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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
4E
4F
Potential for minimal harm
0A
0B
0C
May 14, 2026Complaint inspection · 5 citations
- J
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 survey, the facility failed to ensure residents received adequate supervision to prevent elopement. This was evident in one out of six residents (Resident #1) sampled for elopement. Specifically, Resident #1, who was severely cognitively impaired, with a history of wandering behavior and identified as an elopement risk exited the facility grounds unsupervised on 05/08/2026 at 12:30:40 AM per video surveillance footage and has not been found. Resident #1 exited through the New Wing Hall lobby (1st floor); the alarm on the exit door did not activate due to alarm system malfunction. Resident #1 was last seen on 05/08/2026 at 12:15 AM by Certified Nursing Assistant #1 in a hallway on the first-floor unit. Resident #1 was not identified as missing until 8:20 AM. This resulted in Immediate Jeopardy Past Noncompliance.
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the direct care staffing information based on payroll data was submitted based on the schedule specified by the Centers for Medicare and Medicaid Services. Specifically, the facility failed to submit the direct care staffing data for fiscal year Quarter 1/2026 (10/01/2025 - 12/31/2025) timely.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interviews during survey the facility failed to ensure that services provided or arranged by the facility met professional standards of quality. This was evident in one (1) out of six (6) residents (Resident #1) sampled. Specifically, on 05/08/2026, Licensed Practical Nurse #1 documented in the Medication Administration Record that they administrated medications to Resident #1 and took the resident's vital signs at 7:00 AM. Additionally, Licensed Practical Nurse #1 documented in the Treatment Record that they monitored Resident #1 at 7:30 AM. According to the facility video surveillance footage, Resident #1, who was severely cognitively impaired, with a history of wandering behavior and identified as an elopement risk exited the facility grounds unsupervised on 05/08/2026 at 12:30:40 AM and has not been found. [...]
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator and the Director of Nursing failed to identify hazards and risks to ensure residents were adequately supervised to avoid elopement. Immediate Jeopardy was determined on 05/13/2026 when direct care and nursing staff failed to ensure Resident #1 received adequate supervision with safety monitoring to prevent an elopement. Resident #1 was able to exit the facility unsupervised on 05/08/2026 at 12:30:40 AM due to alarm system malfunction. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, and interviews during survey conducted the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. Licensed Practical Nurse #1 failed to accurately document in Resident #1's medical record. This was evident for one (1) of six (6) residents (Resident #1) sampled. Specifically, on 05/08/2026, Licensed Practical Nurse #1 documented in the Medication Administration Record that they administrated medications to Resident #1 and took the resident's vital signs at 7:00 AM. Additionally, Licensed Practical Nurse #1 also documented that they monitored Resident #1 at 11:30 AM and 7:30 AM in the Treatment Record that they monitored Resident #1 at 7:30 AM. [...]
January 31, 2025Standard inspection, Complaint inspection · 3 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 observation, record review, and interviews during the Recertification and Abbreviated Survey (NY00365258) conducted from 01/26/2025 to 01/31/2025, the facility did not ensure that sufficient nursing staff was consistently provided to meet 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.) Several residents reported the facility was short staffed of Certified Nursing Assistants which resulted in lack of timely staff response to residents who needed assistance, 2.) Multiple nursing staff members reported lack of sufficient staffing, 3.) Facility's staffing levels were repeatedly below facility assessed levels, and 4.) Excessively low weekend staffing was triggered in the Payroll Based Journal Staffing Data Report.
- 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 observation, record review, and interviews during the Recertification Survey conducted from 01/26/2025 to 01/31/2025, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident in 2 of 5 units observed. Specifically, 1.) Unit 4 emergency drug box contained expired medications, and 2.) Unit 5 medication cart was observed with insulin pens that were not properly and sanitarily stored and were not marked with the dates they were opened.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 01/26/2025 to 01/31/2025, the facility did not ensure food were stored in accordance with professional standards for food service safety. This was evident during kitchen and dining observation. Specifically, 1.) The kitchen walk-in refrigerator and freezer contained opened and undated food items. 2.) The 5th floor unit refrigerator contained unlabeled and undated food items.
May 8, 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 (NY00340915), the facility failed to ensure that a resident received adequate supervision to prevent an elopement. This was evident in one out of six residents sampled (Resident #1). Specifically, Resident #1 exited the facility on 05/01/24 at 4:22 pm undetected by staff. Facility staff became aware at 7:10 pm that Resident #1 was missing. According to staff, dinner was served between 5:00 pm and 6:00 pm and they were unaware that Resident #1 was missing. Resident #1 was found by a facility staff member on 05/05/24 at around 4:55 pm at a bus stop and was brought back to the facility. Resident #1 had no visible injuries but was sent to the hospital for a wellness check.
July 3, 2023Standard inspection · 7 citations
- G
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 interview conducted during a Recertification and Abbreviated (NY00312961) survey, the facility failed to ensure a resident received adequate supervision to prevent accidents. This was evident for 1 (Resident #284) of 4 residents reviewed for Accidents of 38 total sample residents. Specifically, on 3/19/2023 Resident #284 fell in their room when left unsupervised by a Certified Home Health Aide (HHA) #1 assigned to provide the resident one-to-one (1:1) observation. Subsequently, Resident #284 sustained a left scalp hematoma (bruising and swelling) and left hip fracture. This resulted in actual harm to Resident #284 that was not immediate jeopardy.
- 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, record review, and staff interview conducted during the recertification survey from 6/26/23 to 7/3/23, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was observed during review of the Kitchen. Specifically, cold sandwiches and milk were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 6/26/23 to 7/3/23, the facility did not implement an effective pest control program so the facility is free of pests. This was evident during environmental observations. Specifically, fruit flies were observed during the initial tour of the kitchen, in food service director's (FSD) office and in the conference room of the facility.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interviews and record review conducted during the recertification survey conducted from 6/26/23 to 7/3/23, the facility did not ensure residents received a Minimum Data Set 3.0 (MDS) assessment not less frequently than once every 3 months. This is evident for 16 (Resident #s 4, 20, 28, 41, 47, 61, 72, 103, 117, 131, 139, 144, 151, 156, 165 and 170) of 17 residents reviewed for Resident Assessment. Specifically, MDS assessments for Resident #4, Resident #20, Resident #28, et al. were not completed within 14 days of the Assessment Reference Date (ARD).
- E
Put firmly secured handrails on each side of hallways.
Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification Survey from 06/26/23 to 07/03/23, the facility did not ensure handrails remain firmly affixed to the wall. Specifically, loose hands were observed on 2 (Unit 1 and 4) of 5 units. Specifically, there were observations of handrails in the hallways on Unit 1 and Unit 4 that were not firmly affixed to the wall.
- 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 interviews conducted during the Recertification survey from 6/26/23 to 7/3/23, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was evident for 1 (Resident #123) of 2 residents reviewed for Dignity out of 38 total sampled residents. Specifically, Resident #123 was observed wearing the same blood-stained shirt on 3 consecutive days.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 6/26/23 to 7/3/23, the facility did not ensure that infection control practices were maintained. This was evident for 1 (Unit 1) of 5 Units observed for Dining. Specifically, a Certified Nursing Assistant (CNA) was observed with their fingers inside cups being served to residents during lunch. The finding is: The facility policy titled Handling Food, Cups & Feeding Utensils dated 05/20/22 documented cups must be picked up touching from the base/bottom. No fingers must touch the rim or inside of the cup. On 06/26/23 at 12:15 PM, CNA #3 was observed during lunch service on Unit 1 with their fingers inside plastic water cups being filled with water and served to residents. [...]
June 10, 2021Standard inspection · 5 citations
- 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 reviews and interviews conducted during the Recertification survey, the facility failed to notify a resident's medical provider when there was a need to alter treatment significantly. Specifically, a resident's medical provider was not informed when the resident's blood sugar increased to 409 on two occasions. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 35. (Resident # 95) The finding is: The Facility's policy titled, Notification of Change In Resident Condition dated 8/23/20 documents it is the policy of the facility that changes in resident's condition are immediately shared with the resident/representative and reported to the attending physician. The nurse should immediately notify the resident's physician and the resident when there is a significant change in the health of the resident. [...]
- 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, interview, and record review conducted during the recertification survey the facility did not ensure that a sanitary environment was maintained. Specifically, a resident's hand splint was worn and caked with dirt on multiple occasions. This was evident for 1 of 2 resident's reviewed for Environment (Resident #43). The finding is: A facility Policy and Procedure titled Braces was dated 3/20/2017 documented Safekeeping - Keep clean/dry; CNA checks for cleanliness and maintenance and sends it to in-house laundry. Resident # 43 diagnosed with contracture of unspecified wrist. Minimum Data Set, dated [DATE] documented Resident # 43 was cognitively intact and had no splints/braces for contracture of wrist. On 06/03/21 at 11:32 AM, Resident #43 was observed with a left hand splint in place on the left hand and lower arm. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification survey, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, there was no evidence that medical follow-up was done to address consistently elevated blood sugars for a resident with Diabetes Mellitus. This was evident for 1 of 35 sampled residents (Resident #59). The finding is: Review of the facility policy dated 8/23/2020, titled Residents with Diabetes documents, Residents with Diabetes will have a plan in place to promote that individuals highest level of wellness. The Interdisciplinary Team (IDT) will evaluate and revise the plan of care on an ongoing basis. Residents response to medication and diet will be monitored in accordance with the best standards of practice. [...]
- 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 staff interview conducted during the Recertification survey, the facility did not ensure that the facility reviewed the resident's total program of care, including medications, and treatments, at each visit. Specifically, there was no documented evidence of medical follow-up for a resident admitted with a diagnosis of Diabetes Mellitus on sliding scale three times a day with Insulin coverage. This was evident for 1 out of a sample of 35 residents (Resident #59). The finding is: Review of the facility policy dated 8/23/2020, titled Residents with Diabetes documents, Residents with Diabetes will have a plan in place to promote that individuals highest level of wellness. The Interdisciplinary Team (IDT) will evaluate and revise the plan of care on an ongoing basis. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interviews, during the recertification survey, the facility did not ensure that infection control practices were followed to prevent the transmission of diseases. Specifically, staff did not change gloves during a wound care observation. This was evident for 1 of 2 residents reviewed for Pressure Ulcers in a sample of 35 (Resident #107). The finding is: The Facility policy on wound care titled, Dressing Change of Pressure Sore and Chronic Wound dated 8/20/2020 documents, All residents with ulceration, sore/chronic wound will be provided treatment as ordered by the Physician. The purpose is to promote healing and or prevent complication of pressure sores and other chronic wounds . [...]
Fire safety inspections
18 fire safety citations on file: 4 on January 31, 2025, 6 on July 3, 2023, 8 on June 10, 2021.
Every fire safety citation18 citations
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 31, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 31, 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 · January 31, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 3, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · July 3, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · July 3, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 3, 2023 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 3, 2023 · Corrected (the home has a date of correction)
- C
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 3, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 10, 2021 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 10, 2021 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · June 10, 2021 · Corrected (the home has a date of correction)