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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
6E
0F
Potential for minimal harm
0A
0B
0C
November 20, 2025Complaint inspection · 2 citations
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review during an abbreviated survey #2616039, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, and the comprehensive person-centered care plan for two (2) of three (3) residents (Resident #1 and Resident #3) reviewed for pain medication. Specifically, for Resident #1 and Resident #3 there was lack of consistent documentation of pain assessments each shift prior to and after administration of physician ordered as needed oxycodone 5 mg tablets.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review during an abbreviated survey #2616039 the facility did not provide pharmaceutical services including procedures that assure the accurate dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two (2) out of three (3) residents reviewed for pain medication administration. Specifically, for Resident #1 and Resident #3 oxycodone 5mg tablets (narcotic) were signed out on the narcotic control sheets but were not accounted for and documented in the resident's Medication Administration Record as administered to the residents. Additionally, there was no evidence that a pharmacist conducted periodic audits or oversight to ensure accurate record keeping and accounting of the controlled substances.
September 13, 2025Complaint inspection · 1 citation
- E
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, interviews, and record reviews during the recertification and abbreviated surveys (Intake #2569939), the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the Daily Nurse Staffing Rosters reviewed from 08/10/2025 through 09/12/2025 documented on four (4) of 34 days, there was one (1) certified nurse aide documented for the A unit night shift (1:35 or 1:36 ratio ) and on one (1) of 34 nights, there was one (1) certified nurse aide assigned to B unit (1:36 ratio). On 29 of 34 days reviewed, assigned staff did not complete their assigned shift (came in late or left early). [...]
July 11, 2025Complaint 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 observations, interviews, and record review during the Abbreviated Survey (NY00376400) the facility did not ensure that 1 of 3 residents (Resident #1) investigated for abuse remained free from abuse. Specifically, on 3/27/2025, Resident #1, who was severely cognitively impaired with a history of wandering and entering other residents' rooms, was found in Resident #2's bed. Resident #2, who was cognitively intact, stated that they did touch Resident #1 on their breasts per their request. Resident #1 lacked the capacity to make sound decisions at the time of the incident. The facility investigative conclusion found that no abuse had occurred.
November 22, 2024Standard inspection, Complaint inspection · 16 citations
- E
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 record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did ensure that a Registered Nurse worked eight cosecutive hours a day, seven days a week. Specifically, the facility was unable to provide documented evidence that a Registered Nurse worked 10/20/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and interview conducted during the recertification survey from 11/16/2024 to 11/22/2024, the facility did not ensure Annual Performance Reviews were completed at least once every 12 months. Specifically, the facility was unable to provide Annual Performance Reviews for 3 of 5 Staff Members (#9, #10, #12) reviewed.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview during the Recertification survey from 11/14/24 to 11/22/24, the facility did not ensure residents were provided food and drink that is palatable, attractive, and at a safe and appetizing temperature. Specifically, food was not served at palatable and safe temperatures for 2 of 3 residents (Resident #17 and Resident #23) reviewed for Food.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey from 11/14/24-11/22/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections. Specifically,1) the Water Management Plan had not been updated annually and the Environmental Risk Assessment had not been performed annually to identify areas where Legionella could spread, 2) Resident #13's urine collection bag was not maintained or emptied in a manner to prevent infection, 3) Resident #51 consented to receive the Respiratory Syncytial Virus vaccine but did not receive it until almost two months later. [...]
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interview conducted during a recertification survey from 11/14/24 to 11/22/24, the facility did not ensure Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services to ensure safe delivery of care. Specifically, the facility was unable to provide documentation that 3 of 6 Certified Nurse Aides (#10, #14, and #15), reviewed for Certified Nurse Aide training, were provided 12 hours of mandatory training.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 of 3 residents reviewed for Abuse (Residents #176) that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation is made, to the State Agency. Specifically, 1) Resident #176's family reported Resident #176 was found with bruises on their forehead when transferred to the hospital for altered mental status. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 (Resident #176)) of 3 resident reviewed for Abuse that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, there was no documented evidence the facility conducted a complete thorough investigation after Resident #176's family member reported Resident #176 had multiple bruises on their forehead when they were transferred to the hospital on 2/19/24.
- D
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 record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 resident (Resident #63) reviewed for hospitalization.
- D
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, interview and record review conducted during a recertification survey, the facility did not ensure the comprehensive care plan was revised for 1 of 5 resident ( Resident #53) reviewed for Accidents. Specifically, for Resident #53, who sustained falls on 8/20/24, 9/27/24 and 10/9/24 there was no documented evidence that care plan interventions were reviewed and/or revised to address the falls.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336697 and NY00324141) from 11/14/24 to 11/22/24, the facility did not ensure 2 (Residents #174 and #177) of 2 residents reviewed for Quality of Care received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, 1.) for Resident #174 who was admitted with a wearable defibrillator (Life Vest) related to a history of Sudden Cardiac Arrest, became unresponsive on 3/16/24 the nurse tending to the resident documented they pushed the response button. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation and interview conducted during the recertification and complaint (NY00336704) surveys from 11/14/24 to 11/22/24, the facility did not ensure adequate supervision to prevent accidents for 1 (Residents #176) of 5 residents reviewed for Accidents. Specifically, fall risk assessments were not completed to identify Resident #176's risk for accident and need for supervision after falls on 1/26/24, 1/28/24, and 2/1/24. There was no documented evidence of enhanced monitoring and one to one supervision as per the 2/27/24 Accident and Incident Report after Resident #176 verbalized suicidal ideation. [...]
- D
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 record review and interview conducted during the recertification from 11/14/24 to 11/22/24, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the staffing schedule from 10/10/24 through 11/21/24 revealed the facility did not consistently provide adequate staffing on all units/shifts to meet the needs of the resident/s 35/43 days reviewed.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review conducted during the recertification survey from 11/14/2024 to 11/22/2024, the facility did not ensure the attending physician documented in the resident's medical record that the identified drug regimen review recommendations were reviewed, and any action taken to address recommendations were completed. This was evident for 1 (Resident #42) of 5 residents reviewed for unnecessary medications, psychotropic medications and medication regimen review. Specifically, there was no documented evidence the Medical Director reviewed and responded to Resident #42's Drug Regimen Reviews dated June 2024.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey 11/14/22-11/22/24, the facility did not ensure necessary dental services were provided in a timely manner for 1 of 1 resident (Resident #25) reviewed for Dental Services. Specifically, Resident #25 was not provided routine dental services since their 2/29/24 admission to facility.
- 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, record review and interview conducted during the Recertification Surveys from 11/14/24 to 11/22/24, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, there was undated ice cream in the meat freezer and vegetable freezer, a dietary aide was observed in the kitchen without a beard covering, there was 8 boxes of deluxe original cheddar macaroni noodles with an expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food room was peeling and had black/brown stains.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview conducted during a recertification survey (11/14/24-11/22/24), the facility did not ensure a safe, clean, comfortable, and homelike environment was provided on 3 of 4 units (West, East and North). Specifically, North Unit had noticeable dirt and food throughout the hallway, a resident over bed table was dirty with food stains and caked on food in room [NAME] 7, and Resident #5 had no privacy curtain dividing the toilet area from the resident's room, allowing anyone entering the room to see the resident on the toilet and 2) Resident #23 was transferred into a wheelchair with a broken left wheel brake.
September 11, 2024Complaint inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record reviews, and interviews conducted during an abbreviated survey (NY00329438), the facility did not ensure that care and treatments were provided to prevent the development of new pressure ulcers for 1 of 3 (Resident #3) residents reviewed for pressure ulcers. Specifically, Resident #3 was admitted to the facility with a deep tissue injury and skin integrity care plan was not put in place; physician orders for the use of a CAM boot (controlled ankle movements, a walking boot) when out of bed and skin checks every shift were not followed; Resident #3 developed a pressure ulcer to the left heel and treatments were not completed as ordered.
- 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 during an abbreviated survey (NY00336418) the facility did not maintain adequate supervision to prevent an elopement for 1 of 4 residents reviewed for accidents (Resident #2). Specifically, Resident #2 left the building on 1/22/24 and staff did not notice the resident's absence until 1/23/24 when the nurse could not find the resident for morning medications. The facility called a Code Gray (missing resident alert) and the resident was located by phone at a friend's house. The resident returned to the facility around 2 PM on 1/23/24.
November 7, 2023Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00326941), the facility did not ensure residents right to be free from abuse for 1 of 3 sampled residents (Resident #1) Specifically, on 10/19/2023 and 10/24/2023 a Certified Nursing Assistant (CNA #2) was witnessed slapping Resident #1 in the face and push them back to bed forcibly.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00326941), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours of occurrence. This was evident for 1 of 3 residents (Resident #1) reviewed for abuse and mistreatment. Specifically, a Certified Nursing Assistant (CNA #2) was witnessed by CNA #1 on 10/19/2023 and 10/24/2023 slap Resident #1 in the face and push them back to bed forcibly. The facility did not report the incident to the NYSDOH until 10/26/2023.
- D
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 record review, and interviews conducted during the Abbreviated Survey (NY00326941), it was determined the facility did not ensure a resident's care plan was revised to reflect the resident's change in condition for one of three residents (Resident #1) reviewed for Abuse. Specifically, when the resident had demonstrated new behaviors related to agitation and aggression on 9/30/2023, 10/01/2023, and 10/19/2023, the care plans for Dementia Care and Behaviors were not updated to include new interventions.
January 6, 2022Standard inspection · 1 citation
- 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 conducted during a recertification survey, it was determined that the facility did not ensure proper food storage in the facility kitchen according to professional standards for food safety practice to prevent foodborne illness.
December 6, 2019Standard inspection · 1 citation
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview and record review conducted during the most recent recertification survey, the facility did not ensure that necessary dental services were provided in a timely manner for one of two residents reviewed for dental services (Resident #12). Specifically, a dental follow-up visit recommended by the dentist was not scheduled to address the resident's need for a partial lower denture.
Fire safety inspections
19 fire safety citations on file: 7 on November 22, 2024, 10 on January 6, 2022, 2 on December 6, 2019.
Every fire safety citation19 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 22, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · November 22, 2024 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · November 22, 2024 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · November 22, 2024 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · November 22, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 22, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 22, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 6, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 6, 2022 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · January 6, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 6, 2022 · Corrected (the home has a date of correction)
- D
Provide outside doors or windows in every resident room.
K 381 · January 6, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 6, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 6, 2022 · Corrected (the home has a date of correction)
- C
Include a process for Emergency Preparedness collaboration.
E 9 · January 6, 2022 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for medical documentation.
E 23 · January 6, 2022 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · January 6, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 6, 2019 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 6, 2019 · Corrected (the home has a date of correction)