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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
3E
3F
Potential for minimal harm
0A
0B
1C
April 30, 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, interview, and record review conducted during an Abbreviated survey (complaint #2717679), the facility failed to keep the resident's environment free from accidents. Specifically, one (1) (Resident #1) of three (3) residents reviewed for accidents was transferred via mechanical lift by Certified Nurse Aide #1, without assistance of another staff member, and the resident fell out of the sling sustaining a laceration on their leg.
December 9, 2025Standard inspection · 10 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 observation, interview, and record review conducted during complaint investigations (NY00353449/786213) conducted during a Standard survey completed on 12/09/2025, the facility did not ensure sufficient staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not have sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs. This involves Residents #2, #4, #7, #22, #41, #55, #67, #72, #77, #82.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review conducted during a Standard and Complaint (#2655733) survey completed on 12/09/2025, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for three (Green Unit, Yellow Unit, and Blue Unit) of three test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #4, #7, #12, #41, #81, #82, #88, #92, #106 and #136 were involved.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 12/09/2025, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This affected one (1) of one (1) Main Kitchen and one (1) (Green Unit) of three (3) Nourishment Rooms. Specifically, the Main Kitchen had issues with opened undated, outdated, and/ or unlabeled foods. [NAME] restraints were not being worn during food preparation. There was a water leak from plumbing in the dishwash area and the window air conditioning unit in the food preparation area was dust laden. In addition, a Nourishment Room refrigerator contained undated and/ or unlabeled food.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview and record review conducted during a complaint investigation (Complaint #'s 786244 and 2655733) during the Standard survey completed on 12/09/2025, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (3) (Yellow, Blue and Green) of three (3) resident units. Specifically, there were stained privacy curtains in resident rooms (first floor-Yellow unit); dirty shower room floors/walls, ceiling tiles in disrepair, and a toilet seat in disrepair (first floor-Blue unit); oxygen (02) concentrator filters covered with thick grey dust, hair in shower drain, personal resident items in shared bathroom and shower room; ripped and stained mattress; lack of paper towels for staff and resident use, and malodorous odors in resident areas (second floor-Green unit). [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 12/09/2025, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #4, #19, and #41 ) of three (3) residents reviewed for infection control. Specifically, during a wound care observation, Resident #4's soiled brief and soiled wound dressing were placed directly on the floor without a barrier; staff did not wear personal protective equipment including gowns during wound care, personal care, and transferring of Resident #41, who was on enhanced barrier precautions; [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #77) of one (1) resident reviewed for medication self-administration. Specifically, Resident #77 was observed with medications in their room, and they self-administered the medications without being evaluated as to whether they could safely do so. The finding is:The policy titled Self-Administration of Medications dated 12/01/2017 documented residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. [...]
- 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 observation, interview, and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure that the resident can make choices about aspects of his or her life that is important to them. Specifically, two (Residents #82 and Resident #7) of four (4) residents reviewed for choices had issues with not receiving a shower per their preference (Resident #82) and the facility did not honor the resident's preference to get out of bed before breakfast (Resident #7).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming for two (2) (Residents #44 and Resident #5) of two (2) residents reviewed for nail care. Specifically, Resident #44 had long fingernails on their right hand, and Resident #5 had long fingernails with brown debris underneath.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint #2609916) during the Recertification Survey completed on 12/09/2025, the facility did not ensure that all residents receive treatment and care in accordance with professional standards of practice for two (2) (Resident #8 and #145) of five (5) residents reviewed. Specifically, there was a delay in obtaining an order for pain management and an x-ray for a resident who sustained a fall and subsequently had a clavicle fracture (break in the S-shaped bone connecting your shoulder blade (scapula) to your breastbone (sternum) (#145). Additionally, there was no assessment or treatment initiated to a skin tear on Resident #8's right forearm.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing for one (1) (Resident #4) of four (4) residents reviewed. Specifically, the Physician Wound Consultant recommendation dated 10/31/2025 for an air mattress (a mattress that provides air flow to relieve pressure) was not implemented, and Resident #4 developed a new pressure ulcer. [...]
January 27, 2025Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review conducted during a Complaint (#NY00350496) investigation the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for one (Resident #7) of three residents reviewed. Specifically, Resident #7 did not receive Levothyroxine Sodium (Synthroid medication used to treat thyroid conditions) as ordered and there was a lack of physician notification. The finding is: The policy titled Administering Medications/Treatments dated 12/1/17 documented medications shall be administered in a safe and timely manner, and as prescribed; [...]
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00341704 and #NY00350496) completed on 1/27/25, the facility menus and nutritional adequacy did not meet the nutritional needs of residents in accordance with established national guidelines and be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. Specifically, two (lunch and dinner) of two meal entrees observed revealed proper amount of protein was not being provided to meet adequate nutritional needs of the residents. The finding is: [...]
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00341704 and #NY00350496) completed on 1/27/25, the facility did not ensure each resident received food that accommodated their allergies, intolerances, and preferences for three (Resident #1,2 and 7) of three residents reviewed. Specifically, Resident #7 was ordered a no added salt renal, gluten free diet and was not being provided gluten free products and food preference choices. Resident #1 and Resident #2 did not receive their food preference choices.
April 26, 2024Standard inspection · 2 citations
- 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 observations, record review, and interviews conducted during the Standard survey completed on 4/26/24, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Residents #61) of 2 residents reviewed for resident choices. Specifically, Resident #61 was given a bed bath instead of a shower as planned and per their stated preference. The finding is: The policy and procedure titled Quality of Life- Accommodation of Needs, dated 9/1/17, documented the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. [...]
- C
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 4/26/24, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected two (First Floor, Second Floor) of two resident use floors and the Basement. The finding is: The policy and procedure titled Carbon Monoxide Detectors, effective 5/2019, documented carbon monoxide detectors shall be installed, tested and cleaned as per manufacturer's recommendations. Additionally, carbon monoxide detectors are to be vacuumed once monthly to remove any accumulated dust. [...]
January 30, 2023Standard inspection · 6 citations
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/30/23, the facility did not maintain an effective pest control program so that the facility was free from insects. Specifically, one (Blue Unit) of three units' and one Main dining room multiple black flies were observed. Residents #1, #42, #50, #52, #53, #57, #74, #83, and #88 involved.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview conducted during a Complaint investigation (Complaint # NY00304636) during the Standard survey completed on 1/30/23, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing for one (Resident #100) of four residents reviewed. Specifically, there were lack of pressure ulcer assessments and ongoing monitoring from a qualified individual for a resident with ankle and Achilles' pressure ulcers to include stage, location, measurements. In addition, the Minimum Data Set (MDS - resident assessment tool), did not reflect pressure ulcers and the comprehensive care plan was not revised to include the use of an air mattress. The finding is: [...]
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/30/23, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with the physician's orders, and the comprehensive person-centered care plan for one (Resident #20) of one resident reviewed. Specifically, there was lack of assessment and dressing changes of a PICC line catheter (peripherally inserted central catheter - a catheter that is inserted through a vein and advanced until the tip enters the central venous system) and flushes were not administered as ordered. Additionally, inaccurate documenting of IV (intravenous) therapy/care/treatment. The finding is: [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/30/2023 the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice. Specifically, one (Resident #42) of one resident reviewed for dialysis had an issue involving the lack of the AVF (arteriovenous fistula) access site (a tube or device surgically implanted to create an artificial connection between an artery and a vein) pressure dressing not being removed. The finding is: Review of the facility policy and procedure (P&P) titled Dialysis dated1/19/2019, documented the facility has established standards of care for the dialysis resident. [...]
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review, and interview conducted during a Standard survey completed 1/30/23, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Unit Blue and Unit Yellow) of three resident units and the Main Dining Room (MDR) reviewed for food temperatures during meals had issues involving food items that were not palatable and at safe and appetizing temperatures. Residents' #1, #84, #42 and #18 were involved.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey started 1/23/23 and completed 1/30/23, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. One of one main kitchen had issues with safe food handling. Specifically, the [NAME] did not change their gloves or wash their hands in accordance with professional standards, touched multiple surfaces, and did not use appropriated utensils to serve food.
Fire safety inspections
10 fire safety citations on file: 5 on December 9, 2025, 2 on April 26, 2024, 3 on January 30, 2023.
Every fire safety citation10 citations
- E
Provide properly protected cooking facilities.
K 324 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · December 9, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 30, 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 · January 30, 2023 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · January 30, 2023 · Corrected (the home has a date of correction)