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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
0E
1F
Potential for minimal harm
0A
1B
0C
April 22, 2025Standard inspection · 3 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 04/15/2025 to 04/22/2025, the facility did not ensure that resident or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and/or resident's representatives were not consistently invited to participate in their care plan meetings. This was evident for 1 (Resident #116) of 2 residents reviewed for Care Plan out of 37 sampled residents.
- 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 04/15/2025 to 04/22/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 2 (Resident #67 and Resident #482) of 3 residents reviewed for Beneficiary Notification out of 37 total sampled residents. Specifically, 1). the facility did not ensure that assistive devices were used to make appropriate notification, and 2). the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage were not mailed to a resident's representative on the same day the telephone notification was made.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 04/15/2025 through 04/22/2025, the facility did not ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident for 1 (Resident #151) of 5 residents investigated for Accidents, and 1 (Resident #127) of 1 resident investigated for Pressure Ulcers of 37 total sampled residents. Specifically, (1) Resident #151 had documented wandering behavior which was not accurately coded, and (2) Resident #127 had a pressure ulcer that was not accurately coded on the Minimum Data Set assessment.
April 24, 2023Standard inspection · 6 citations
- F
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 observations, interviews, and record review conducted during the Recertification Survey from 04/17/2023 to 04/24/2023, the facility did not ensure that menus were followed. This was evident for 2 of 3 residents reviewed for Food out of 39 sampled residents (Resident #91 and Resident #288) and 182 residents present on 4/17/23. Specifically, 1) Resident # 91 received food items that did not match items on the tray ticket, and 2) Resident #288 reported they were served pork, fried foods and not their preferred foods. In addition, 3) on 4/17/23, the vegetable listed on the posted menu was changed, and residents were not informed.
- 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 interview conducted during a Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 4 of 5 resident floors (Floors 3, 5, 6, and 7). Specifically, resident rooms were observed with broken window blinds (Floors 3 and 5), torn window screens (6th Floor), and missing blinds and privacy curtains (7th floor). Resident wheelchairs had stained cushions (3rd and 6th Floor) and wheel noted with worn tires on both sides with decreased tread chipped paint on oxygen canister holder with a missing screw, wheelchair tires were noted to have multiple decreased rubber tread on bilateral wheels (6th floor).
- 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 and Complaint survey (NY00313269) from [DATE] and [DATE], the facility did not ensure that residents' comprehensive care plans (CCPs) were reviewed and revised by the interdisciplinary team after each assessment and as needed. This was evident for 3 out of 39 sampled residents (Residents #19, #16 and #134). Specifically, (1) Resident #19's Advance Directive CCP was not reviewed and revised when their code status was changed to Do Not Resuscitate (DNR) and after the quarterly assessment; (2) Resident #16's CCP related to Anemia and gastrointestinal (GI) bleeding was not reviewed and revised to reflect a change in the resident's status after hospitalization; and (3) Resident #134's elopement risk CCP was not reviewed and revised for 6 months.
- 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, interviews, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (6th Floor medication room) of 5 medication storage areas reviewed. Specifically, 1) emergency medications were stored in a plastic emergency box missing the tamper proof seal.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interviews during the Recertification survey from 04/17/23 and 04/24/23, the facility did not ensure that laboratory services were provided timely to meet resident needs for 1 (Resident #19) of 5 residents reviewed for Unnecessary medications. Specifically, laboratory (lab) blood work [Complete Metabolic Profile (CMP) and Complete Blood Count (CBC) with differentials, Lipids, B12, Folate, Thyroid -stimulating hormone (TSH), and Hemoglobin A1c] ordered for Resident #19 on 3/30/2023 and 04/19/23 was not done. The finding is: The facility's policy titled Laboratory- Specimen Collection, last reviewed 07/2022, documented that the facility will be responsible to contract with a laboratory to provide diagnostic laboratory services. [...]
- 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 observations, record review and interviews, during the Recertification survey the facility did not ensure each resident received food that accommodated resident's allergies, intolerances, and preferences. This was evident for 2 of 39 residents sampled for dining observations. (Resident #91 and Resident #288). Specifically, (1). Resident #91's menu did not follow the resident's preferences, and (2). the food preferences of Resident #288 were not honored when the resident expressed a preference for cottage cheese, oatmeal and whose meal ticket specified food dislikes gravy, sauces, fried foods, beef, beef stew.
September 15, 2020Standard inspection · 1 citation
- 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 staff interview and record review conducted during the recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that the comprehensive care plan included measurable goals, objectives and interventions to address a resident with behavior that included verbal abuse and rejection of care. This was evident for 1 of 6 residents reviewed for Unnecessary Medications out of a sample of 29 residents. (Resident # 57).
Fire safety inspections
24 fire safety citations on file: 1 on April 22, 2025, 15 on April 24, 2023, 8 on September 15, 2020.
Every fire safety citation24 citations
- 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 · April 22, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 24, 2023 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · April 24, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · April 24, 2023 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · April 24, 2023 · deficient, provider has
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 24, 2023 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · April 24, 2023 · Corrected (the home has a date of correction)
- F
Have proper power supply for life support equipment.
K 915 · April 24, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · April 24, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 24, 2023 · Corrected (the home has a date of correction)
- D
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
K 255 · April 24, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 24, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 24, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · April 24, 2023 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · April 24, 2023 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · April 24, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · September 15, 2020 · 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 · September 15, 2020 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 15, 2020 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 15, 2020 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 15, 2020 · 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 · September 15, 2020 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · September 15, 2020 · Corrected (the home has a date of correction)
- B
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · September 15, 2020 · Not yet corrected