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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
1E
0F
Potential for minimal harm
0A
0B
0C
March 11, 2024Standard inspection, Complaint inspection · 4 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 3/5/24- 3/11/24, the facility did not ensure that the call bell system was accessible for 1 of 27 residents reviewed for environment. Specifically, Resident #4 was observed on two occasions with the call bell system not within the resident's reach.
- 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, interviews and record review conducted during a recertification survey 3/5/24-3/11/24, the facility did not ensure that the comprehensive person-centered care plan was developed for 1 of 1 residents (#92) reviewed for eye infections. Specifically, there was no care plan in place to address Resident #92's medical needs for an eye infection.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey from 3/5/24 to 3/11/24, the facility did not ensure that the necessary assistance and care were provided to carry out activities of daily living (ADLs) for 1 of 2 residents reviewed for dignity. Specifically (Resident #261) was not toileted or provided with continent care from 3/4/23 at 6:00 PM until 3/5/24 at 11:40 AM the following day after asking for assistance and using call bell.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record reviews and staff interviews on the recertification and abbreviated surveys (NY00328105) from 3/5/24 to 3/11/24, the facility did not ensure that necessary medications were administered according to the physician order for 1 of 5 residents (Resident #92) reviewed for medications. Specifically, Resident #92 was prescribed antibiotic eye drops for 3 days but was given 8 extra doses beyond the three days.
September 14, 2021Standard inspection · 0 citations
April 5, 2019Standard inspection · 3 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, record review and interview conducted during the recertification survey, the facility did not ensure that food contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with standards for food service safety. Chapter 1 Sub-Part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated; non-food contact surfaces are to be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey, the facility did not ensure that staff followed facility protocol and standards of practice to ensure safe delivery of medication. Specifically, (1) a randomly observed resident was not provided direct supervision of the medication administration by the medication nurse (2) the resident was not assessed by the interdisciplinary team to determine if the resident can safely self-administer medication. (Resident #31).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that staff followed proper gloving, handwashing technique, and protection of unused items that would be returned to the treatment cart, to prevent cross contamination and the spread of infection. This was evident for 1 of 2 residents (Resident # 99) reviewed for pressure ulcers on the B Unit.
Fire safety inspections
5 fire safety citations on file: 2 on March 11, 2024, 3 on September 14, 2021.
Every fire safety citation5 citations
- D
Have exits that are accessible at all times.
K 271 · March 11, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 11, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 14, 2021 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 14, 2021 · Corrected (the home has a date of correction)
- D
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 · September 14, 2021 · Corrected (the home has a date of correction)