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
19D
1E
1F
Potential for minimal harm
0A
3B
0C
June 12, 2026Standard inspection, Complaint inspection · 8 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services necessary to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, Specifically, 1.) Residents reported the facility was short staffed of Certified Nursing Assistants which resulted in lack of timely staff response to residents who needed assistance, 2.) Multiple nursing staff members reported lack of sufficient staffing, 3.) Facility's staffing levels were repeatedly below facility assessed levels, and 4.) Excessively low weekend staffing was triggered in the Payroll Based Journal Staffing Data Report for Quarter 2 2026 (January 1 - March 31).
- 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 observation, record review, and interviews, the facility failed to ensure the resident representative was notified of an accident involving the resident which results in injury and has the potential for requiring physician intervention. This was evident in one of one resident (Resident #25) reviewed for notification of change out of 38 total sampled residents. Specifically, the facility failed to notify Resident #25's representative of the resident's fall with injury on 03/23/2026.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident was free from physical restraints. This was evident in one (Resident #52)of three residents reviewed for abuse out of 35 total sampled residents. Specifically, on 09/26/2024, Resident #52 was observed by the staff with their hand mitten tied to the bed side rail. Refer to F609 - Reporting of Alleged ViolationsThe
- 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, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are 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, or not 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 administrator of the facility, including to the State Survey Agency. This was evident in two (Residents #52 and #75) of five residents reviewed for abuse and accidents out of 35 total sampled residents. [...]
- 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, record review, and interview, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident in one (Resident # 75) of three residents reviewed for abuse out of 35 total sampled residents. Specifically, following Resident #75's allegation of abuse reported on 05/04/2026, the facility failed to develop and implement an abuse related care plan until 06/01/2026.
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure quarterly Minimum Data Set assessments were completed within the required timeframe. This was evident in three (Residents #23, #59, and #225) of 13 residents reviewed for resident assessment. Specifically, the quarterly Minimum Data Set assessments were not completed within 14 days of the Assessment Reference Date.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Minimum Data Set assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System within 14 days after assessments were completed. This was evident in two (Residents #98 and #149) of 13 residents reviewed for timely Minimum Data Set transmission. Specifically, quarterly [NAME] Data Set assessments for Residents #98 and #149 were submitted after the required timeframe.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the Minimum Data Set assessments accurately reflected residents' clinical status. This was evident in two (Residents #21 and #29) of 38 total sampled residents. Specifically, The Minimum Data Set assessment inaccurately documented internal bleeding for Resident #21, and failed to identify an indwelling urinary catheter for Resident #29.
March 9, 2026Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure that each resident received adequate supervision to prevent elopement. This was evident for one (1) out of three (3) residents (Resident #1) sampled for elopement. Specifically, on two (2) occasions Resident #1exited the facility without the facility's knowledge and supervision. On 08/03/2025 at 5:57 PM, Housekeeping [NAME] #1 left the facility's exit back door alarm disabled and Resident #1 exited the facility without activating the alarm. Resident #1 was located at their adult sibling's house and transferred to hospital. Resident #1 returned to the facility on [DATE] at 9:15 PM with no injury. On 12/31/2025 at 2:25 AM, Resident #1 exited the front door after Security Guard #1 pressed the button at front desk to open the door and let Resident #1 out of the facility. [...]
August 7, 2024Standard inspection, Complaint inspection · 10 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 and interviews during the recertification survey on 07/31/2024 to 08/07/2024 the facility did not ensure that housekeeping and maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, observations of multiple floors revealed rooms, corridors, and dining rooms with chipped, broken plaster, bubbled up paint, furniture and wall hanging in disrepair, torn window screens, loose and dirty moldings. This was evident on 5 of 6 Units. (Units 3, 7, 2, 5, and 6)
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interviews and record review conducted during the Recertification survey from 07/31/2024 to 08/07/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 1 (Resident #581) of 3 residents reviewed for Beneficiary Notification out of 38 total sampled residents. Specifically, the Notice of Medicare Non-Coverage was not mailed out to Resident #581 designated representative on the same day that telephonic notification was made. The facility policy titled Notice of Medicare Non-Coverage, Benefits Exhaust Letter with an effective date of 1/2024 states that the notice must be validly delivered which means that the beneficiary must be able to understand the purpose and contents of the notice to sign for receipt of it. [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview conducted during the Recertification survey from 07/31/2024 to 08/07/2024 the facility did not ensure that residents' personal privacy and confidentiality was maintained. Specifically, during observation of the Medication Administration Task, Registered Nurse #1 left the computer screen on the Electronic Health Record open and in public view displaying a resident's Personal Health Information. (Resident #140). The finding is: The facility's policy and procedure dated 04/2024 titled Health Insurance Portability and Accountability Act (HIPPA) documented that it is a privacy and confidentiality act as it relates to residents' health care related issues. The Lesson Plan for Health Insurance Portability and Accountability Act, dated 04/2024, documented, Do Not leave your computer/laptop unattended when the screen is open showing a resident's information. [...]
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey from 7/31/2024 to 8/07/2024, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #10) of 2 residents reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #10 was observed with bilateral half siderails in place and was unable to independently use or release the side rails.
- 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 staff interviews conducted during the Recertification and Complaint survey (NY00326505) conducted from 07/31/2024 to 08/07/2024, the facility did not ensure that resident Comprehensive Care Plans were reviewed and revised after each assessment. This was evident for 1 (Resident #38) of 5 Residents reviewed for Unnecessary Medications and 1 (Resident #69) of 4 residents reviewed for Abuse out of 38 sampled residents. Specifically, Resident #38 has a diagnosis of Non-Alzheimer's Dementia and the Comprehensive Care Plan for Dementia had not been reviewed and revised, and Resident #69's care plan was not revised to include verbally abusive behavior, biological needs, and verbal sexual expressions toward staff.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation and interviews conducted during the Recertification survey from 07/31/2024 to 08/07/2024, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. Specifically, medications were left unattended on the medication cart, the medication cart was left opened, unlocked, and unattended, and the Electronic Medical Record on the medication cart was left open and unattended exposing a resident's confidential medical information. This was evident during a Medication Administration Task. The finding is: The facility policy and procedure dated 01/2024 titled Professional Standards stated that all employees are expected to maintain high standards of professional conduct, ethics, and competence in their roles. [...]
- 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 observations and staff interviews conducted during the Recertification survey conducted from 07/31/2024 to 08/31/2024, the facility did not ensure that all medications and biological's were stored and labeled properly. Specifically, medications on the medication cart, were left unattended, and the medication cart was left unlocked and unattended. This was evident during observations conducted for the Medication Administration Task.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interviews conducted during the Recertification survey from 07/31/2024 to 08/07/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #180) of 6 residents observed for Respiratory Care and for 1 (Resident #514) of 3 residents observed for Pressure Ulcer out of a total sample of 38 residents. Specifically, Respiratory Therapist #1 failed to practice proper hand hygiene for Resident #180 while doing respiratory care, and Registered Nurse #2 failed to practice proper hand hygiene for Resident #514 while doing wound care. [...]
- D
Put firmly secured handrails on each side of hallways.
Inspectors wroteBased on observation and interviews conducted during a Recertification Survey from 07/31/2024 to 08/07/2024, the facility did not ensure handrails remain firmly affixed to the wall. Specifically, there were observations of handrails in the hallways on 2 (Unit 2 and Unit 6) that were not firmly affixed to the wall.
- 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 a Recertification and Abbreviated survey (NY00327342) from 7/31/2024 to 08/07/2024, the facility did not ensure that an alleged violation involving a resident was reported to the New York State Department of Health. This was evident for 1 (Resident #112) of 4 residents reviewed for Abuse out of 38 sampled residents. Specifically, the facility did not report an allegation of abuse to the New York State Department of Health.
February 22, 2023Standard inspection · 5 citations
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and staff interview conducted during the Recertification/Complaint survey, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan. This was evident for 1 of 2 residents reviewed for Care Planning out of a sample of 37 residents. (Resident #74). The finding is: The facility policy and procedure titled Baseline Care Plan Summary dated 01/2020 documented: The facility will develop and implement a Baseline Care Plan Summary for each new resident within 48 hours of admission . The Social Services Director/designee will print the 48-Hour Baseline Care Plan Summary and review it with the resident/representative. The resident/representative signature will be obtained to verify the meeting and agreement with the plan. A signed copy will be maintained in the medical record. [...]
- 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 during the Recertification/Complaint Survey, the facility did not ensure that residents were afforded the opportunity to participate in CCP (Comprehensive Care Plan) meetings. This was evident for 1 of 2 residents reviewed for Care Planning out of a sample of 37 residents (Resident #74). Specifically, the facility did not ensure that the resident and resident representative, if applicable, was involved in developing the care plan and included in the review and revision of the care plan.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observation, record review and interview conducted during Recertification/Complaint survey from 02/14/2023 to 02/22/2023, the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of the resident to be an active partner and effectively transition the resident to post-discharge care, and the reduction of factors leading to preventable readmission. Specifically, no discharge planning process was developed and implemented since Resident's admission to the facility. This was evident for 1 of 2 residents reviewed for discharge out of 37 sampled residents (Resident #74).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 2/14/23 to 2/22/23, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. This was evident for 1 of 1 resident reviewed for General - Constipation/diarrhea (Resident #314). Specifically, nursing staff did not report Resident #314's repeated episodes of diarrhea to the Medical Doctor (MD).
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 2/14/23 to 2/22/23, the facility did not ensure a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. This was evident for 1 (Resident #125) of 1 resident(s) reviewed for position/mobility. Specifically, there were multiple observations of Resident #125 without the left gauze handroll in place per Medical Doctor Order (MDO).
Fire safety inspections
8 fire safety citations on file: 2 on June 12, 2026, 3 on August 7, 2024, 3 on February 22, 2023.
Every fire safety citation8 citations
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 12, 2026 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · June 12, 2026 · 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 · August 7, 2024 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 7, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 7, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 22, 2023 · Corrected (the home has a date of correction)
- D
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 · February 22, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 22, 2023 · Corrected (the home has a date of correction)