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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
3E
1F
Potential for minimal harm
0A
0B
1C
August 15, 2025Standard inspection, Complaint inspection · 10 citations
- F
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 interviews, during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not maintain an effective pest control program. This was identified during the kitchen task. Specifically, the exit door from the kitchen, which is used to remove refuse and leads to the parking lot and garbage disposal bins, had an approximate half-inch gap at the bottom of the door. This is a repeat citation. The finding is:The undated facility policy titled Pest Control documented to maintenance of an effective pest control system. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. [...]
- E
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 interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure that Physician Responses (actions) documented on Monthly Medication Regimen Reviews were carried out to address irregularities identified by the Pharmacist. This was identified for three (3) (Resident #1, #32, and #12) of five (5) residents reviewed for Unnecessary Medications. Specifically, recommendations were provided by the Pharmacy consultant on the Medication Regimen Review Form for Resident #1, Resident #32, and Resident #12; however, the recommendations were not implemented, and there was no documented evidence in the residents' medical records that the identified irregularities were reviewed and what, if any, actions were taken to address the irregularities.
- 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 during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs. This was identified for one (1) (Resident #14) of three (3) residents reviewed for Skin Conditions and one (1) (Resident #32) of five (5) residents reviewed for Unnecessary Medications. Specifically, 1) Resident #14 had a diagnosis of Methicillin-Resistant Staphylococcus Aureus (a type of bacteria that is resistant to antibiotics) infection in the chest wounds. There was no care plan developed for the wound infection and the contact precautions. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure services provided as outlined in the comprehensive care plan met professional standards of quality. This was identified for one (1) (Resident #75) of four (4) residents reviewed for Medication Administration. Specifically, during the medication administration observation for Resident #75 on 08/12/2025, Registered Nurse #6 did not follow the five rights (right person, right time, right medication, right route, right dosage) of medication administration and poured liquid Keppra (a medication for seizures) from another resident's medication bottle without checking the label. Additionally, Registered Nurse #6 did not check the placement of the gastrostomy tube before administering the medications to Resident #75. [...]
- 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 during the Recertification Survey and Abbreviated Survey (2572082) initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was identified for one (Resident #24) of two residents reviewed for Activities of Daily Living. Specifically, upon several observations, Resident #24 was not clean-shaven, and their hair was mussed. Resident #24's plan of care indicated the resident was to receive scheduled showers at least two times per week. Review of the resident's record indicated Resident #24 received only one shower from 07/23/2025 to 08/12/2025. The finding is: [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews during the recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure each resident received treatment and care in accordance with professional standards. Specifically, Resident #32 had an active physician's order for Midodrine (a medication used to treat low blood pressure) every eight (8) hours as needed when the resident's systolic blood pressure (the top number in a blood pressure reading representing the pressure in the arteries when the heart muscle contracts) was below 120 millimeters of mercury. Review of Resident #32's Medication Administration Record for July and August 2025 revealed that in 08/2025 the resident did not receive the medication as ordered for 16 out of 16 opportunities from 08/01/2025 to 08/13/2025; [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review, and interviews during the Recertification survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure each resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing. This was identified for two (2) (Resident #16 and Resident #2) of two (2) residents reviewed for pressure ulcers. Specifically, 1) Resident #16 weighed 84.7 pounds and was observed lying in bed with the air mattress weight setting set at 350 pounds. 2) Resident #2 was observed with an air mattress with a low-pressure warning light illuminated on 08/11/2025, 08/12/2025, and 08/13/2025. When the mattress was replaced, the weight setting on the air mattress was set at 350 pounds. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure each resident received pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident. This was identified for one (1) (Resident #75) of four (4) residents reviewed for Medication Administration. Specifically, during the medication administration observation for Resident #75 on 08/12/2025, Registered Nurse #6 did not check the placement of the gastrostomy tube before administering the medications. The finding is:The facility's policy titled Medication Administration via Feeding Tube, revised 06/2023, documented disconnect tube feeding (if in progress) and cap the tube; assess resident's abdomen; [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2023, the facility did not ensure that 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. This was identified on one (second floor) of two nursing units. Specifically, the facility staff did not utilize appropriate personal protective equipment and did not perform hand hygiene to prevent the spread of infection. The finding is:The facility's policy titled Infection Control/Nursing/Contact Precautions, revised 11/2023, documented to prevent the transmission of organisms among residents, staff, and visitors. [...]
- C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit. This was identified during the Sufficient Nursing Staffing Task. Specifically, the Facility Assessment, last reviewed in July 2025, did not indicate nursing staffing (Certified Nursing Aides, Licensed Practical Nurse, and Registered Nurse) needs for each resident unit. The finding is:The facility's undated policy titled Facility Assessment documented the facility will evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. [...]
April 11, 2024Standard inspection, Complaint inspection · 11 citations
- 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 observations, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not provide a homelike environment and maintenance services to maintain a comfortable interior for three (Unit 1 North, Unit 1 South, and Unit 2 South) of four units observed during the environmental task. Specifically, Rooms 217 (Unit 2 South) 117 (Unit 1 South), 115, and 111 (Unit 1 North) had unrepaired water damage in the walls. Resident #60's room (Unit 1 North) was observed with holes in the wall due to the removal of the soap dispenser from the wall and the area was left unrepaired. The finding is: The facility's Quality of Life: Homelike Environment policy dated 4/2024 documented to provide residents with a comfortable and homelike environment. [...]
- 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 interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, during the initial kitchen tour on 4/7/2024, a carton of frozen egg product, that was intended to be used on 4/8/2024 for the breakfast meal, was observed on a table thawing at room temperature. The finding is: The facility's undated policy titled, Thawing Frozen Raw Food documented to ensure the proper temperature is maintained during food storage, plan ahead to allow enough time for proper thawing; remove raw food from the carton and place it on a sheet pan; place the sheet pan on the bottom shelf of the refrigerator, never above the ready to eat food; [...]
- 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 during the Recertification Survey and Extended Survey (NY 00321584), the facility did not ensure that it reported each injury of unknown origin to the New York State Department of Health within 24 hours as required. This was identified for one (Resident #35) of four residents reviewed for Discharge. Specifically, on 8/5/2023 Resident #35 was identified by facility staff with discoloration and swelling to the right arm; an x-ray on 8/6/2023 confirmed an acute oblique fracture of the distal radius (a fracture that is on an angle of one of the bones in the forearm that connects to the wrist). The incident was not reported to the New York State Department of Health until 8/7/2023. The finding is: [...]
- 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 during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure that a comprehensive person-centered care plan was developed or implemented for each resident to meet a resident's medical and nursing needs. This was identified for one (Resident #47) of one resident reviewed for Limited Range of Motion. Specifically, Resident #47 had a physician's order for a hand roll to be worn on the right hand at all times due to limited mobility. Resident #47 was observed multiple times without the hand roll as per the physician's order. The finding is: [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #55) of one resident reviewed for Pressure Ulcers. Specifically, Resident #55 had multiple Stage 4 pressure ulcers to the sacrum, right upper back, and left upper back. The resident was utilizing an air mattress as per the physician's order. The weight setting on the resident's air mattress was set at 240 pounds, while the resident's most recent weight was recorded as 123 pounds. [...]
- D
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 observations, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure that the staff implemented and provided care and services according to resident's needs and professional standard of practice for each resident with a feeding tube. This was identified for one (Resident # 302) of three residents reviewed for Tube Feeding. Specifically, on 4/7/2024 at 9:28 AM and 4/8/2024 at 6:11 AM, Resident #302 was observed receiving enteral tube feeding; the enteral tube feeding and the water bags were observed hanging on a feeding tube stand without a label including the resident's name, and the time the tube feeding was started. The finding is: [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 the facility did not ensure a resident requiring dialysis services received such services consistent with professional standard of practice. This was identified for one (Resident #31) of two residents reviewed for Dialysis. Specifically, Resident #31, who receives Dialysis treatment three times a week, was observed on 4/7/2024 with swelling to their left upper arm. Resident #31 returned from their dialysis treatment on 4/6/2024 with recommendations to apply warm compresses to the left upper arm. The recommendations were communicated from the dialysis center staff to the facility staff via a Dialysis Communication Notebook. [...]
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00326378) initiated on [DATE] and completed on [DATE], the facility was not administered in a manner that enabled 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, facility administration allowed an unlicensed, graduate nurse to work in the capacity of a Registered Nurse until [DATE], almost four months beyond the Public Health Emergency (PHE) waiver expiration date of [DATE]. The finding is: [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 the facility did not ensure that it maintained medical records for each resident in accordance with accepted professional standards and practices. This was identified for one (Resident #39) of five residents reviewed for Unnecessary Medications. Specifically, Resident #39 had a physician's order to self-administer their insulin and obtain their blood glucose via finger stick. The results of the blood glucose readings and self-administered insulin dosage were not accurately recorded in the resident's medication administration record on 4/9/2024 at 11:30 AM. The finding is: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure it maintained an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #55) of one resident reviewed for Pressure Ulcers. Specifically, on 4/11/2024 Resident #55 was on contact precautions for Candida Auris (a fungal infection). There was a contact precautions sign at the doorway directing staff and visitors to wear appropriate personal protective equipment. The Director of Maintenance was observed in the resident's room examining the resident's air mattress and coming in substantial contact with the resident's environment (bed sheets, privacy curtain, air pump). [...]
- 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 interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 the facility did not ensure that it took measures to eradicate or contain a pest control concern in the kitchen. Specifically, the exit door from the kitchen, which is used to remove refuse and leads to the parking lot and the garbage disposal bins, had an approximate half-inch gap at the bottom of the door. Kitchen staff reported sightings of mice in the kitchen. The finding is: The undated facility policy titled, Pest Control, documented to maintain an effective pest control system. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. [...]
July 19, 2022Standard inspection · 3 citations
- 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 record review and interviews during the Recertification Survey initiated on 7/12/2022 and completed on 7/19/2022, the facility did not ensure that the comprehensive person-centered care plan (CCP) that includes measurable objectives and timeframes to meet each resident's medical and nursing needs were implemented. This was identified for one (Resident #43) of one resident reviewed for pressure ulcer. Specifically, Resident #43 was identified with a Stage II pressure ulcer to the Sacral area on 7/5/2022. There was no documented evidence that a CCP with measurable goals and interventions was completed to address the resident's Stage II pressure ulcer. The finding is: The facility Policy titled Care Plans-Comprehensive dated 2/1/2017 and last revised on 2/1/2018 documented: [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 7/12/2022 and completed on 7/19/2022 the facility did not ensure that its medication error rate was not five percent or greater based on observation of the administration of 25 medications. Specifically, a Registered Nurse (RN #2) did not follow the Physician's orders to administer two eyedrops at the prescribed time for Resident #26. Additionally, RN #2 administered four different eye drop medications to Resident #26 that were not in accordance with the Physician's orders. This resulted in a medication error rate of greater than five percent. The finding is: The facility's policy titled, Medication Administration-General, dated 3/5/2017, documented that medications are administered in accordance with the written orders of the Prescriber. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 7/12/2022 and completed on 7/19/2022 the facility did not ensure that each resident was free from significant medication errors. This was identified for one (Resident #26) of four residents reviewed for Medication Administration. Specifically, during the medication administration observation task on 7/13/2022, the Registered Nurse (RN) #2 medication nurse administered four different eye drop medications to Resident #26 that were not in accordance with the Physician's orders. RN #2 was observed administering one eye drop medication immediately after the other eye drop medication. The finding is: [...]
Fire safety inspections
15 fire safety citations on file: 5 on April 11, 2024, 10 on July 19, 2022.
Every fire safety citation15 citations
- F
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · April 11, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 11, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 11, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 11, 2024 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · April 11, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · July 19, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 19, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 19, 2022 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 19, 2022 · 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 · July 19, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · July 19, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 19, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 19, 2022 · Corrected (the home has a date of correction)
- D
Have a properly installed medical gas master alarm panel.
K 904 · July 19, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 19, 2022 · Corrected (the home has a date of correction)