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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
4D
1E
0F
Potential for minimal harm
0A
0B
0C
January 29, 2026Standard inspection · 2 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 observation, record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with resident rights that included measurable objectives and time frames to meet a resident's needs for one (1) of two (2) residents (Resident #7) reviewed for anticoagulant medication. Specifically, Resident #7 was on an anticoagulant medication (blood thinner) and there was no documented evidence that a care plan to address risks and care related to the anticoagulant medication was developed and/or implemented.
- 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 the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services for one (1) of four (4) residents (Resident #165) reviewed for Activities of Daily Living. Specifically, Resident #165, who required dependent assistance with activities of daily living, was observed during multiple observations with fingernails that were long and ungroomed.
December 13, 2023Standard inspection, Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY00315889), from 12/06/23 to 12/13/23, it was determined the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #42) reviewed for accidents. Specifically, Resident #42 fell from their bed when the plan of care for a 2 person assist with bed mobility was not followed. Subsequently, Resident #42 sustained fractures to both lower extremities. This resulted in actual harm that was not immediate jeopardy.
- 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 interview, the facility did not ensure food was prepared and stored according to professional standards for food safety. Specifically, cold foods were not held at a safe holding temperature, prior to service, to prevent bacterial contamination.
January 29, 2020Standard inspection · 2 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 interview and record review conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan with measurable goals, time frames and interventions to meet the needs of 1 of 4 residents (#54) reviewed for pressure ulcers and 1 of 3 resident (#133) reviewed for respiratory care. Specifically, Resident # 54 did not have a care plan in place to address a stage 3 sacrum pressure ulcer and Resident # 133 did not have a care plan to address oxygen therapy.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not implement an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development of communicable diseases and infections. Specifically, 1. a Licensed Practical Nurse (LPN) did not perform hand hygiene prior to administration of medications and 2. the facility did not protect oxygen equipment from surface and air contaminants.
Fire safety inspections
16 fire safety citations on file: 2 on January 29, 2020, 11 on May 31, 2018, 3 on January 9, 2017.
Every fire safety citation16 citations
- D
Meet other general requirements.
K 200 · January 29, 2020 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 29, 2020 · Corrected (the home has a date of correction)
- 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 · May 31, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 31, 2018 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · May 31, 2018 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · May 31, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 31, 2018 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · May 31, 2018 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · May 31, 2018 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · May 31, 2018 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · May 31, 2018 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · May 31, 2018 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · May 31, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 9, 2017 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 9, 2017 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 9, 2017 · Corrected (the home has a date of correction)