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 2, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 2, 2025 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · May 2, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 18, 2023 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 18, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · August 18, 2023 · 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 · August 18, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · August 18, 2023 · Corrected (the home has a date of correction)
- E
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 24, 2021 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · May 24, 2021 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 24, 2021 · Corrected (the home has a date of correction)