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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
5E
1F
Potential for minimal harm
0A
1B
0C
February 25, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review conducted during an Abbreviated Survey (2741076), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment, was reported immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) of six (6) residents (Resident #1) sampled for abuse. [...]
December 4, 2025Complaint inspection · 1 citation
- 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 the abbreviated survey (#2622204), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) of one (1) (Resident #1) sampled. Specifically, Resident #1 had an unwitnessed incident on 09/06/2025 when they were observed on the floor and noted with swelling to the forehead, left peri-orbital (area around the eye) swelling and an abrasion on the nose. [...]
August 26, 2025Standard inspection · 5 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and staff interviews conducted during the Recertification survey, the facility did not ensure that each resident was treated with respect, dignity and care in a manner that promotes maintenance or enhancement of their quality of life and recognizes each resident's individuality. This was observed on five (5) out of five (5) units observed during the kitchen and Dining Observation Task. Specifically, the residents' meals were served on disposable dishware with plastic cutlery.
- 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 interviews, observations and record reviews conducted during a recertification survey, the facility did not ensure that a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment. This was evident for one (Resident #192) of five residents sampled for Unnecessary Medications. Specifically, Resident #192 was taking medication for Gastrointestinal issues and there was no care plan in place.
- 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 interview conducted during the Recertification survey, the facility did not ensure that the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the episodic, comprehensive, and quarterly review assessments. This was evident for one resident (Resident #8) reviewed for Hospice and one resident (Resident #192) reviewed for Unnecessary Medications out of an investigative sample of 38 residents. Specifically, 1). The care plan related to Hospice for Resident #8 was last reviewed on 04/09/2025, and 2). Resident #192's care plan related to Cognitive loss was last reviewed on 01/03/2025, the care plan related to Social Isolation was last reviewed on 10/22/2024, and the care plan related to psychosocial well-being was last reviewed on 07/22/2024.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices and that they were complete and accurately documented for each resident. This was evident for one (Resident #57) of five residents reviewed for Unnecessary Medication and one (Resident #174) of five residents reviewed for Pressure Ulcer/Injury) out of 85 total sampled residents. Specifically, 1). A care plan for schizophrenia was documented for Resident #57 who does not have a schizophrenia diagnosis, and 2). The Treatment Administration Records for Resident #174 documented nursing staff performed wound care when Resident #174 refused to allow the facility staff to perform the treatments.
- B
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 interviews conducted during the Recertification Survey from 08/19/2025 to 08/26/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident on 3 units (Unit1, Unit 2, and Unit 4) out of 5 units observed during the Environmental Task. Specifically, 1). On Unit 1 doors to the foyer and utility room were observed with multiple large areas of chipped and scrapped paint. The wall of the pull station was observed with dried uneven plaster, and the first-floor conference room windowsills were observed with peeling tape and 1 ripped window shade. 2) On Unit 2, multiple resident rooms were observed with broken and or missing slats from vertical blinds. The ceiling in room [ROOM NUMBER] was observed brown stained with peeling paint and a cracked window. [...]
June 11, 2025Complaint inspection · 1 citation
- 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 interviews conducted during an Abbreviated Survey (NY00344413 and NY00376155), the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in two (2) out of seven (7) residents (Resident #3 and #5) sampled. Specifically, on 05/30/2025 at 9:30 AM, Resident #3 was escorted by Certified Nursing Assistant #6 for clinic appointment and Resident #3 had an accident by sliding off from wheelchair in the vehicle. Certified Nursing Assistant #6 did not report the incident to anyone at the facility. [...]
June 21, 2023Standard inspection · 8 citations
- E
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 6/13/23 to 6/21/23, the facility did not ensure residents received notices orally and in writing with the list of names and addresses of the State regulatory agencies, resident advocacy groups, and Ombudsman information. This was evident for 6 (Resident #s 133, 113, 64, 30, 96, 109) of 8 residents in attendance at Residnt Council out of 30 total sampled residents. Specifically, Resident #s 133, 113, 64, 30, 96, and 109 stated they were not aware of their rights and were not provided with contact information for State agencies and advocates.
- 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, interviews, and record review conducted during the recertification survey from 6/13/23 through 6/21/23, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during the Kitchen facility task. Specifically, 2 cold sandwiches were not held at a safe temperature of 41 F or below.
- D
Give residents a notice of rights, rules, services and charges.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure a resident received notice of their rights and services upon admission. This was evident for 1 of 30 total sampled residents. Specifically, Resident #64 was not provided with an admission Agreement explaining their rights and services upon admission to the facility.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interviews, and record review conducted the recertification survey from 6/13/23 to 6/21/23, the facility did not ensure incorporate the recommendations from the Pre-admission Screening and Resident Review) PASARR level II determination into the resident's assessment, care planning, and transitions of care. This was evident for 1 (Resident #123) of 30 total sampled residents. Specifically, The facility did not obtain a neurology consult for Resident #123 after the resident was admitted with a PASARR level II recommendation for a neurology consult.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 6/13/23 to 6/21/23 the facility did not ensure a Comprehensive Care Plan (CCP) was developed and implemented to address resident needs. This was evident for 1 (Resident #149) of 30 total sampled residents. Specifically, a CCP related to oxygen use was not developed and implemented for Resident #149.
- 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, interviews, and record review conducted during the recertification survey from 6/13/23 through 6/21/23, the facility did not ensure the comprehensive care plans (CCP) were reviewed and revised after each assessment. This was evident for 2 of 2 residents (#101 and #21) reviewed for Nutrition out of 30 total sampled residents. Specifically, 1) the CCP related to oral care/dental and cancer for Resident #101 were not reviewed upon significant change assessment, and 2) the CCP related to diabetes mellitus (DM) was not reviewed or reviewed or revised upon change in the resident's medication regime.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 6/13/23 to 6/21/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #123) of 30 total sampled residents. Specifically, Resident #123 was delayed in receiving an appointment to be seen by the neurologist.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 6/13/23 to 6/21/23 the facility did not ensure a resident was provided with respiratory care in accordance with professional standards of practice. This was evident for 1 (Resident #149) of 30 total sampled residents. Specifically, Resident #149 was ordered to receive oxygen via nasal canula and was observed with a oxygen face mask and received no oxygen saturation monitored.
April 13, 2021Standard inspection · 8 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review conducted during the Recertification survey conducted 4/5/21 to 4/13/21, the facility did not ensure that a qualified dietician was employed either full time, part time, or on a consultant basis. Specifically, the facility did not have the services of a Registered Dietician (RD) from April 2020 to March 2021. The finding is: During the tour of the Kitchen on 4/13/21 at 11:30 AM, the facility provided a resume which documented that the dietician had a Bachelor of Arts in Home Economics and had completed Master Program and courses in clinical nutrition. Administrator stated that the facility did not have any additional documentation regarding the dietician being certified or registered. [...]
- E
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 staff interview during the recertification survey, the facility did not ensure that the comprehensive care plans were reviewed and/or revised after each assessment and as needed. Specifically, the care plan was not reviewed and/or revised (1) after a resident on isolation for an infection kept leaving the room, (2) after a resident had multiple falls, and (3) after quarterly and annual assessment. This was evident for 3 out of 31 sampled residents. (Resident #s 126, 137, and 46).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, during a Recertification survey, the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. Specifically (1). Systems in place did not prevent diversion of controlled medications on 2 resident units, (2). Systems in place did not prevent diversion of controlled medications from the nursing office and (3). Medications were not removed timely from the narcotic cabinet on resident units resulting in diversion of narcotics. This was evident on Unit 5, Unit 2, and the Nursing Office.
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on record review and staff interview during the recertification and abbreviated survey (#NY00253374), the facility did not ensure that the resident's representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative of the resident. Specifically, the facilty presented the spouse of Resident#44 with change of Health Insurance forms to sign, however the spouse was not the resident's representative to excercise those rights. The resident had two chidren designated as Health Care Proxies and one child was also designated as the resident's Power of Attorney. Neither were presented with information regarding change of Health Insurance. The change in health coverage was executed without their permission. This was evident for 1 of 3 residents reviewed for Notification of Changes out of a sample of reviewed for Resident rights. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and staff interview conducted during the recertification survey, the facility did not ensure that each resident maintained acceptable parameters of nutritional status such as usual body weight range and electrolyte balance. Specifically, a resident with significant weight loss and decreased meal intake was not reassessed timely to determine whether changes to the nutritional plan of care were warranted. This was evident for 1 of 2 residents reviewed for nutrition hydration (Resident #21). The finding is: Resident #21 was a resident admitted to the facility with diagnoses which include: Dysphagia, Unstable Angina, and Type 1 Diabetes Mellitus. The Minimum Data Set 3.0 (MDS) assessment dated 01/21 2021 documented the resident had intact cognition. The resident required the extensive assist of one person for Activities of Daily Living (ADLs). [...]
- 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 during the recertification survey and abbreviated survey (# NY00267480), the facility did not ensure that the residents' attending physicians reviewed the total program of care at each visit. Specifically, the physician increased psychotropic medications twice within four months to treat a resident with Dementia and dementia-related behaviors. This was evident for 1 of 31 residents reviewed in the investigation sample (Resident #74). The finding is: The facility Policy and Procedure titled Psychotropic Drugs dated 11/2018 documents and quotes the F758 of the State Operation Manual (SOM), Appendix PP (Rev. 11-22-17), that residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observations, record reviews, and staff interviews conducted during an Abbreviated (NY00267480) and Recertification Survey, the facility did not ensure a resident was free from unnecessary medications. Specifically, a resident with a diagnosis of Dementia was given increased dosages of psychotropic medications to treat the dementia-related behavior of screaming. This was evident for 1 of 6 residents reviewed for Unnecessary Medications (Resident #74). The Finding is: The facility Policy and Procedure titled Psychotropic Drugs dated 11/2018 documents and quotes the F758 of the State Operation Manual (SOM), Appendix PP (Rev. 11-22-17), that residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. [...]
- D
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 and staff interview the facility did not ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, open insulin was not labeled with an expiration date or discarded after expiration. This was evident for 1 of 4 units observed for Medication Storage (Unit 2). The finding is: The Medication Storage Policy of the facility revised on 06/2019 states : Pelham Parkway Nursing Care shall store all drugs and biologicals in a safe, secure and orderly manner. [...]
Fire safety inspections
11 fire safety citations on file: 2 on August 26, 2025, 5 on June 21, 2023, 4 on April 13, 2021.
Every fire safety citation11 citations
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 26, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 26, 2025 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · June 21, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 21, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 21, 2023 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · June 21, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 21, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 13, 2021 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 13, 2021 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 13, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 13, 2021 · Corrected (the home has a date of correction)