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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
6E
1F
Potential for minimal harm
0A
0B
0C
July 30, 2026Complaint 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 survey, the facility failed to ensure each resident remained free from sexual abuse. This was identified for one (Resident #5) of three residents reviewed for sexual abuse. Specifically, Resident #5 and Resident #6 were not assessed to have capacity to consent. Resident #6 was witnessed inappropriately touching Resident #5 and was engaging in non-consensual sexual contact with Resident #5.
March 11, 2026Complaint inspection · 3 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, and interviews during a survey, the facility failed to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately but no later than two (2) hours to the New York State Department of Health. This was identified for seven (7) residents of seven (7) residents: Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 reviewed for abuse. Specifically, 1) Resident #1's Designated Representative alleged Resident #1 stated to them that their (Resident #1's) arm was twisted. 2) Resident #2 alleged that a certified nursing assistant was rough during care, violated their dignity and did not follow their plan of care during their transfer. 3) Resident #3 alleged that a certified nursing assistant was rough with them (and tossed them around during care. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, and interviews during the Abbreviated Complaint Survey (Intake ID 2702583), the facility did not ensure that all alleged violations involving abuse, mistreatment, or neglect were thoroughly investigated. This was identified for seven (7) residents of seven (7) residents: Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 reviewed for abuse. Specifically, 1) Resident #1's Designated Representative alleged Resident #1 stated their (Resident #1's) arm was twisted and the allegation and the allegation was not thoroughly investigated. 2) Resident #2 alleged that a Certified Nursing Assistant was rough during care, violated their dignity and did not follow their plan of care during transfer and the allegation was not thoroughly investigated. [...]
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated Survey (Intake ID 2702583), the facility did not ensure each resident was served food and drink that was palatable, attractive, and at a safe and appetizing temperature. This was identified for two (2) of nine (9) residents, Resident #1 and Resident #8 who identified hot foods being served cold. Specifically, on 02/27/2026 during the lunch meal service on one unit (DePorres Unit) the lunch entree and vegetable were not served at a safe and appetizing temperature. The finding is: The facility's policy titled, Food Temperatures with a review date of February 2025 documented all hot foods must be cooked to appropriate internal temperatures, held and served at a temperature of at least 140 degrees Fahrenheit. [...]
July 2, 2025Standard inspection, Complaint inspection · 12 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, staff interviews, and record review during the Recertification Survey, the facility did not ensure a comfortable environment for residents, staff, and visitors. This was identified on one ([NAME] Unit) of seven units observed during the Environmental Task. Specifically, during an initial tour on 6/25/2025 between 12:45 PM and 1:00 PM of the [NAME] Unit, elevated environmental temperatures between 81 degrees Fahrenheit (F) to 87 degrees Fahrenheit were noted in resident rooms, hallways, and dining areas. The [NAME] Side corridor of the [NAME] Unit Heating Ventilation Air Conditioning Unit (HVAC) and the Package Terminal Air Conditioners (PTAKS) units in multiple resident rooms and the general use area were not functioning as intended. [...]
- 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 record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00359206 ) initiated on 6/24/2025 and completed on 7/2/2025 the facility did not ensure sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. This was identified on four ([NAME], [NAME], Deporres and [NAME]) of eight nursing units. Specifically, on the 3:00 PM to 11:00 PM shift, the [NAME] Unit, the [NAME] Unit, the Deporres Unit, and the [NAME] Unit were not staffed according to the levels specified in the Facility Assessment on 6/27/2025 to 6/29/2025 (Friday, Saturday, and Sunday).
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety. This was evident during the Dining Observation task for one ([NAME] Unit) of seven units. Specifically, during the dining observation on the [NAME] Unit, the temperature of cold food items (tuna sandwich, turkey sandwich, and milk) was above acceptable standards for safe serving temperatures. In addition, there was no system in place to monitor the temperature of cold food items. The finding is:A facility policy and procedure titled Food Temperatures, reviewed 2/2025, documented that the Culinary Department will review and manage food temperatures to ensure the safety of food being served to residents. [...]
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, initiated on 6/24/2025 and completed on 7/02/2025, the facility did not maintain the cooling system in proper working conditions to provide a healthy, functional, and comfortable environment for residents, personnel, and the public. This was identified on one ([NAME] Unit) of seven units observed during the Environmental Task. The [NAME] Side corridor of the [NAME] Unit Heating Ventilation Air Conditioning Unit (HVAC) and the Package Terminal Air Conditioners (PTAKS) units in multiple resident rooms and the general use area were not functioning as intended. The finding is: [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interviews during the recertification survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for one (Resident #57) of one resident reviewed for the Resident Assessment task. Specifically, Resident #57's two quarterly and one Skilled Nursing Facility Prospective Payment System (PPS) discharge assessment was not transmitted within 14 days of the resident assessment completion date. The finding is: [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview during the recertification survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure the accuracy of Minimum Data Set Assessments. This was identified for one (Resident #187) of four residents reviewed for Accidents. Specifically, based on the Resident #187's Comprehensive Care Plan and Fall Risk assessment, the resident utilized a chair alarm daily. The resident's Quarterly Minimum Data Set assessment, dated 4/11/2025, and a Significant Change Minimum Data Set assessment dated [DATE], did not indicate the use of the chair alarm. The finding is:A facility policy and procedure titled Minimum Data Set Assessments, effective 5/1/2025, documented that each resident admitted to the facility will be assessed utilizing the Minimum Data Set tool as a means of improving resident care. [...]
- 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 initiated on 6/24/2025 and completed on 7/02/2025, the facility did not develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #51) of two residents reviewed for Abuse. Specifically, Resident #51 was diagnosed with Legal Blindness, and the facility did not develop a visual impairment care plan with person-centered interventions to address the resident's needs. The finding is: [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 6/24/2025 and completed on 07/02/2025, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. This was identified for one (Resident #40) of five Residents reviewed for Bladder and Bowel Incontinence. Specifically, Resident #40 had a history of diarrhea and constipation, and the staff were administering Imodium (used to treat diarrhea) and Senna (a stimulant laxative to treat constipation) daily to the resident. The finding is:The facility's policy titled Bowel Protocol, last reviewed 4/30/2025, documented that nursing staff will monitor and document the daily bowel function of the residents. The evacuation sheet is to be checked by nurses daily. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration states. This was identified for one (Resident #10) of one resident reviewed for Nutrition. Specifically, Resident #10 had a 5.3% significant weight loss in one month, from January 2025 to February 2025. The Registered Dietitian documented the resident's significant weight loss on 2/10/2025. On 2/19/2025, a 3-Day Calorie Count was completed and revealed the resident was not meeting their estimated calorie and protein needs; however, the Registered Dietitian did not put any new nutritional interventions into place to prevent the resident from losing further weight. The finding is: [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey, initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that pain management was provided to each resident who requires such services, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #110) of one resident reviewed for Pain management. Specifically, Resident #110 did not receive their pain medication in a timely manner on 6/25/2025. The finding is:The facility's policy titled Pain Management, dated 9/2024, documented the facility will review the resident's level of pain on a daily basis and promote each resident's level of comfort through pharmacological and non-pharmacological interventions. [...]
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that the medical care of each resident was supervised by the Physician, including monitoring changes in the resident's medical status. This was identified for one (Resident #10) of one resident reviewed for Nutrition. Specifically, Resident #10 had a 5.3% significant weight loss in 30 days, from January 2025 to February 2025, which was not addressed by their Physician. The finding is: The facility's policy titled, Weight Changes, last reviewed in September 2024, documented it is the responsibility of the Dietitian, Medical Services, and Nursing Services that any new specific (significant) weight change (gain or loss) of greater than or equal to 10% in 6 months; greater than or equal to 7.5% in 3 months; [...]
- 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 record review and staff interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that the irregularities identified by the Pharmacist were reviewed by the medical provider and documented that the action had been taken to address the irregularities. This was identified for one (Resident #126) of two residents reviewed for Mood and Behavior. Specifically, a Medication Regimen Review form dated 4/8/2025 by the Consultant Pharmacist documented that the co-administration of Seroquel (antipsychotic medication) and Remeron (antidepressant medication) may increase the risk for abnormal electrocardiogram and Serotonin syndrome. The Pharmacist recommended assessing the continued co-administration of Seroquel and Remeron. The Nurse Practitioner agreed with the recommendations; [...]
April 12, 2024Standard inspection · 5 citations
- F
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on record review and interviews conducted during a Recertification Survey initiated on 4/7/2024 and completed on 4/12/2024, the facility did not ensure that their policy regarding the use and storage of foods brought to residents by family and other visitors included to ensure facility staff assists the resident in accessing and consuming the food if the resident is not able to do so on their own. Specifically, the facility did not provide accommodations for heating and storage of food brought to residents from outside the facility. Additionally, the facility Administrator and the Director of Culinary Services stated that residents who were unable to eat on their own would be provided feeding assistance by facility staff only when facility prepared food was consumed. The finding is: [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record review, and interviews conducted during a Recertification Survey initiated on 4/7/2024 and completed on 4/12/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen observation conducted on 4/7/2024. Specifically, the walk-in refrigerator for dairy was observed with multiple trays including eight trays of coconut custard pie and two trays of diet vanilla pudding, the items were not labeled and dated. The walk-in refrigerator adjacent to the freezer was observed with one carton of liquid eggs that was opened and dated 4/18/2024. There was no indication when the egg carton was first opened. The walk-in freezer was observed with one pan of frozen leftover entrée, cornflake chicken, labeled and dated 1/23/2024. [...]
- 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 during the Recertification Survey initiated on 4/7/2024 and completed on 4/12/2024 the facility did not ensure that each 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 identified for one (Resident #77) of two residents reviewed for dignity. Specifically, during a lunch meal observation on 4/7/2024 Certified Nursing Assistant #1 was observed standing over Resident #77 while they assisted Resident #77 with their lunch meal. The finding is: The facility's policy titled, Feeding a Resident, documented to ensure that all residents receive the assistance required to complete a meal in a comfortable, pleasant, and supportive environment to enhance the experience as well as the resident's overall intake. [...]
- 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 observation, record review, and interviews during the Recertification Survey initiated on 4/07/2024 and completed on 4/12/2024 the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. This was identified for one (Resident #199) of one resident reviewed for Tube Feeding. Specifically, on 4/07/2024 at 10:40 AM and again on 4/07/2024 at 12:40 PM Resident # 199's tube feeding, and hydration bottles were not labeled including the resident's name, flow rate, date, and time the feeding was initiated. The finding is: The facility's policy titled, Gastrostomy Tube Feeding via Enteral Feeding Pump dated 4/2023 documented the feeding product container is labeled with the date, time, rate of flow, and the nurse's initials. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/07/2024 and completed on 4/12/2024 the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for one (Resident #608) of three residents reviewed for Respiratory Care. Specifically, Resident #608 had a physician's order to administer 3 liters of oxygen via a nasal cannula as needed (PRN); however, on 4/07/2024 at 10:13 AM, the resident was observed receiving 4 liters of oxygen instead of the prescribed 3 liters. Additionally, there was no documented evidence in the medical record that the resident was being administered oxygen therapy as ordered by the physician.
March 18, 2022Standard inspection · 2 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00274868) initiated on 3/14/2022 and completed on 3/18/2022, the facility did not ensure accidents were thoroughly investigated to rule out abuse, neglect, or mistreatment for one (Resident #394) of three residents reviewed for accidents. Specifically, Resident #394 had an unwitnessed fall in the facility on 4/21/2021; however, the investigation was not thorough and did not address the root cause of the resident's fall. Additionally, the investigation did not address the resident's behavior of disarming the chair and bed alarms. The finding is: [...]
- 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 interviews and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00274868) initiated on 3/14/2022 and completed on 3/18/2022, the facility did not ensure that each resident's comprehensive care plan (CCP) was reviewed and revised to meet the needs of the resident. This was identified for one (Resident #394) of three residents reviewed for Accidents. Specifically, Resident #394 who was at risk for falls was identified by the facility staff with behaviors of turning off their bed and chair alarms. The CCP was not updated and revised to reflect the resident's behavior. Subsequently, on 4/21/2021 the resident had an unwitnessed fall with no alarm sounding. The CCP was not revised after the fall to include the resident's behavior of disarming the chair and bed alarms. The finding is: [...]
Fire safety inspections
15 fire safety citations on file: 4 on July 2, 2025, 4 on April 12, 2024, 7 on March 18, 2022.
Every fire safety citation15 citations
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 2, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 2, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 2, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · July 2, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 12, 2024 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · April 12, 2024 · Waiver
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 12, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed windows in hallway walls or doors.
K 364 · April 12, 2024 · Corrected (the home has a date of correction)
- F
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · March 18, 2022 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · March 18, 2022 · Waiver
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 18, 2022 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 18, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 18, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 18, 2022 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 18, 2022 · Corrected (the home has a date of correction)