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
1G
0H
0I
Potential for more than minimal harm
20D
3E
0F
Potential for minimal harm
0A
0B
0C
July 10, 2026Complaint inspection · 3 citations
- D
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 observation, record review, and interviews, the facility failed to ensure that each resident has a safe, clean, comfortable and homelike environment and received maintenance services necessary to maintain an orderly and comfortable interior. This was identified for one (Resident #1) of three residents reviewed for Environment. Specifically, on 06/17/2026, a bed remote was observed with exposed wires for the bed and room where Resident #1 had resided prior to their discharge from the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interviews during the survey, the facility failed to 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. Specifically, Resident #13 was admitted to the facility on [DATE] with a Stage 2 (partial-thickness skin loss where the outer layer of skin is broken) pressure ulcer to the sacrum (triangular bone in lower back). There was no documented physician's order for wound care until 04/06/2026 and no documentation in the treatment administration record that wound care treatment was administered for the Stage 2 pressure ulcer until 04/07/2026.
- 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 a survey, the facility failed to ensure complete, accurate, accessible, and systematically organized medical records were available for each resident. This was identified for one (Resident #4) of five residents reviewed for medication administration. Specifically, on 09/18/2025 Resident #4 had a physician's order for Ceftriaxone (antibiotic) intravenously every 24 hours for seven days for urinary tract infection. The electronic medication administration record for Resident #4 contained no documentation that the medication was administered two of the seven days on 09/20/2025 and 09/23/2025.
January 10, 2025Standard inspection · 9 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey, initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that pain management was provided to each resident who requires such services, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (1) (Resident #234) of four (4) residents reviewed for Pressure Ulcers. Specifically, Resident #234 had a Stage 3 pressure ulcer to the sacrum (a large, triangular bone at the base of the spine). The resident was heard from the hallway loudly complaining of pain and they wanted to die. The resident did not have a physician's order for pain medications. Interviews with the facility staff revealed the resident complained of pain since they developed a pressure ulcer. [...]
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for three (Resident #335, Resident#283, and Resident #284) of three residents reviewed for Dignity. Specifically, Resident #335, Resident #283 and Resident #284 were not provided a privacy cover for their urinary catheter bags. Both residents' urinary catheter bags contained urine and were visible from the hallway.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that comprehensive assessments of residents were conducted within 14 calendar days after admission and not less than once every 12 months. This was identified for two (Resident #67 and Resident #37) of six residents reviewed during the Resident Assessment Task. Specifically, Resident #67 and Resident #37's annual Minimum Data Set Assessment was not completed within 14 days of the Assessment Reference date. The finding is: The facility policy titled MDS Assessments, dated 12/10/2024, documented all Minimum Data Set assessments are to be completed and submitted to Centers for Medicare and Medicaid Services as per the guidelines provided in the Resident Assessment Instrument Manual. [...]
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that the Quarterly Minimum Data Set assessments were completed within the prescribed time frames. This was identified for three (Resident #6, Resident#113, Resident #13) of six residents reviewed during the Resident Assessment Task. Specifically, Resident #6, Resident#113, and Resident #13 Quarterly Minimum Data assessment was not completed within 14 days of the Assessment Reference date. The finding is: The facility policy titled MDS Assessments, dated 12/10/2024, documented all Minimum Data Set assessments are to be completed and submitted to Centers for Medicare and Medicaid Services as per the guidelines provided in the Resident Assessment Instrument Manual. [...]
- 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 staff interviews during the Recertification survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that a comprehensive care plan was developed and implemented for each resident including measurable objectives and timeframe to meet each resident's medical and nursing needs. This was identified for one (Resident#233) of one resident reviewed for Hydration; one (Resident #68) of seven residents reviewed during the Medication Administration Task; and one (Resident #285) of two residents reviewed for Urinary Catheter or Urinary Tract Infection. Specifically, 1) Resident #233 had a physician's order for intravenous hydration therapy; however, there was no comprehensive care plan developed for the insertion, care, and use of the Intravenous Catheter. [...]
- 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 initiated on 1/5/2025 and completed on 1/10/2025, 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 #94) of one resident reviewed for Activities of Daily Living. Specifically, Resident #94 was observed on multiple occasions with long, untrimmed fingernails on both hands. Resident #94 stated they were unable to trim their fingernails on their own and wanted them trimmed. The finding is: The facility's policy titled Activities of Daily Living Care, dated 10/2024, documented the nursing home shall provide Activities of Daily Living care that promote and maintains residents' health, safety, independence, and dignity. [...]
- 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 1/5/2025 and completed on 1/10/2025, the facility did not ensure 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, for one (Resident #234) of four residents reviewed for Pressure Ulcers. Specifically, Resident #234 had a physician's order for a positioning triangle wedge for pressure relief due to the resident having a Stage 3 pressure ulcer (full-thickness tissue loss; a deep wound extending through all layers of the skin into the fatty tissue beneath, indicating significant tissue damage) to the sacrum (a large, triangular bone at the base of the spine). [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 01/05/2025 and completed on 01/10/2025, the facility did not ensure that each resident was offered a therapeutic diet when there is a nutritional problem, and the healthcare provider ordered a therapeutic diet. This was identified for one (Resident #54) of six residents reviewed for Nutrition. Specifically, Resident #54 experienced a 10% weight loss over one month, decreasing from 99 pounds on November 5, 2024, to 89 pounds by December 12, 2024. Registered Dietician #1 recommended weekly weights; however, there was no documented evidence the resident's weights were obtained weekly to monitor further weight loss. Subsequently, Resident #54 had an additional 7% weight loss from 12/12/2024 to 1/7/2024. The finding is: [...]
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025 the facility did not ensure Intravenous antibiotics were administered consistent with professional standard of practice and in accordance with physician's orders and the comprehensive person-centered care plan. This was identified for two (Resident #336 and Resident #285) of two residents reviewed for Urinary Tract Infection. Specifically, 1) Resident #336 had a Midline Intravenous Catheter (a type of peripheral intravenous access, flexible tube inserted into a vein in the upper arm) on the left arm. There were no physician orders for monitoring and flushing the Midline Intravenous Catheter. 2) Resident #285 was observed with a peripheral intravenous catheter (Midline Intravenous Catheter ) in their right arm. [...]
December 2, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews and record review during an abbreviated survey (Complaint Number: NY00340154) the facility did not ensure each resident receives adequate supervision and assistance to prevent accidents. Specifically, one (Resident #1) of three residents reviewed for accident sustained 10 falls during a short-term stay. Resident #1 sustained a fall 3-day post admission which required hospitalization. During hospitalization, Resident #1 required continuous visual monitoring. Resident #1 was readmitted to the facility and sustained 9 additional unwitnessed falls. [...]
June 28, 2023Standard inspection · 8 citations
- E
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 6/21/2023 and completed on 6/28/2023, the facility must develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #42) of one resident reviewed for Advance Directives; for one (Resident #79) of two residents reviewed for Communication-Sensory care area; and one (Resident #22) of four residents reviewed for Positioning/Mobility care area. Specifically, 1) Resident #42 had no CCP developed for their Advance Directives. 2) Resident #79 whose primary language is Spanish; however, no CCP was developed to address the resident's communication needs. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey ( Complaint #NY00297167 and NY00313454) initiated on 6/21/2023 and completed on 6/28/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #107) of two residents reviewed for Pressure Ulcers; one (Resident #292) of five residents reviewed for Accidents; and one (Resident #22) of four residents reviewed for Positioning/Mobility. Specifically, 1) Resident #107 was admitted on [DATE] with a Stage II pressure ulcer to the sacrum as per the nursing admission assessment; however, a treatment for the sacrum wound was not started until 2/15/2022; [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, record review and interviews during the Recertification Survey and Abbreviated survey (NY00318753 and NY00313454), initiated on 6/21/2023 and completed on 6/28/2023, the facility did not ensure that all alleged violations were thoroughly investigated. This was identified for two (Resident #292 and Resident #76) of 6 residents reviewed for Accidents. Specifically, 1) for Resident #292, who was found on the floor, the facility investigation did not include statements from all involved parties to accurately identify the root cause for Resident #292's fall on 10/26/22; and 2) The facility did not obtain statements from the 1st floor 11P-7AM staff and the Maintenance Worker when Resident #76 eloped from the facility on 6/21/2023.
- 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 observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY00313454) initiated on 6/21/2023 and completed on 6/28/2023 the facility did not ensure that each resident's comprehensive person-centered Care Plan (CCP) was reviewed and revised by the Interdisciplinary Team after each assessment. This was identified for one (Resident #292) of five residents reviewed for Accidents, 2) for one (Resident #82) of two residents reviewed for Pressure Ulcers and 3) one (Resident #35) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #292 had five falls between 10/25/2022 and 11/29/2022. The resident's Falls care plan was not updated after each fall to reflect new interventions to prevent further falls; [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on record review and staff interview during the Recertification Survey initiated on 6/21/2023 and completed on 6/28/2023, the facility did not ensure that residents were given the appropriate treatment and services to maintain or improve their ability to carry out Activities of Daily Living (ADLs). This was identified for one (Resident #33) of two residents reviewed for the Rehabilitation and Restorative care area. Specifically, Resident #33 was not ambulated according to their Floor Ambulation Program (FAP) as ordered by the Physician. The finding is: [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, and interviews, during a Recertification Survey initiated on 6/21/2023 and completed on 6/28/2023 the facility did not ensure a 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 #82) of two residents reviewed for Pressure Ulcers (PU). Specifically, Resident #82 was identified as having a Stage II Pressure Ulcer to the Sacral region on 9/15/2022 as per a Physician's orders dated 9/15/2022. There was no documented evidence in the medical record that the Sacral PU was evaluated or assessed by a qualified clinician until 9/29/2022. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY00318753), the facility did not ensure that all residents received adequate supervision to prevent accidents. This was identified for one (Resident #76) of three residents reviewed for Accident Hazards. Specifically, Resident #76 exhibited exit seeking behaviors. On 6/21/2023, Resident #76 left the facility through two alarmed doors undetected by the facility staff and was located outside the facility by a community member. Additionally, during observation the fire exit door alarm that Resident #76 had previously breached was not audible to staff on the 1st floor, including the reception area. The finding is: [...]
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 6/21/2023 and completed on 6/28/2023, the facility did not assure that each resident was provided medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #42) of one resident reviewed for Advance Directives. Specifically, Resident #42 was admitted to the facility on [DATE]. Social Services conducted initial Social Services Evaluation upon admission on [DATE]; however, there was no documented evidence that the Advance Directives were reviewed with Resident #42 or their designated representative after 3/12/2022 as per the facility's policy. The finding is: [...]
June 11, 2021Standard inspection · 3 citations
- 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 observation, record review, and staff interviews during the Recertification Survey completed on 6/11/2021, the facility did not ensure that a baseline care plan was developed within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was identified for 1 (Resident # 183) of 3 residents reviewed for Respiratory Care. Specifically, Resident #183 had an admitting diagnosis of Acute Respiratory Failure and was on Oxygen therapy without a baseline Comprehensive Care Plan (CCP) developed. The finding is: Resident # 183 was admitted on [DATE] with diagnoses that include Acute Respiratory Failure with Hypoxia and Hypercapnia. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review and staff interviews during the Recertification Survey completed on 6/11/2021, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. This was identified for one (Resident #183) of three residents reviewed for Respiratory care. Specifically, Resident #183 had an admitting diagnosis of Acute Respiratory Failure and was receiving Oxygen therapy without a Physician's order. The finding is: The undated policy and procedure for Oxygen administration documented to verify there is a physician order for the procedure and to review the resident's care plan to assess for any special needs of the resident. The policy included to monitor and document the rate of oxygen flow, route and rationale and all assessment data before, during, and after the procedure. [...]
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey completed on 6/11/2021, the facility did not ensure that for one (Resident # 183) of 3 residents reviewed for Respiratory care, the physician reviewed the resident's total program of care, including treatments. Specifically, Resident #183 was administered Oxygen without a Physician's evaluation and without Physician's orders for the use of Oxygen. The finding is: The undated policy and procedure for Oxygen administration documented to verify there is a Physician order for the procedure and to review the resident's care plan to assess for any special needs of the resident. Resident #183 was admitted on [DATE] with diagnoses that include Acute Respiratory Failure with Hypoxia and Hypercapnia. [...]
Fire safety inspections
15 fire safety citations on file: 2 on January 10, 2025, 7 on June 28, 2023, 6 on June 11, 2021.
Every fire safety citation15 citations
- E
Use approved construction type or materials.
K 161 · January 10, 2025 · Waiver
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 10, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 28, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 28, 2023 · 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 · June 28, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 28, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 28, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 28, 2023 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 28, 2023 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · June 11, 2021 · Waiver
- E
Install an approved automatic sprinkler system.
K 351 · June 11, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 11, 2021 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · June 11, 2021 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 11, 2021 · 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 · June 11, 2021 · Corrected (the home has a date of correction)