Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
4E
0F
Potential for minimal harm
0A
0B
0C
May 6, 2026Complaint inspection · 1 citation
- 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 interview, the facility failed to ensure the providers wrote, signed, and dated their progress notes at each visit for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Nurse Practitioner #4 initiated and completed a federally mandated visit on Resident #1 including a physical assessment, after Resident #1 was discharged to the hospital and did not return to the facility.
December 10, 2024Standard inspection, Complaint inspection · 10 citations
- 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 survey conducted 12/3/2024-12/10/2024, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 4 of 5 residents (Residents #5, #58, #61, and #106) reviewed. Specifically, Resident #58 was not called by their preferred name and a certified nurse aide in the resident's room loudly communicated personal information to a nurse across the hall; Resident #61 was not provided with a toothbrush to complete oral care; and Residents #5 and #106 were transported backwards in their wheelchairs.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure each resident had the right to be fully informed in a language that they can understand for 1 of 1 resident (Resident #104) reviewed. Specifically, Resident #104's primary language was not English, and the resident was not fully informed of their health care status in a language they understood, and communication tools were not used by direct care staff to determine the resident's needs.
- 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, record review, and interview during the recertification survey conducted 12/3/2024 -12/10/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 3 units (3rd Floor) reviewed. Specifically, the 3rd Floor had multiple unclean floors and walls, damaged walls, and unpleasant odors.
- 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, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives to meet medical, nursing, and mental and psychosocial needs for 3 of 6 residents (Residents #58, #100, and #101) reviewed. Specifically, Resident #100 had a physician order to receive nothing by mouth and was care planned to be offered a bedtime snack; Resident #58 did not have a comprehensive care plan that addressed their diagnosis of liver disease, their care plan was not updated when their transfer status changed, and they did not have fall mats as planned; Resident #101 had physician orders for an antipsychotic medication and did not have a care plan to address the medication and non-pharmacological interventions.
- 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 survey conducted 12/3/2024-12/10/2024, 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 1 of 4 residents (Resident #86) reviewed. Specifically, Resident #86 had unclean and untrimmed fingernails.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 5 residents (Residents #100 and #101) reviewed. Specifically, Resident #101 was not invited to or assisted to attend activities that were meaningful to them and met their interests and preferences; and Resident #100 was not provided with in-room stimulation that met their interests and preferences.
- 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, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure a resident who was fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #100) reviewed. Specifically, Resident #100's tube feeding water flushes were not administered as ordered and the tube feeding was observed unlabeled.
- 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 12/3/2024 through 12/10/2024, the facility did not provide on-going assessment and did not obtain informed consent prior to the installation of bed rails (side rails) for 1 of 2 residents (Resident #68) reviewed. Specifically, Resident #68 had bed rails on both sides of the bed and did have informed consent for the placement of bed rails and was not regularly assessed to ensure the bed rails remained appropriate.
- 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 12/3/2024 - 12/10/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the main kitchen had unclean surfaces and expired food items.
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00326659) surveys conducted on 12/3/2024-12/10/2024, the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for 1 of 2 residents (Resident #100) reviewed. Specifically, Resident #100 was referred to neurosurgery and pulmonology (lung specialist) and the facility did not follow up on these referrals in a timely manner.
November 7, 2023Complaint inspection · 1 citation
- 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 review and interview during the abbreviated Survey (NY00323447), the facility did not immediately inform the resident's representative and did not consult with the physician when there was a significant change in the resident's physical status and/or a need to alter treatment significantly for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 did not have capacity to make medical decisions and their health care proxy (HCP, person appointed to make healthcare decisions when the individual can no longer do so) was not notified when the resident had changes in their medical status and treatments. Additionally, the medical provider was not notified when the resident missed 2 diagnostic cardiology appointment and they were not rescheduled and the HCP was not notified of scheduled diagnostic tests.
December 2, 2022Standard inspection · 5 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 11/28/22-12/2/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 7 facility areas (main kitchen, third floor elevator hallway, third floor common area near resident room [ROOM NUMBER], main laundry area, and resident rooms 102, 114, 116, and 302). Specifically, there were multiple stained/damaged solid ceilings tiles; damaged equipment in the main kitchen; the laundry lacked an appropriate hand washing sink; and resident rooms 102, 104, 116, and 302 had multiple stained, unclean, and damaged areas.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 11/28/22-12/2/22, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 6 of 7 residents (Residents #30, 50, 66, 76, 78, and 103) reviewed. Specifically, Residents #50 and 103 (who resided on the dementia unit), and Residents #30, 50, 76 and 78 were not offered meaningful activities and were not provided with activities of their choosing. Additionally, Resident #78's room was not personalized with individual activity items, such as television, radio, and/or reading materials.
- D
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 11/28/22-12/2/22, the facility failed to 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 2 of 7 residents (Residents #30 and 85) reviewed. Specifically, Resident #30 was not shaved and did not receive assistance or adaptive equipment at 2 meals as planned; Resident #85 was observed on multiple occasions with their call bell out of reach.
- 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 11/28/22-12/02/22, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident (Resident #87) reviewed. Specifically, Resident #87 had a urinary catheter (a tube used to empty the bladder and collect urine in a drainage bag), complained of urinary tract symptoms, had a physician order for a urinalysis (U/A) and culture and sensitivity (C&S) and the urine specimen was not collected and submitted to the laboratory timely. Additionally, there was no medical rationale, physician order, or comprehensive care plan (CCP) for the use of a urinary catheter.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 11/28/22-12/2/22, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #73) reviewed. Specifically, Resident #73 was observed not receiving oxygen as ordered.
December 6, 2019Standard inspection · 8 citations
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review during the recertification survey, the facility did not inform each resident when changes in Medicare coverage occurred for 4 of 4 residents (Residents #14, 27, 465 and 466) reviewed for beneficiary notices. Specifically, Residents #14, 27, 465, and 466 were not provided with Notice of Medicare Non-Coverage (NOMNC) CMS (Centers for Medicare and Medicaid Services)-10123 letters.
- 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, interview, and record review during the recertification survey the facility did not maintain drugs and biologicals used in the facility in accordance with currently accepted professional principles for 1 of 2 medication rooms and 2 of 3 medication carts reviewed for medication storage and labeling. Specifically, there were expired stock medications in the Unit 1 and 2 medication carts and Unit 2 had an open undated vial of Lidocaine (liquid anesthetic) on a medication room shelf.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure the right to receive services with reasonable accomodation of needs and preferences for 1 of 2 residents (Resident #365) reviewed for choices. Specifically, Resident #365 had to purchase his own sheets for his bariatric bed (a heavy duty, extra wide bed).
- 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 interview and record review, the facility did not ensure the participation of the resident and the resident's representative in comprehensive care planning for 2 of 4 residents (Residents #53 and 92) reviewed for care plans. Specifically, Residents #53 and 92 or their designated representatives were not invited to participate in the development of their comprehensive care plan.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #37) reviewed for unnecessary medications. Specifically, Resident #37 had extreme fluctuations in his blood glucose levels and was not provided with sufficient diabetes management and did not receive an endocrine (specialist for diabetes management) consult as ordered to address his diabetes.
- 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 during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (main kitchen), in 1 of 3 nourishment refrigerators (Unit 1), and for 1 of 21 residents (Resident #23) reviewed for dining. Specifically, there was outdated food in a nourishment refrigerator, unclean equipment in the kitchen, and Resident #23's food was served without safe food handling during a breakfast observation.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #365) reviewed for non-pressure skin conditions. Specifically, proper hand hygiene and glove use was not performed during a dressing change for Resident #365.
- D
Have enough outside ventilation via a window or mechanical ventilation, or both.
Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not have adequate outside ventilation by means of windows for 5 of 5 windows (resident rooms 203, 206, 209, 211, and 212) observed. Specifically, there were not operable windows in resident rooms.
Fire safety inspections
33 fire safety citations on file: 11 on December 10, 2024, 13 on December 2, 2022, 9 on December 6, 2019.
Every fire safety citation33 citations
- E
Install a two-hour-resistant firewall separation.
K 133 · December 10, 2024 · Waiver
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 10, 2024 · Waiver
- E
Have an enclosure around a vertical opening shaft.
K 311 · December 10, 2024 · Waiver
- 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 · December 10, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 10, 2024 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · December 10, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 10, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · December 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · December 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 10, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 2, 2022 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 2, 2022 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · December 2, 2022 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · December 2, 2022 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · December 2, 2022 · 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 · December 2, 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 · December 2, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 2, 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 · December 2, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · December 2, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 2, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · December 2, 2022 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · December 2, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 6, 2019 · 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 · December 6, 2019 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 6, 2019 · Corrected (the home has a date of correction)
- D
Install a two-hour-resistant firewall separation.
K 133 · December 6, 2019 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · December 6, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 6, 2019 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 6, 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 · December 6, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 6, 2019 · Corrected (the home has a date of correction)