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 25 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
5E
0F
Potential for minimal harm
0A
1B
0C
July 31, 2026Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review, the facility failed to ensure that medical records are maintained in accordance with accepted professional standards and practices to be complete and accurately documented. This was evident for one (Resident #5) of one resident investigated for medication error. Specifically, Registered Nurse #5 failed to accurately document the time Resident #5 received hydromorphone and Registered Nurse #5 failed to document that Resident #5 received a second dose of hydromorphone approximately two and a half hours later.
October 28, 2024Standard inspection, Complaint inspection · 5 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident in 2 (Resident #208 and Resident #269) of 4 residents reviewed for Infection Control out of 37 total sampled residents. Specifically, 1.) Licensed Practical Nurse #6 failed to perform hand hygiene and glove changes while performing wound treatment for Resident #208 and 2. ) Enhanced Barrier Precautions were not maintained when Licensed Practical Nurse #5 flushed Resident #269's indwelling urinary catheter. In addition, Licensed Practical Nurse #5 failed to clean / sanitize the Resident's bedside table after using it for the procedure.
- D
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 10/21/2024 to 10/28/2024, the facility did not ensure that residents are treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident in 1 (Resident #28) of 1 resident reviewed for dignity. Specifically, Resident #28 was observed wearing the same outfit two days in a row.
- 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 the Recertification and Abbreviated (NY00349557) Survey, the facility failed to ensure that a resident was free from sexual abuse. This was evident in 2 (Residents #447 and #463) of 6 residents reviewed for abuse out of 37 total sampled residents. Specifically, on 07/26/2024 at approximately 6:00 PM, Certified Nursing Assistant #4 observed Residents #447 and #463 lying in bed with no undergarments. Resident #447's hand was observed touching Resident #463's private area.
- 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 interview conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that a person-centered Comprehensive Care Plan was developed and implemented to meet the resident's goals, and address the resident's medical, physical, mental and psychosocial needs. This was evident in 1 (Resident #28) of 2 residents reviewed for care planning out of 37 total sampled residents. Specifically, Resident #28 who had a diagnoses and was receiving treatment for Glaucoma, had no comprehensive care plan developed to address the Resident's impaired vision.
- 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, record review, and interviews conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences. This was evident in 1 (Resident #841) of 3 residents reviewed out of 37 total sampled residents. Specifically, Resident #841, who had a documented allergy to fish and fish containing products, received a lunch tray containing fish.
October 6, 2022Standard inspection · 8 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure the accuracy of a resident's assessment. This was evident for 1 (Resident #77) of 7 residents reviewed for Accidents out of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 (MDS) assessment documented Resident #77 had wandering behavior and using a Wander/elopement alarm.
- 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 record review and staff interviews conducted during a Recertification Survey from 09/29/22 to 10/06/22, the facility did not ensure that the resident and their representative were provided with a written summary of the Baseline Care Plan (BCP). This was evident for 1 resident of 1 resident reviewed for Tube Feeding, and 1 of 5 residents reviewed for Unnecessary Meds, out of 38 sampled residents. (Residents #170 and #387)
- 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, staff interview and record review conducted during a Recertification and Complaint survey (NY00295603) from 09/29/22 to 10/06/22, the facility did not ensure that a person-centered care plan with measurable goals, time frames and interventions were developed and implemented to address resident concerns, consistent with the resident rights to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, 1). a Comprehensive Care Plan (CCP) was not developed and implemented for a resident with diagnosis of Uterine prolapse and 2). a CCP was not developed and implemented for resident with impaired skin integrity. This was evident for 1 of 1 resident reviewed for UTI/Catheter and 1 of 1 resident reviewed for Skin Conditions out of 38 sampled residents (Residents #417 and #6).
- 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 observations, record reviews and interviews conducted during the Recertification survey from 9/29/2022 to 10/6/2022, the facility did not ensure that resident's Comprehensive Care Plan (CCP) was reviewed and revised to accurately reflect the current residents status. Specifically, 1). Activities of Daily Living and a respiratory care plan was not reviewed and revised in a timely manner, and 2). A comprehensive care plan was not reviewed and revised for a resident with a history of a fall. This was evident for 1 of 1 resident reviewed for Respiratory Care and 1 of 7 residents reviewed for Accidents out of 38 sampled residents (Residents #83 & Resident #332)
- 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 observation, record review, and interview, the facility did not ensure a resident who is fed by enteral means received appropriate treatment and services to prevent complications of enteral feeding. This was evident for 1 of 1 resident reviewed for Tube Feeding. (Resident #170). Specifically, Resident #170 was observed doing self-administration of tube feeding, and there was no documented evidence the resident was assessed or educated regarding self-administration of tube feeding. In addition, the staff were not aware the resident was doing self-administration of tube feeding or monitoring the tube feeding completed by the resident to prevent complications. The finding is: Resident #170 was admitted to the facility on [DATE], with diagnoses that included Cancer and Malnutrition. [...]
- 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 staff interviews conducted during the Recertification and Complaint survey (NY00295603) from 9/29/2022 to 10/6/22, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices. Specifically, there was no documented evidence in the Treatment Administration Record (TAR) that Resident #6 and Resident #212 received their wound care treatment and preventative treatment as per physician's order on multiple occasions. This was evident for 2 of 3 residents reviewed for Skin Conditions out of a sample of 38 residents. (Resident #6 and Resident #212)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 9/29/22 to 10/6/22, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident receiving Tube feedings was not properly monitored and supervised to ensure that proper infection control measures were maintained to prevent the development and transmission of infections. This was evident for 1 of 1 resident reviewed for Tube Feeding out of 38 sampled residents. (Resident #170)
- 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 interview during the Recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 13 of 16 residents reviewed for the Resident Assessment facility task (Resident #s 12, 7, 13, 11, 19, 17, 6, 16, 10, 14, 15, 4, and 20). Specifically, comprehensive assessments for Resident #s 12, 7, 13, 11, 19, 17, 6, 16, 10, 14, 15, 4, and 20 were not transmitted and submitted to QIES within 14 days of their completion date.
January 31, 2020Standard 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, interviews, and record review conducted during the recertification and abbreviated survey (NY00250470), the facility did not ensure that maintenance and housekeeping services to provide a safe, clean, comfortable, and homelike environment were provided. Specifically, resident rooms were observed with the following: air conditioner (AC) unit exterior panels with rust with debris, broken floor tiles, rusted sink water knobs, peeling wall paint, a dirty bedside table, and torn bed bumper guards. This was evident for 8 resident rooms (resident rooms #s C706, C714, C717, C718, C720, C722, C726, and C115) on 2 out of 16 units observed for Environmental Observations (C-7 and C-1).
- E
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 during the recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, Annual assessments were not transmitted within 14 days of the care plan completion date, and Quarterly MDS assessments were not submitted and transmitted within 14 calendar days from the MDS Completion Date. This was evident for 11 of 11 residents reviewed for the Resident Assessment Facility Task (Residents #s 12, 13, 15, 10, 21, 7, 8, 9, 14, 20, and 16).
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure that garbage and refuse was disposed of properly. Specifically, the two garbage compactors were observed with open lids during several observations. This was evident during the Kitchen Observation facility task.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review conducted during the Recertification and abbreviated survey (NY 00250470), the facility did not ensure that infection control practices were maintained. Specifically (1) contact precautions were not maintained by multiple staff members for a resident with a diagnosis of clostridium difficile (C-diff); (2) A Registered Nurse did not practice appropriate hand hygiene before and during Tracheostomy care (Resident #28); and (3) hand hygiene was not performed with glove changes during wound care and feces was not cleaned prior to beginning wound care (Resident #150). This was evident for 1 of 3 residents reviewed for Infections (Resident #110), 1 of 1 resident reviewed for Respiratory Care/Tracheostomy (Resident #28), and 1 of 1 resident reviewed for Pressure Ulcer (Resident #150) out of a total sample of 35 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, the facility did not provide the appropriate liability notice of Medicare beneficiaries. Specifically, the facility did not provide residents/representatives with Notice of Medicare Non-Coverage (NOMNC) at the termination of Medicare Part A benefits. This was evident fro 3 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 40 residents (Residents #868, #225, and #411).
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on staff interviews and record review during the recertification survey, the facility did not ensure that required documentation was sent to the receiving provider in a hospital transfer. Specifically, there was no transfer summary completed and no evidence that documentation accompanied the resident to the hospital. This was evident for 1 of 1 resident reviewed for Hospitalization (Resident#241).
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interviews and record review conducted during the recertification survey, the facility did not ensure that a copy of the Notice of Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman within a timely manner when a resident was discharged from the facility to the hospital. This was evident for 1 of 1 resident reviewed for Hospitalization (Resident #141).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that services provided met preofessional standards of quality. Specifically, pain levels were not taken before and after a resident received opioid pain medications to ensure the resident's pain managment was being adequately monitored for effectiveness, and opioid pain medication was administered when the pain level was below the ordered parameters. This was evident for 1 of 2 residents reviewed for Pain Management out of a total sample of 43 residents (Resident #515).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure that pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, pain levels were not taken before and after a resident received opioid pain medications to ensure the resident's pain management was being adequately monitored for effectiveness. Opioid pain medication was administered when the pain level was below the ordered parameters, and the pain level parameters for Tramadol and Acetaminophen overlapped. In addition, the comprehensive care plan did not include any person-centered non-pharmacological or pharmacological interventions regarding how the resident's pain would be addressed. [...]
- 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 observation, interview and record review during the recertification survey the facility did not ensure that an expired medication was properly discarded according to the manufacturer's recommendation. Specifically, Tuberculin Purified Protein Derivative (PPD) was not disposed of 30 days after opening. This was evident for 1 of 8 units reviewed for medication Storage. ( Hospital- 1st Floor- North side) The finding is: The facility policy titled, Multi-Dose Vials-Injectables revised date 10/19/19 documents: Nurse administering medication- 1) Write date on vial when opened. 2) Discard after 6 months or as per manufacturers's recommendation. i.e. PPD - discard after 30 days after opening. 3) Check label to determine storage conditions, i.e. Refrigerate, store at room temperature, etc. 4) Discard vials into sharps container. 5) Check open vials nightly to ensure the following: [...]
- 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 and staff interview during the recertification survey, the facility did not ensure that all equipment was being maintained in a clean, sanitary manner. Specifically, During an interview a member of the kitchen staff stated that they had cleaned the meat slicer. However, grime and debris was still observed on both the knob to turn the meat slicer on and off and the switch for manual or automatic slicing. This was evident during kitchen inspection. The Findings Include: The manufacturer's manual for the Globe Food equipment instructs: sanitize all removal parts and the entire slicer in a clean sink solution of warm, clean water and properly diluted sanitizer, soak the removal parts and allow them to air dry without removing the sanitizer from the surface. [...]
Fire safety inspections
12 fire safety citations on file: 4 on October 28, 2024, 4 on October 6, 2022, 4 on January 31, 2020.
Every fire safety citation12 citations
- 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 · October 28, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · October 28, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 28, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 28, 2024 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · October 6, 2022 · Corrected (the home has a date of correction)
- D
Have horizontal exits used in accordance with safety requirements.
K 226 · October 6, 2022 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · October 6, 2022 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 6, 2022 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · January 31, 2020 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · January 31, 2020 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 31, 2020 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 31, 2020 · Corrected (the home has a date of correction)