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
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
2E
0F
Potential for minimal harm
0A
3B
1C
July 18, 2024Standard inspection, Complaint inspection · 8 citations
- 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 review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This was identified for one (Resident #71) of three residents reviewed for skin conditions. Specifically, Resident #71 was observed with tissues and rubber bands wrapped around two fingers on multiple occasions and Nursing staff did not revise the comprehensive care plan to address the resident's behavior. The finding is: The facility's policy, titled Behavioral Assessment, Intervention, and Monitoring, last reviewed in January 2024, documented behavior symptoms will be identified using a facility-approved behavior screening tool and a comprehensive assessment. [...]
- D
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 initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #260) of three residents reviewed for Choices. Specifically, Resident #260 was admitted on [DATE] after a Micra Leadless Pacemaker Implantation (electronic device that is implanted in the body to monitor heart rate and rhythm) and required pacemaker remote monitoring. The facility did not initiate the pacemaker remote monitoring until 7/11/2024 and there was no documented Physician Order for the monitoring until 7/15/2024, seven days after Resident #260 was admitted to the facility. The finding is: [...]
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey, initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. This was identified for one (Resident #135) of two residents reviewed for Rehabilitation Services. Specifically, the Rehabilitation Department recommended a floor ambulation program for Resident #135, however, the floor ambulation program was not completed. The finding is: [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that residents who are incontinent of bowel and bladder received the appropriate treatment and services to prevent Urinary Tract Infection. This was evident for one (Resident #117) of three residents reviewed for Activities for Daily Living. Specifically, Resident #117 required total assistance from one caregiver for toileting and was frequently incontinent of bowel and bladder. Resident #117 was observed wearing a urine-soaked brief and had wet linens underneath them on 7/11/2024 at 11:11 AM. The resident was last changed on the 11:00 PM to 7:00 AM shift before the observation. The findings is: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (Resident #57) of four residents reviewed for Respiratory Care. Specifically, Resident #57 had a Physician's Order to receive 4 liters of oxygen therapy per minute via mist collar to a tracheostomy continuously. However, on multiple occasions, Resident #57 was observed receiving 6 liters of oxygen per minute via mist collar to their tracheostomy. The finding is: The facility's Assessing Oxygen Saturation Policy, last revised in January 2024, documented to assess the resident for the following signs and symptoms of impaired oxygen saturation: [...]
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure it obtained laboratory services to meet the needs of each resident. This was identified for one (Resident #41) of three residents reviewed for Transmission-Based Precautions. Specifically, Resident #41 was receiving the antibiotic Vancomycin for Methicillin-Resistant Staphylococcus aureus (a bacteria that causes serious infection) in the urine and mastoid bone (the bone behind the ear) and the Physician ordered a Vancomycin trough level (a laboratory test used to determine therapeutic dosage) to be drawn on 7/9/2024. There was no documented evidence in the resident's medical record that the laboratory order was completed. 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 7/11/2024 and completed on 7/18/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #112) of six residents reviewed in the Medication Administration Task. Specifically, Resident #112 had a physician's order for Strict Contact Precautions for Pseudomonas Aeruginosa (a type of bacteria) in the urine which required the use of Personal Protective Equipment including a gown and gloves. The Licensed Practical Nurse (Medication Nurse) #1 was observed on 7/12/2024 entering the room without wearing a gown and gloves and administered medications to Resident #112. The finding is: [...]
- B
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 during the Recertification and Abbreviated (NY00323936) Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not maintain medical records on each resident that were complete and accurate for one (Resident #91) of one resident reviewed for Abuse. Specifically, Resident #91's family member reported bruising to Resident #91's left eye on 9/13/2023. However, the resident's skin assessment and medical evaluation to rule out trauma were not documented in the medical record. The finding is: The facility's Charting and Documentation policy, last reviewed in 1/2024, documented objective observations, treatments or services performed, events, incidents or accidents involving the resident are to be documented in the medical record. [...]
April 1, 2022Standard inspection · 12 citations
- J
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interviews during a Recertification Survey and Abbreviated Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility failed to Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; the facility failed to reassess the resident after the weight loss was identified and failed to notify the Physician and the Dietician to implement interventions to address and monitor the unplanned weight loss. The facility's failure to implement an existing weight monitoring policy and failure to monitor each residents' nutritional intake was identified for two (Resident #45 and Resident #80) of seven residents reviewed for Nutrition. [...]
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessment and individual plans of care. This was identified through staff interviews, resident council task, review of facility assessment and staffing assignments. Specifically, 1) The facility nursing staffing assignments did not reflect the staffing needs as indicated in the facility assessment; [...]
- E
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 3/23/2022 and completed on 4/1/2022 the facility did not ensure that pharmaceutical services including administration of all medications was provided to meet the needs of all residents. This was identified for one (Resident #358) of one resident reviewed for Pharmacy Services. Specifically, on 3/25/2022 Registered Nurse (RN) #3 did not administer 9 AM Physician-ordered medications to Resident #358 timely. The finding is: The facility's policy titled Administering Medications, revised on 1/2022, documented medications must be administered in accordance with the [Physician's] orders, including any required time frame, and medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure resident rights to be free from neglect. This was identified for one (Resident #99) of five residents reviewed for Activity of Daily Living (ADL). Specifically, Resident #99 required staff assistance for ADL and incontinence care. The resident did not receive ADL and incontinence care on 3/25/2022 from 6:14 AM until 12:15 PM. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips and stated with an elevated loud tone that no one took care of them today. The resident stated they were wet and had been asking for staff assistance all morning; however, no staff came to assist. 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 record review and staff interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that the comprehensive person-centered care plan (CCP) for each resident was implemented. This was identified for one (Resident #110) of seven residents reviewed for nutrition. Specifically, Resident #110 had a Physician's (MD) order for daily weights for 3 days and weekly weights every 7 days for four weeks for weight monitoring. There was no documented evidence the weights were completed according to the Physician's order. The finding is: The facility Weight Assessment and Intervention policy reviewed on 1/2022 documented the nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weight will be measured monthly thereafter. [...]
- 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 3/23/2022 and completed on 4/1/2022, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADL) receive the necessary services to maintain grooming and personal hygiene. This was identified for one (Resident #99) of five residents reviewed for ADLs. Specifically, Resident #99, who was alert and oriented and required staff assistance for ADL care, did not receive morning care on 3/25/2022 during the 7 AM-3 PM nursing shift until 12:15 PM because no Certified Nursing Assistant (CNA) was assigned to provide care for the resident. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips and stated with an elevated loud tone that no one took care of them today. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interviews and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that all residents received adequate supervision to prevent Accidents. This was identified for one (Resident #85) of three residents reviewed for Accidents. Specifically, Resident #85 was observed shaving themselves with a razor without supervision and had blood on their face. The finding is: The facility Hazardous Areas, Devices and Equipment Policy dated July 2017, documented all hazardous devices in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to: [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that residents who are incontinent of Bowel and Bladder receive appropriate treatment and services to prevent Urinary Tract Infections (UTI) and that a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. This was identified for one (Resident #99) of five residents reviewed for ADLs and one (Resident #356) of three residents reviewed for Urinary Catheter. [...]
- 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, interviews, and record review, during the Recertification survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure all medications and tube feedings were accurately labeled and medications were safely stored in 1 of 4 medication carts reviewed for Medication Storage Task and for 1 (Resident #110) of 3 residents reviewed for Tube Feeding. Specifically, 1) an unopened bottle of Latanoprost (glaucoma medication) eye drops was not refrigerated as per the pharmacy instructions; and an opened pro-source bottle was not labeled with the opened date. Additionally, two unmarked tablets were observed in the medication cart in an unlabeled souffle cup. 2) on 3/23/2022 Resident #110's tube feeding bottle was not labeled with the start time, the feeding rate, and the signature of nurse who initiated the feeding. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey completed on 4/1/2022 the facility did not maintain 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 for one Resident (#357) of one resident reviewed for Infection Control and one (Resident #356) of three residents reviewed for urinary catheter. Specifically, 1) Resident #357 was a new admission and placed on droplet precautions due to partial COVID-19 vaccination status; on 3/24/2022 staff members were observed in the resident's room providing care and not wearing appropriate Personal Protective Equipment (PPE); [...]
- C
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not implement policies and procedures to ensure that all staff were completely vaccinated for COVID-19 and did not include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19. Specifically, the facility allowed one unvaccinated staff member (Registered Nurse (RN) #10) to provide direct resident care and one unvaccinated staff, the Food Service Director, to interact in close proximity to residents while not wearing an N95 mask. The finding is: The facility policy, Vaccination Compliance Plan dated 8/16/2021, did not include a contingency plan that addressed actions the facility would take for staff with valid medical exemptions. [...]
- B
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY 00290462) initiated on 3/23/2022 and completed on 4/1/2022 the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial wellbeing. Specifically, the facility did not ensure adequate linen supplies were available to meet the residents' needs on two (Unit 1 and Unit 2) of four units observed. The finding is: Resident #30 was admitted with diagnoses that include Hypertension, Type II Diabetes Mellitus and was Legally Blind. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. [...]
October 18, 2019Standard inspection · 4 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 staff interviews during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and interventions to meet each resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for 1 (Resident #140) of 2 residents reviewed for vision/hearing. Specifically, Resident #140 was identified on the Minimum Data Set (MDS) assessment as having moderate difficulty with hearing. The CCP developed for hearing deficit did not include person-centered interventions to assist the resident to effectively communicate with staff. The finding is: The facility's policy and procedure dated March 2019 titled Care Plans, Comprehensive Person-Centered documented . 13. [...]
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on facility record review and staff interview during the recertification survey, the facility did not ensure that their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption specifically included how facility staff would ensure that: 1) a resident is assisted in accessing and consuming the food, if the resident is not able to do so on his or her own and 2) family and visitors understood safe food handling practices; such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, and hand hygiene. The finding is: The facility's Personal Food Policy dated 3/19/18 was reviewed on 10/16/19 at 9:20 AM. The policy did not specifically include how the facility would ensure that: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interviews during the Recertification Survey the facility did not ensure that for each resident infection control measures were employed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #149) of two residents reviewed for Respiratory Care. Specifically, during the tracheostomy (trach) care observation the nurse removed the old dressing, did not change gloves or wash hands before proceeding with the cleaning process, and then applied the clean dressing with the same gloved hands that were used to remove the old dressing. The finding is: The facility's policy and procedure titled Tracheostomy Care, revised 5/2017, documented that after the old dressing is removed the soiled glove should be pulled over the dressing and then discarded followed by hand washing. [...]
- B
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 staff interviews during the recertification survey, the facility did not ensure that each resident's environment was safe, clean, and homelike. This was identified for two (Residents #16 and #70) of two residents reviewed for environment. Specifically, the floor mats designated for Residents #16 and #70 were dirty and heavily stained with grayish colored materials.
Fire safety inspections
16 fire safety citations on file: 4 on July 18, 2024, 5 on April 1, 2022, 7 on October 18, 2019.
Every fire safety citation16 citations
- F
Use approved construction type or materials.
K 161 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 18, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · July 18, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · April 1, 2022 · Waiver
- F
Provide at least two remote exits on each floor or fire section of the building.
K 252 · April 1, 2022 · Waiver
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 1, 2022 · Waiver
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 1, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 1, 2022 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · October 18, 2019 · Waiver
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 18, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 18, 2019 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · October 18, 2019 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 18, 2019 · Corrected (the home has a date of correction)
- B
Provide at least two remote exits on each floor or fire section of the building.
K 252 · October 18, 2019 · Corrected (the home has a date of correction)
- B
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 18, 2019 · Corrected (the home has a date of correction)