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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
20D
4E
2F
Potential for minimal harm
0A
0B
1C
March 19, 2026Complaint inspection · 1 citation
- G
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 conducted during survey, the facility failed to ensure a resident receiving enteral feeding received appropriate care and was monitored for complications related to tube feeding. This was evident for one (1) out of five (5) residents reviewed for enteral feeding (Resident #1). Specifically, on 02/20/2026, Resident #1 who received feeding and medications through a nasogastric tube (medical tube inserted through the nose into the stomach) had a change in their breathing pattern and was transferred to the hospital. Resident #1 was diagnosed with respiratory failure due to aspiration pneumonitis (an inflammation of the lung, which may lead to infection often presents rapidly with breathing difficulty, cough, and fever, requiring supportive care like oxygen) caused by a misplaced nasogastric tube in the left lung. [...]
July 9, 2025Complaint inspection · 2 citations
- F
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 onsite visit for Complaint NY00384371, it was determined that the facility failed to maintain safe and comfortable temperature levels. This was evident on six (6) of the seven (7) resident floors, where 22 out of 34 rooms sampled had temperatures above the Federal and State requirements in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29 range of 71 degrees Fahrenheit to 81 degrees Fahrenheit. Specifically, on 06/23/2025, Resident #1 submitted a complaint to the New York State Department of Health that there was loss of air conditioning on the sixth floor. The temperature on the sixth floor was 86.9 degrees Fahrenheit. [...]
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey and Partial Extended Survey (NY00384371), the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 06/23/2025 to 06/25/2025, complaints were submitted to the New York State Department of Health regarding high temperatures throughout the facility. The Administrator failed to provide effective leadership and oversight to ensure that comfortable and safe temperature levels were maintained in residents' rooms and common areas in the facility.
June 12, 2025Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00371268), the facility failed to ensure that a resident was free from resident-to-resident abuse. This was evident for one (1) out of five (5) residents (Resident #1) sampled. Specifically, on 01/31/2025 at 2:50 PM, Licensed Practical Nurse #1 witnessed an altercation between Resident #1 and Resident #2 in the elevator at the lobby level . Licensed Practical Nurse #1 separated the residents. Resident #1 and Resident #2 were assessed by Registered Nurse Supervisor #1 and there were no injuries. The facility failed to ensure timely safety measures to prevent further abuse. On 01/31/2025 at 5:25 PM, Resident #1 complained of left side chest pain and stated that Resident #2 entered their room and hit them. [...]
March 31, 2025Standard inspection, Complaint inspection · 14 citations
- 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 the onsite survey for the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that food was handled in accordance with professional standards for food service safety and staff did not ensure that infection control practices were maintained in the kitchen. This was evident during the Kitchen task. Specifically, dietary staff with visible facial hair and no beard restraints were observed assisting with food tray preparation on the tray line and removing cleaned items from the dish machine.
- 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 03/24/2025 to 03/31/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification via mail at the termination of Medicare Part A benefits. This was evident for 1 (Resident #129) of 3 residents reviewed for Beneficiary Notification out of 39 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made.
- 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 interviews conducted during the Recertification Survey and Complaint survey (NY00365250) from 03/24/2025 to 03/31/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident in 1 (7th Floor) out of 2 laundry rooms and in 19 out 38 resident rooms and shower rooms on the 7th floor observed during Environmental Task. Specifically, (1) the dryer on the 7th floor resident laundry room was noted with visible gray colored dust vents in the back, (2) multiple room fans were noted to have dusty front and back areas and dusty blades, and (3) water damage on the ceiling, broken wall tiles, and soiled curtains were observed in the bathrooms on both wings.
- 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 observation, interview, and record review conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that a copy of all transfers and discharges were sent to a representative of the Office of the State Long-Term Care Ombudsman in a timely manner. This was evident for 1 (Resident #743) of 1 resident reviewed for Discharge. Specifically, Resident #743 was transferred to the hospital on [DATE] and the discharge notice was not sent to the Office of the State Long-Term Care Ombudsman until 03/25/2025.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure that Minimum Data Set assessments accurately reflected a resident's status. This was evident for 1 (Resident #743) of 1 resident reviewed for accuracy of assessment out of 39 total sampled residents. Specifically, Resident #743's Minimum Data Set assessments did not accurately reflect the Resident's gender.
- 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 interviews conducted during a Recertification Survey between 03/24/2025 and 03/31/2025, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Residents #379) of 2 residents reviewed for Care Planning out of 39 residents sampled residents. Specifically, Resident #379 and their representative were not provided with a copy of the baseline care plan.
- 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 staff interviews conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that a person-centered comprehensive care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #102) of 2 residents reviewed for Edema out of a sample of 39 residents. Specifically, a person-centered care plan was not developed and implemented for Resident #102 who had edema.
- 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 between 03/24/2025 and 03/31/2025, the facility did not ensure that 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 2 (Resident #376 and Resident #194) of 5 residents reviewed for Unnecessary Medications out of an investigative sample of 39 residents. Specifically, 1). The Comprehensive Care Plan for Infection/Antibiotic Use for Resident #376 was last reviewed on 02/25/2025 and was not updated to reflect use of a Peripheral Intravenous Catheter line to give intravenous antibiotics or after Resident #376 completed a course of intravenous antibiotics, and 2). [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 03/24/2025 to 03/31/2025 the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain mobility and function. This was evident for 1 (Resident #120) of 2 residents reviewed for Rehab and Restorative out of a total sample of 39 residents. Specifically, Resident #120 did not receive the Nursing Rehabilitation Standing and Balance Program in March 2025 as recommended by the Rehabilitation Department. The finding is: The facility policy titled Restorative Nursing Programs implemented 01/2000 and last revised 01/2025 states it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 (Resident #17) out of 3 residents reviewed for Respiratory Care out of 39 sampled residents. Specifically, Resident #17 was observed using oxygen via an undated nasal cannula at a rate of 3 liters per minute when the Physician's Order was written for oxygen to be received at a rate of 2 liters per minute.
- 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 during the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that recommendations in the medication regimen reviews were identified and acted upon by the attending physician. This was evident for 1 (Resident #125) of 5 residents reviewed for Unnecessary Medication out of 39 sampled residents. Specifically, four Medication Regimen Reviews which recommended that an order for psychotropic medications for a diagnosis other than an approved chronic psychiatric condition be evaluated, were not addressed.
- 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 observation, interview, and record review conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure a resident was given psychotropic medication to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #12U) of 5 residents reviewed for Unnecessary Medication out of 39 total sampled residents. Specifically,1. Resident #125 was not provided with nonpharmacological interventions to address behavior before an antipsychotic medication was restarted, and 2. Resident #125 was prescribed a psychotropic medication without an appropriate diagnosis.
- C
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 conducted during the Recertification Survey from 03/24/2025 to 03/31/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 5 (Residents #148, #318, #28, #102, #407) of 5 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview conducted during the Recertification and Complaint Survey (NY00369624 and NY00354365) conducted from 03/24/2025 to 03/31/2025, the facility did not ensure residents received adequate supervision and assistance devices consistent with resident's needs, goals, and care plan to prevent accidents. This was evident for 2 (Residents #108 and #260) of 2 residents investigated for Accidents out of 39 total sampled residents. Specifically, (1) Resident #108 fell and hit the back of head causing injury to left eye orbital while being transferred to bed by 2 Certified Nursing Assistants, and 2. (2) Resident #260 who required a harness while out of the crib and in a wheelchair was removed from wheelchair with harness and placed in a Gerichair without any harness causing Resident #260 to move and fall to the floor.
March 26, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, record review, and interviews, conducted during an Abbreviated Survey (NY00355337) the facility failed to ensure that a resident was treated with respect and dignity and cared for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. This was evident for one (1) out of six (6) residents (Resident #6) sampled. Specifically, on 09/24/2024 Licensed Practical Nurse #1 reported when they entered Resident #1's room the Resident immediately started to cry stating Certified Nursing Assistant #1 told them none of the staff members liked them. [...]
October 23, 2023Standard inspection, Complaint inspection · 4 citations
- 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 and interview conducted during the Recertification survey 10/16/2023 to 10/23/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, 1) a dietary staff did not change contaminated gloves after disposing garbage and proceeding to handle soiled dishes which were scraped before cleaning for the tray line and no hand hygiene between changing gloves. This was observed during the Kitchen facility task.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review, and staff interview conducted during the recertification survey 10/16/2023 to 10/23/2023 and complaint NY00315981, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident on 2 of 13 units. (8 [NAME] and 10 West). Specifically, a live mouse was observed crawling in a resident's room on 8 [NAME] and in the hallway near the nursing station on the 10th floor. The facility policy and procedure titled Pest Control revised 03/2023 documented the facility is to maintain an effective pest control program that eradicates and contains common household pests and rodents that include roaches, ants, mice, and rats. The finding is: 1. [...]
- 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 conducted during the Recertification/Complaint Survey from 10/16/23 to 10/26/23, the facility did not ensure a comprehensive person-centered care plan (CCP) was reviewed and revised to address a resident's needs (NY00320501). This was evident for 1 of 3 residents (Resident #212) reviewed for Resident-to-Resident Physical Abuse out of 43 total sampled residents. Specifically, Resident #212's CCP related to at risk to be abused/abused others was not reviewed or revised after the Resident-to-Resident Physical Abuse allegation which occurred on 7/20/23.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review conducted during a Recertification and Complaint survey (NY00323515) from 10/16/2023 to 10/23/2023, the facility did not ensure a resident received adequate supervision to prevent a resident from eloping. This was evident for 1 (Resident #592) of 3 residents investigated for Accidents out of an investigative sample of 43 residents. Specifically, Resident #592 left unit on 9/3/23 at approximately 10:23 AM to go to the lobby and sit in front of the building and was discovered missing at approximately 2:40 PM. The resident did not return to the unit for lunch served from 12:00 PM to 12:30 PM, and the medication nurse reported resident was not in room at 1:30 PM to receive medication. Resident was able to exit the lobby area undetected by staff by sliding under the fence on the outside of the building.
October 20, 2023Complaint 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 an Abbreviated Survey (NY 00319068), the facility failed to ensure that an alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, if the event that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause he allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency (NYSDOH). This was evident in one of the five residents reviewed for abuse (Resident #1). Specifically, on 04/26/2023 at approximately 5:00 PM, Behavioral Health Associate (BHA) #2 reported that BHA #1 grabbed their personal phone from Resident #1 hand in an aggressive way and bumped Resident #1's forehead. The incident was not reported to the New York State Department of Health (NYSDOH).
August 6, 2021Standard inspection · 5 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that residents were free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, Specifically, residents were observed with four side rails during multiple observations. This was evident for 3 of 3 residents reviewed for Physical Restraints out of a sample of 38 residents. (Resident #222, Resident # 296, Resident # 297).
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review conducted during the recertification Survey the facility did not ensure that it promoted and facilitated resident self-determination through support of resident choice. Specifically, residents bathing preferences were not honored. This was evident for 1 of 3 residents reviewed for Choices out of 38 sampled residents (Resident #45).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review and staff interviews conducted during recertification survey, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, the most recent MDS did not accurately capture that residents were receiving oxygen. This was evident for 2 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents (Resident # 41 and Resident # 222).
- 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 interview conducted during the recertification, the facility did not ensure that a resident's person-centered, comprehensive care plans (CCP) were revised in a timely manner. Specifically, care plans were not revised after the quarterly assessment. This was evident for 1 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents. (Resident #41)
- 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 a recertification survey, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, a resident with a diagnosis of Alzheimer's Dementia was prescribed an anti-psychotic medication without documented evidence in the clinical record to support the use of psychotropic medication for the resident. This was evident for 1 of 5 residents reviewed for the Unnecessary Medication out of a sample of 38 residents. (Resident #67)
Fire safety inspections
23 fire safety citations on file: 2 on March 31, 2025, 14 on October 23, 2023, 7 on August 6, 2021.
Every fire safety citation23 citations
- E
Have properly located and lighted "Exit" signs.
K 293 · March 31, 2025 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 31, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · October 23, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 23, 2023 · Waiver
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · October 23, 2023 · 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 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · October 23, 2023 · Corrected (the home has a date of correction)
- D
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · October 23, 2023 · Corrected (the home has a date of correction)
- C
Establish an Emergency Preparedness Program (EP).
E 1 · October 23, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 6, 2021 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 6, 2021 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 6, 2021 · 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 6, 2021 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · August 6, 2021 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 6, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 6, 2021 · Corrected (the home has a date of correction)