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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
10E
4F
Potential for minimal harm
0A
1B
0C
May 6, 2025Standard inspection, Complaint inspection · 2 citations
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on observation, record review, and interviews during a recertification and complaint survey, NY00371941, the facility did not ensure the resident's/family's right to receive notice, including the reason for resident's room change before the resident's room in the facility was changed. This was evidence for 1 of the 1 resident reviewed of out 38 residents sampled. (Resident #212) Specifically, the facility changed Resident's room without providing the resident's family with advanced notification.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that infection control practices were maintained. This was evident for 2 (Resident #7 and Resident #158) residents during the Dining Task. Specifically, Certified Nursing Assistant #1 failed to clean their hands in between residents while assisting both residents with eating.
December 30, 2024Complaint inspection · 1 citation
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record review and interviews conducted during the abbreviated complaint investigation survey (NY00356207) from 12/27/2024 to 12/30/2024, the facility did not 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. This was evident during review of Application for Employment submitted by the Assistant Director of Nursing dated 05/18/23. Specifically, the facility did not ensure that background information was properly completed and verified prior hiring the staff. The findings including, not limited to: The Facility Application for Employment dated 05/18/2023 documented: Please provide complete and legible information. An incomplete application may affect your consideration for employment. [...]
May 9, 2024Standard inspection, Complaint inspection · 13 citations
- J
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 the Recertification and Abbreviated (NY00340290) survey from 4/29/2024 to 5/9/2024, the facility did not ensure a resident was free from physical abuse. This was evident for 1 (Resident #77) of 3 residents reviewed for abuse out of 39 total sampled residents. Specifically, surveillance camera footage revealed on 4/23/2024 at 12:06 PM, Certified Nursing Assistant #1 struck Resident #77 causing the resident to fall backwards onto the floor. Certified Nursing Assistant #1 then grabbed Resident #77 by their wrists, lifted the resident off the floor, and pulled them to their room. Registered Nurse #1 and Certified Nursing Assistant #2 witnessed the incident and did not intervene. Subsequently, Resident #77 was diagnosed with a left wrist fracture because of the incident. [...]
- J
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 Recertification and Abbreviated (NY00340290) Survey from 4/29/2024 to 5/9/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 5 (Resident #77, Resident #32, Resident #111, Resident #79, and Resident #91) of 39 total sampled residents. [...]
- J
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00340290) Survey from 4/29/2024 to 5/9/2024, the facility failed to ensure that all alleged violations involving abuse, neglect, and mistreatment were thoroughly investigated, prevent further potential abuse while an investigation was in progress, and report the results of the investigation to the New York State Department of Health within 5 working days. This was evident for 2 (Resident #77 and Resident #111) of 39 total sampled residents. Specifically, 1) an allegation of staff-to-resident abuse involving Certified Nursing Assistant #1 and Resident #77 occurred on 4/23/2024 and the investigation results were not reported to the New York State Department of Health until 5/3/2024. [...]
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and staff interviews conducted during the Recertification and Extended Survey on 4/29/2024 to 5/9/2024, the facility did not ensure that performance reviews of every nurse aide were conducted at least once every 12 months This was evident for 12 of 12 Certified Nursing Assistants reviewed for nurse aides' training requirements. Specifically, the facility was unable to provide evidence that Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18 were provided 12 hours of in-service training, including dementia and resident abuse prevention training.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and extended survey from 4/29/2024 to 5/9/2024, the facility did not 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. This was evident during review of Resident Rights, Abuse, Activities, and Staffing. [...]
- F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and staff interviews conducted during the Recertification and Extended Survey on 4/29/2024 to 5/9/2024, the facility did not ensure that certified nurse aides were provided the required 12 hours of in-service training per year, including dementia management and resident abuse prevention training, to ensure continuing competence. This was evident for 12 of 12 Certified Nursing Assistants reviewed for nurse aides' training requirements. Specifically, the facility was unable to provide evidence that Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18 were provided 12 hours of in-service training, including dementia and resident abuse prevention training.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 04/29/2024 to 05/09/2024, the facility did not ensure each resident was treated with respect and dignity. This was evident for 4 (Resident #s 24, 125, 5, and 87) of 39 total sampled residents. Specifically, 1) Resident #24's Foley drainage bag was not placed in a dignity bag and was visible from the hallway, and 2) care was provided to Resident #125 without a privacy curtain and was visible to their 3 roommates, and 3) Resident #5's and #87's point of care testing was carried out in the unit day room without providing privacy for the residents.
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, interview, and record review during the recertification survey from 4/29/2024 to 5/9/2024, the facility did not ensure each resident had the right to be fully informed in a language that they can understand. This was evident for 3 (Resident #159, #191, and #195) out of 39 total sampled residents. Specifically, 1) Resident #159 was Korean-speaking and was not provided with language interpretation services, 2) Resident #191 was Cantonese-speaking and was not provided with language interpretation services, and 3) Resident #195 was Mandarin-speaking and was not provided with language interpretation services.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 04/29/2024 to 05/09/2024, the facility did not ensure ea resident's right to privacy. This was evident for 4 (Resident #s 24, 125, 5, 87)) of 39 total sampled residents. Specifically, 1) Resident #24's foley drainage bag was not placed in a dignity bag and was visible from the hallway, 2) care was provided to Resident #125 without a privacy curtain and the resident was visible to their 3 roommates, and 3) Resident #5's and #87's point of care testing was carried out in the unit day room without providing privacy for the residents.
- 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 interviews conducted during the Recertification survey from 04/29/2024 to 05/09/2024, the facility did not ensure resident comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment. This was evident for 6 (Resident #s 116, 197, 91, 125, 462, and 195) of 39 total sampled residents. [...]
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 4/29/2024 to 5/9/2024, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the residents. This was evident for 4 (Resident #191, #260, #107 and #462) of 39 total sampled residents. Specifically, 1) Resident #191 was not engaged in an ongoing activity program in accordance with their preferences, 2) Resident #260 was observed for extended periods of time without meaningful activities, 3) there were multiple observations of Resident #107 not being engaged in meaningful activities, and 4) Resident #462 was not observed engaged in a meaningful activities program.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interviews conducted during the Recertification and Extended Survey on 04/29/2024 to 05/09/2024, 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 3 of 6 units observed during the Medication Administration task. Specifically, licensed nurses were observed not practicing hand hygiene, not sanitizing medical equipment in between residents' use, and failed to practice Enhanced Barrier Precaution.
- B
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 04/29/2024 to 05/09/2024, the facility did not ensure Minimum Data Set 3.0 assessments were electronically transmitted within 14 days of completion. This was evident for 3 (Resident #1, #156, and #211) of 3 residents reviewed for resident assessment out of 39 total sampled residents. Specifically, the Minimum Data Set 3.0 assessments for Residents #1, #156, and #211 were not transmitted within 14 days of completion.
November 21, 2023Complaint inspection · 2 citations
- 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 interviews and record review conducted during Abbreviated Survey (NY00309995), the facility failed to ensure that a resident's discharge care plan was reviewed and revised by the interdisciplinary team. This was evident in 1 out of 4 residents (Resident #1) sampled. Specifically, Resident #1 was discharged on 12/31/22. The care plan was not reviewed and revised to reflect that Resident #1 was discharged home on [DATE].
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (NY00309995), the facility did not provide a discharge summary to a resident that includes, but is not limited to, the following: a recapitulation of the residents stay that includes, but is not limited to diagnoses, course of illness/ treatment or therapy, pertinent lab work, radiology, and consultation results. This was evident for 1 out of 4 (Resident #1) residents reviewed for discharged . Specifically, there was no documented evidence of a final discharge summary identifying that Resident #1 was medically cleared for discharge. Additionally, there was no physician's order to discharge Resident #1.
October 31, 2022Standard inspection · 10 citations
- 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 and staff interview conducted during the Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, (1) prepared and frozen foods were not labeled, dated appropriately, and (2) cold sandwiches were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below. This was observed during the Kitchen Task.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review conducted during the Recertification and Complaint survey (NY00302339) from 10/25/22 to 10/31/22, the facility did not ensure that the resident's personal privacy was maintained. Specifically, (1) a Nurse Practitioner was observed examining a resident in the hallway corridor, and (2) a resident's mail was not unopened and delivered in a timely manner. This was evident for 1 of 4 residents reviewed for Privacy and 1 of 3 residents reviewed for Activities of Daily Living out of a sample of 38 residents (Resident #84 & #81). The finding is: 1. [...]
- E
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/Complaint Survey from 10/25/22 to 10/31/22, 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 3 of 8 residents reviewed for Baseline Care Plan out of 38 sampled residents. (Residents #30, #111 & #189).
- 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 observation, record review, and interviews conducted during the Recertification survey from 10/25/2022 through 10/31/2022, the facility did not ensure that (1) residents' Comprehensive Care Plans (CCP) were reviewed and revised after each assessment, and (2) each resident or resident representative was offered the opportunity to participate in the review of their CCP. Specifically, (1) care plans for anticoagulant use, vision, Parkinson's Disease were not revised for Resident #88 and care plans for pain and Osteoarthritis were not revised quarterly for Resident #161, and (2) Resident #9 representative was not invited to participate in the residents' care plan meetings. This was evident of 1 of 5 residents reviewed for Unnecessary Medication, 1 of 4 residents reviewed for Pain Management and 1 of 2 residents reviewed for Abuse out of a sample of 38 residents. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review conducted during the Recertification survey conducted 10/25/22 to 10/31/22, the facility did not ensure that residents received services with reasonable accommodation of resident's needs. Specifically, a resident's ability to use a call bell or other form of device to call for staff assistance if needed based on the resident's functional ability was not evaluated or assessed in a timely manner. This was evident for 1 of 2 residents reviewed for the Environmental Task out of a sample of 38 residents. (Resident # 30)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview conducted during a Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflect the resident's status. Specifically, the most recent MDS did not accurately document the presence of pain for a resident. This was evident for 1 of 4 residents investigated for Pain Management out of 38 sampled residents. (Resident #161).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record reviews and interviews conducted during the Recertification survey conducted 10/25/22- 10/31/22, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility. This was evident for 1 of 1 resident reviewed for Preadmission Screening and Resident Review (PASARR) out of 38 sampled residents. (Resident #146)
- 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 observations, record review and interviews conducted during the Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no documented evidence that a CCP was developed and implemented for at risk for Abuse for a resident who had behavioral symptoms of yelling and screaming. This was evident for 1 of 4 residents reviewed for Accidents out of 38 sampled residents. (Resident #22)
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review conducted during a Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that residents received proper treatment and assistive devices to maintain vision abilities. Specifically, the resident did not receive Ophthalmology follow-up care as recommended. This was evident for 1 of 3 residents reviewed for Communication/Sensory out of a sample of 38 residents. (Resident #88)
- 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 observations, record reviews and interviews conducted during the Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. Specifically, the physician did not review the Rehab assessment and place an order for the resident's use of bed side rails. This was evident for 1 of 2 residents reviewed for Physical Restraints out of a sample of 38 residents reviewed. (Resident #189).
Fire safety inspections
7 fire safety citations on file: 1 on May 6, 2025, 2 on May 9, 2024, 4 on October 31, 2022.
Every fire safety citation7 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 · May 6, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 9, 2024 · Corrected (the home has a date of correction)
- B
Use approved construction type or materials.
K 161 · May 9, 2024 · Waiver
- F
Address subsistence needs for staff and patients.
E 15 · October 31, 2022 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · October 31, 2022 · Waiver
- F
Have proper power supply for life support equipment.
K 915 · October 31, 2022 · Waiver
- 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 31, 2022 · Corrected (the home has a date of correction)