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
0G
0H
0I
Potential for more than minimal harm
20D
4E
5F
Potential for minimal harm
0A
0B
0C
August 19, 2025Standard inspection, Complaint inspection · 15 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 wroteF725 Based on observation, interviews, and record review during the recertification and abbreviated survey (Case #s:), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels were not met on multiple shifts and multiple units between 8/04/2025 and 8/17/2025. Additionally, there were multiple residents and family complaints regarding the lack of sufficient staffing, resulting in staff's timely response to call lights and not providing scheduled showers and treatments both during initial resident and family interviews and Resident Council, and complaints made through the complaint department of the New York State Department of Health nursing home complaint hotline. [...]
- F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that drug records were in order; and that an account of all controlled drugs was maintained and periodically reconciled on six (6)(Birch, Willow, Oak, Elm, Maple, and Cedar) of (6) six units reviewed. Specifically, the shift-to-shift staff signature form for controlled drugs, titled Shift Count, did not consistently include the signatures of staff members at each shift change, validating the correct narcotic count. This is evidenced by: The policy and procedure titled Narcotic Count, dated 8/2018, documented the on-coming and the off-going nurses assigned to the medication cart would be responsible for ensuring the accuracy of the controlled drug count. [...]
- F
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 record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review that included time frames for the different steps in the process. Specifically, the policy did not include time frames for the different steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: The policy and procedure titled Medication Regimen Reviews (MRR) dated 7/19/2019 with no review or revision dates stated if the situation was serious enough to present a risk to a person's life, health, or safety, the Consultant Pharmacist would contact the Physician directly to report the information to the Physician. There was no time frames included to state when this contact would happen. [...]
- F
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 observation and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2) (Cedar unit Side #2, [NAME] unit Side #1, ) of six (6) medication carts and two (2) (Elm unit #1 and #2 medication rooms) of six (6) medication rooms reviewed. Specifically, (a.) (1) (one) bottle of purified protein derivative (PPD) solution had no open and or expiration date; (b.) an opened insulin pen had no open and or expiration date; (c.) one (1) unopened insulin pen was stored improperly; (e.) stock medications in medication rooms had expired; (f.) opened stock medications were not dated; (g.) a resident specific medication was not dated and (h.) a medication cup with unidentified medication was found in the medication cart. This is evidenced by: [...]
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteF804 Based on observation and interviews conducted during a recertification survey and abbreviated survey (Case #NY00596012), the facility did not ensure residents were provided food and drink that was palatable, flavorful, at an appetizing temperature for two (2) of two (2) meals reviewed (Lunch meals on 8/14/2025 and 8/15/2025). Specifically, food was not served at a palatable and appetizing temperature during the lunch meal on 8/14/2025 and 8/15/2025. This is evidenced by: During an observation on 8/11/2025 at 11:51 AM, meal trays were prepped by Dietary Aides in the unit kitchenette. During an interview on 8/07/2025 at 11:18 AM, Resident #239 stated the food was terrible, so they bought their own food. During an interview on 8/7/2025 at 11:35 AM, Resident #157 stated the food was not good and the only food items they ate were the macaroni salad and meatloaf. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews conducted during recertification and abbreviated (Case #s: 2578580, 2576246, 596027, 2566657, 596028, 594500, 596019, 596018, 596016, 596012, 596015, 59600, 596011, 596005) surveys, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for (seven) 7 of 35 residents reviewed. Specifically, (a) for Resident #14, medication was not administered per physician orders. Specifically, (b) for Resident #35, medication was not administered per physician orders. Specifically, (c) for Resident #103, medication was not administered per physician orders. Specifically, (d) for Resident #177, medication was not administered per physician orders. Specifically, (e) for Resident #146, weekly weights were not obtained per physician orders. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity, and care in a manner and in an environment that promoted maintenance or enhancement of their quality of life for two (2) (Resident #68 and #100) of thirty-five (35) residents reviewed. Specifically, (a.) Resident #100 did not receive showers as scheduled, or when requested for July and August 2025. On or about 8/1/2025, Resident Representative #1 was approached by Certified Nurse Aide # 1 to bring in toiletries for Resident #100 such as soap, deodorant, and shampoo, because Resident #100 had an odor ; (b.) On 8/08 /2025, staff did not respond to Resident #68 yelling out for help during mid-morning and then again at lunch time. This is evidenced by: [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interviews conducted during recertification and abbreviated (Case #s: 2578580, 2576246, 596027, 2566657, 596028, 594500, 596019, 596018, 596016, 596012, 596015, 596007, 596011, 596005) surveys, the facility did not ensure residents were free from neglect for one (1) (Resident #253) of thirty-five (35) residents reviewed for neglect. Specifically, Resident #253 was admitted to the facility on [DATE] with NPO status (nothing by mouth) and received nutrition/hydration via a gastrostomy tube (G-tube, a feeding tube inserted through the abdomen into the stomach. It is used to deliver nutrition, fluids, and medications when a person is unable to eat or drink adequately on their own.) Tube feedings (a way to provide nutrition and hydration) were not initiated until the following day the resident was admitted to the facility (6/24/2025) at 10:00 AM. [...]
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen was free from chemical restraints. This was identified for 1 (one) of 1 (one) residents reviewed for unnecessary medications. Specifically, Resident # 14 was ordered Buspirone 7.5 milligrams twice a day for anxiety, Seroquel 50 milligrams twice a day for antipsychotic, Seroquel 25 milligrams daily at bedtime for antipsychotic, oxycodone 5 milligrams three times a day for severe pain, and OxyContin 5 milligrams every 12 hours for severe pain. There was no evidence that a gradual dose reduction was attempted, and Resident #14 was observed to be lethargic-looking when observed during the day. This is evidenced by: [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 2 (Resident #s 185 and 218) of 35 residents reviewed. Specifically, the Preadmission Screening and Resident Review was incorrect for Resident #185 and incomplete for Resident #218. This is evidenced by: The facility Policy titled, Preadmission Screening and Resident Review /Screens, dated 12/2019, documented every admission to the facility would have a completed Level 1 Screen prior to admission to ensure the resident was appropriate for admission to the facility. Residents with identified serious mental illness or intellectual disability would have a completed Level II Preadmission Screening and Resident Review prior to admission, if indicated on their Level 1 Screen. [...]
- 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 reviews, and interviews, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for five(5) (Resident #s 35, 48, 146, 157, and 199) of 35 residents reviewed for comprehensive care plans. Specifically, (a.) for Resident #35 there was no documented evidence that there was a care plan in place related to the known contracture of Resident #35's right hand; [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and abbreviated surveys (NY00596011; NY00596018; NY00594500), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for three (3) of nine (9) residents (Resident #100, #218 and #250) reviewed. Specifically, (a.) Resident #100 was not showered per the facility schedule and as requested. (b.) Resident #'s 218 and 250 were not provided toileting checks or care in accordance with their plan of care. This is evidenced by: The facility's Policy and Procedure titled Activities of Daily Living Care and Support, revised 2/28/2025, documented: 1. [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of one (1) (Resident #8) of three (3) residents reviewed. Specifically, Resident #8 (eight) did not consistently participate in meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for 1(one) of 6 (six) residents (Resident #35) reviewed for Pressure Ulcers. Specifically, for Resident #35 there was no documented evidence that preventative measures were taken to prevent skin breakdown due to their hand contracture. The is evidenced by: The facility policy titled Contracture Prevention dated 8/2020, documented that each resident must be assessed for need of contracture prevention procedures on admission and as needed. Additionally, hand rolls may be placed in any hand that the resident cannot move. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that are in accordance with professional standards of practice, the resident's care plan and the resident's choice, for (two) 2 (Residents #48 and #163) of 3 (three) residents reviewed for oxygen administration. Specifically, a) Resident #48, the oxygen tubing was not dated and labeled to reflect when the tubing was changed; b) Resident # 163, nebulizer tubing was not dated and labeled to reflect when the tubing was changed, and the nebulizer mask was not stored per facility policy (in a plastic bag with the resident's name on it) when not in use. Resident #48 Resident #48 was admitted to the facility with the diagnoses of acute infarction of the intestine, hypertension, and hypoxemia. [...]
September 18, 2023Complaint inspection · 3 citations
- 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 record review and interviews during an abbreviated survey (Case # NY00289779), the facility did not inform the resident representative(s) when accidents occurred for one (1) (Resident #3) out of sixteen (16) sampled residents. Specifically, the facility did inform Resident #3's representative after the resident had an unwitnessed fall on 3/3/2022.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00278031) the facility did not ensure prompt efforts were made to resolve a grievance and keep the resident or resident representative appropriately apprised of progress towards resolution for one (1) resident (Resident #8) out of sixteen (16) sampled residents. Specifically, when a grievance was filed on behalf of Resident #8 on 6/14/2021, the facility did not complete a thorough investigation of the grievance and did not document that follow-up or resolution was ever provided to the resident and/or resident's spouse who filed the grievance.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review and interviews during an abbreviated survey (Case #NY00276279), the facility did not ensure the resident environment remained as free of accident hazards as is possible for one (1) (Resident #7) out of sixteen (16) residents reviewed. Specifically, the facility did not ensure that Resident #7, a resident at risk for wandering and elopement, did not leave the facility. This is evidenced by: The Policy and Procedure (P&P) titled, Elopement Prevention, last revised June 2023, read in pertinent part, The facility strives to promote resident safety and protect the rights and dignity of the residents. [...]
April 5, 2023Standard inspection · 2 citations
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure a resident requiring dialysis services received such services consistent with professional standards of practice for three (3) (Residents #73. #105, and #168) of three (3) residents reviewed. Specifically: for Resident #'s 73, the facility did not consistently provide an ongoing documented assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Specifically, for Resident #105, the facility did not ensure the resident received ongoing assessments and monitoring for complications before and after dialysis treatments and did not ensure there was ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; [...]
- 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, record review, and interviews during the recertification survey dated 03/27/23 through 04/05/23, the facility did not ensure food was stored, prepared, distributed, or served food in accordance with professional standards for food service safety in the main kitchen and six (6) of 6 kitchenettes. Specifically, in the main kitchen the automatic dishwashing machine was being utilized to wash dishes while the LED (liquid crystal display) thermometer on the dishwashing machine was not functioning, a test kit to measure the concentration of chemical sanitizer was not available, the gaskets on the 3 walk-in refrigerator doors had splits, the 2-bay sink faucet leaked, 2 fire extinguishers were soiled with food particles, and a pocketbook and sandals were stored with food (thickener). [...]
November 2, 2020Standard inspection · 9 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, manufacturer's directions review, and staff interview during the recertification survey, the facility did not prepare food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer, and food temperature thermometers were not in calibration. This is evidenced as follows. The kitchen was inspected on 10/27/2020 at 10:19 AM. The concentration of QAC used in the sanitizing rinse sink, and the third sink, was found to be between 0 and 150 parts per million (ppm) when measured at 66 degrees Fahrenheit (F). [...]
- 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 record review and interviews during the recertification survey, the facility did not ensure to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative for 1 (Resident #117) of 6 residents reviewed for unnecessary medications. Specifically, the facility did not notify the Medical Doctor (MD) when the resident missed multiple doses of insulin. This is evidenced by: Resident #117: Resident #117 was admitted with diagnoses of diabetes with diabetic neuropathy, end-stage renal disease (ESRD) on dialysis, and congestive heart failure (CHF). The Minimum Data Set (MDS - an assessment tool) dated 9/25/20 documented the resident was cognitively intact. Medical Doctor orders documented Admelog Insulin 100Units /milliliter: [...]
- 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 observations, interviews and record reviews during a recertification survey the facility did not ensure summaries of the baseline care plans were provided to the resident and the residents representative for 4 (Residents #'s 12, 66, 113, and #407) of 21 residents reviewed. Specifically, the medical record did not contain evidence that the summary was given to the resident and resident representative, if applicable. This is evidenced by: A facility policy titled Care Plans - Baseline last reviewed 1/2020 documented; the facility will provide the resident and representative if applicable with a written summary of the baseline care plan by completion of the comprehensive care plan. Facility will document and record receipt of information by family, whether in the form of a copy of signed acknowledgement or note within resident's clinical record. Resident #66: [...]
- 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 interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #'s 12, 53, 87, and 117) of 35 residents reviewed for comprehensive care plans (CCPs). [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, record review and interviews during the recertification survey, the facility did not ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living including functional communication systems for 2 (Resident #'s 58 and 190) of 2 residents reviewed for communication. Specifically, for Resident #58, the facility did not ensure the resident, whose primary language was not English, was consistently provided a functional communication system to independently and effectively communicate his/her needs and for Resident #190, the facility did not ensure the resident's hearing aids and glasses were applied daily. This is evidenced by: Resident #58: Resident #58 was admitted to the facility with the diagnoses of cerebral infarction, hypertension, and diabetes. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and staff interviews during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for one (Resident #103) of three residents reviewed for Activities of Daily Living. Specifically, for Resident #103, the facility did not ensure the resident, who was unable to carry out activities of daily living, received hair/scalp care to maintain good personal hygiene. This is evidenced by: The Policy and Procedure titled ADL- Bath (Shower) last revised 7/2019, documented it was the policy of the facility to shower the resident to cleanse and refresh the resident, observe the skin, and to provide increased circulation. Resident #103: [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, record review and interviews during the recertification survey, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of two (Resident's #58 & 192) reviewed. Specifically for Resident #192, the facility did not ensure accurate monitoring of the residents fluid intake per the Medical Doctor (MD) ordered fluid restriction and for Resident #58, the facility did not ensure there was documentation of ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This is evidenced by: Resident #192: Resident #192 was admitted with diagnoses of End-Stage Renal Disease on dialysis and hypertension. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that its medication error rates were not 5 percent or greater. Specifically, for 30 medication administration opportunities there were 12 errors resulting in a medication error rate of 40%. This is evidenced by: A Policy and Procedure titled Medication Administration with a date last revised of 12/2019, documented medications are to be administered within one hour of their prescribed time. It documented, if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose and the individual administering the medication will record the date and time the medication was administered. Finding #1: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and interviews during the recertification survey, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #'s 42 &165) of 4 wound dressings observed, and for 2 of 4 units. Specifically, for Resident #42, the facility did not ensure that infection control measures and hand hygiene were used during a dressing change, that medications were handled with gloves, and that ointments stored in the multi resident use medication cart were stored in a manner that prevented cross contamination, for Resident #165, the facility did note ensure a bedside table was sanitized after contaminated items were placed on it. This is evidenced by: [...]
Fire safety inspections
13 fire safety citations on file: 6 on August 19, 2025, 3 on April 5, 2023, 4 on November 2, 2020.
Every fire safety citation13 citations
- E
Install proper backup exit lighting.
K 281 · August 19, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 19, 2025 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 19, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 19, 2025 · Corrected (the home has a date of correction)
- E
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
K 928 · August 19, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 19, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 5, 2023 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 5, 2023 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · April 5, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · November 2, 2020 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 2, 2020 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 2, 2020 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 2, 2020 · Corrected (the home has a date of correction)