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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
26D
4E
2F
Potential for minimal harm
0A
0B
0C
November 20, 2025Standard inspection, Complaint inspection · 13 citations
- F
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 observations, interviews, and record reviews during the recertification survey from 09/23/2025-09/30/2025, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the minimum staffing levels did not meet the needs of the residents and residents, family, and staff expressed concerns about low staffing and delays in receiving care.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey from 09/23/2025 to 09/30/2025, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1) the daily refrigerator/freezer logs had missing temperature, 2) the kitchen refrigerators and spice/seasoning areas contained food items that were expired or were not documented with date opened, use by date or expiration dates, 3) the Unit resident refrigerators contained food products that were not labelled with resident name, bought into facility date and dispose by date, and 4) the dry storage pantry contained food products that did not contain date opened or expiration dates.
- E
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on observations, interviews, and record review conducted during the rectification survey from 09/23/2025 to 09/30/2025, the facility did not ensure residents received contact information for the New York State Department of Health in a format and language they could understand for seven residents (Resident #42, #48, #49, #54, #96, #118, and #173) at the Resident Council meeting. Specifically, the New York State Department of Health contact information was not posted in a format understood by the Resident Council members.
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated (#2575165) survey from 09/23/2025 to 09/30/2025, the facility did not ensure the resident's right to be free of abuse. This was evident for two (Resident #8 and #118) of 19 residents reviewed for abuse. Specifically, 1) Resident #8 reported Resident #14 wandered into their room and touched their leg. There was no evidence the facility developed a plan to prevent further potential abuse of Resident #8 by Resident #14; and 2) Resident #14, who had a known history of wandering and resident-to-resident altercations, wandered into Resident #118's room at night. Resident #118 injured their left elbow trying to remove Resident #14 from their room. As a result, Resident #118 reported being fearful and began closing their door at night to prevent Resident #14 from wandering into their room.
- 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 observations, interviews, and record review conducted during the recertification survey from 09/23/2025 to 09/30/2025, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for one (Resident #14) of three residents reviewed for dementia care. Specifically, an odor of urine was observed in Resident #14's room and coming from their mattress.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews and record review during the recertification and abbreviated surveys (NY00335938) from 9/23/2025 to 9/30/2025, the facility did not ensure all alleged violations of abuse were reported immediately, but not later than two (2) hours to the state survey agency and the results of an alleged abuse investigation was reported to the state survey agency within five (5) working days of the incident for one (1)(Resident #170) of 20 residents reviewed for abuse. Specifically, on 3/12/2024, Resident #170 alleged their hands were held by a registered nurse during a medication administration. The facility reported the incident to the New York State Department of Health on 3/13/2024 at 5:49 PM and the 5-day investigative conclusion submission was not submitted until 04/25/2024.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observations, interviews and record review during the recertification and abbreviated survey (NY00335938/647446) from 9/23/2025 to 9/30/2025, the facility did not complete a thorough investigation of an alleged violation of abuse to prevent further potential abuse for one (1) (Resident #170) of 20 residents reviewed for abuse. Specifically, on 3/12/2024, Resident #170 alleged their hands were held by a Registered Nurse #12 during a medication administration and the facility did not complete a thorough investigation resolve inconsistencies and to rule out abuse.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review conducted during a recertification survey from 09/23/25 through 09/30/25, the facility did not ensure residents received the necessary assistance for bathing to maintain personal hygiene for 1 of 4 residents (Residents #114), reviewed for activities of daily living (ADLs). Specifically, Resident #114 did not receive twice weekly showers as scheduled.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 09/23/2025 to 09/30/2025, the facility did not ensure a resident received proper treatment and assistive devices to maintain hearing. This was evident for 1 of 1residents (Resident #8) during review of communication. Specifically, nursing staff were unable to locate Resident #8's hearing aids after taking possession to charge and safekeep them for the resident overnight.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated (#2575165) surveys from 09/23/2025 to 09/30/2025, the facility did not ensure a resident diagnosed with dementia, received treatment and services to maintain their highest practicable well-being. This was evident one (Resident #14) of three residents reviewed for dementia care. Specifically, Resident #14 presented with adjustment difficulties after their room was changed to address their dementia behaviors; and a recommended follow-up neurology consult was not scheduled for Resident #14 following a hospitalization due to a change in their mental status.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated survey (#2575165) from 09/23/2025 to 09/30/2025, the facility did not ensure a resident's right to be free from unnecessary drugs. This was evident for one (Resident #14) of three residents reviewed for dementia care. Specifically, Resident #14 was ordered to receive Haldol 2 milligrams without a labeled indication and without consideration of recommendations by Psychiatry to decrease the dosage.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 09/23/2025 to 09/30/2025, the facility did not ensure special eating equipment and utensils for a resident who need them was provided for 1 of 1 resident (Resident #3) reviewed for adaptive equipment. Specifically, built up utensils were not provided for Resident #3 as per physician order.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/23/25 to 09/30/25, the facility did not establish and 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 1 of 4 residents (Resident #12) reviewed for activities of daily living. Specifically, staff were observed transferring Resident #12 from the bed to chair in a lift and not wearing the required personal protective equipment for Enhanced Barrier Precautions.
February 14, 2024Complaint inspection · 2 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 record review and interviews conducted during an Abbreviated Survey (NY00332525), the facility did not ensure that a resident's Care Plan was reviewed and revised to reflect the resident's changing needs and current status as evidenced by 1 of 3 residents reviewed for skin impairment. Specifically, Resident #1 acquired two pressure injuries on the buttocks and the care plan was not updated to reflect the goals and interventions to promote wound healing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00320442), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accident hazards for 1 of 8 residents (Resident #1) reviewed. Specifically, on 07/19/2023 Certified Nursing Assistant (Staff #1) served Resident #1 (who required 1-person assistance for eating) rewarmed coffee from the microwave without assistance/setup. Resident #1 poured milk into the coffee and the coffee spilled onto their skin causing a blistering burn, measuring 3x3 inches to the right thigh.
March 30, 2023Standard inspection · 11 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review during a recertification survey 3/22/2023-03/30/2023, the facility did not ensure residents had the right to a dignified existence for one of two residents screened for dignity. Specifically, Resident #66 was observed their Foley catheter (tube draining urine from the bladder) bag uncovered with urine visible to staff, residents, and visitors.
- 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, interview, and record review conducted during the recertification survey from 3/22/23 to 3/30/23, the facility failed to ensure that housekeeping and maintenance services provided a safe, clean, comfortable, and home-like environment for 1 of 1 residents reviewed for Environment (Resident #2). Specifically, a window unit AC (air conditioner) was observed to be in disrepair in the room of Resident #2. An observation was made on 03/22/23 at 10:00 AM, in Resident #2's room, of a window unit AC with visible gaps of approximately 1 centimeter to the outdoors on both sides of the unit. The gaps appeared to have been previously covered with duct tape, which was hanging off the bottom of both sides of the AC, and cold air was noted to be blowing through the gaps. [...]
- 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 record review and interview conducted during the recertification survey from 3/22/23 to 3/30/23, the facility failed to ensure the resident or the resident's representative were notified in writing of the reason for transfer/discharge to the hospital in a language they understood and failed to notify the Ombudsman for 1 of 3 residents (Resident #2) reviewed for hospitalizations. Specifically, Resident #2 was transferred to the hospital on [DATE] and the facility could not provide evidence a written notice of transfer/discharge was provided to the resident or the resident's representatives, or that notification was sent to the Ombudsman. The Findings Include: [...]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review conducted during the recertification survey from 3/22/23 through 3/30/23 and an abbreviated survey (#NY00296823), it was determined that for 2 of 2 residents (#2 and #494) reviewed for hospitalizations, the facility failed to ensure that the resident or the resident's representatives were notified in writing of the facility's Bed Hold Policy. Specifically, Resident #2 and Resident #494 were transferred to the hospital and the facility could not provide evidence that a written notice of the facility's Bed Hold Policy was provided to the residents or the resident's representatives.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview conducted during the recertification survey from 3/22/23 through 3/30/23, the facility failed to ensure the required Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) was conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process. This was evident for 1 of 1 residents reviewed for Resident Assessment (Resident #86).
- 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, interview, and record review conducted during the recertification and abbreviated surveys (NY00296823, NY00307253) from 3/22/2023 to 3/30/2023, the facility did not develop and/or implement comprehensive person-centered care plans to ensure the services were provided to maintain the resident's highest practicable physical well-being for 5 of 7 residents (#38, #66, #114, #344, #494) reviewed for Care Plans. Specifically, Resident #38's plan for weekly weights was not implemented;Resident #23 had diagnosis of thyroid disorder and no care plan to address the thyroid disorder; Resident #114 was not provided assistance with eating as planned, Resident #344 did not have a care plan for the presence of actual pressure ulcers, and Resident # 494 did not have a care plan for risk for pressure ulcers.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review during the recertification survey, dated 3/22/2023-3/30/2023, the facility did not ensure that each resident received the necessary assistance to maintain good nutrition for one (Resident #114) of one resident reviewed for activities of daily living (ADL). Specifically, Resident # 114 was not provided assistance with meals as planned.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review during the recertification survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for one (Resident #23) of five residents reviewed for Unnecessary Medications. Specifically, Resident #23's Medication Administration Record (MAR) revealed 13 administration omissions within 14 days.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey 3/22/2023-3/30/2023, it was determined that the facility did not ensure the environment remained as free of accident hazards as possible for 2 of 7 residents reviewed for accidents and hazards. Specifically, space heaters were observed in resident rooms #270 and #271.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review conducted during the recertification survey 3/22/23-3/30/23, it was determined for 1 of 7 residents (Resident # 38) reviewed for Nutrition and Hydration, the facility did not ensure the resident was provided the necessary care to maintain, to the extent possible, acceptable body weight. Specifically, for Resident #38 weekly weight monitoring was not implemented as ordered.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that personnel handled, stored, processed, and transported linens in a manner to prevent the spread of infection. Specifically, a housekeeper was observed distributing linens in an unclean manner and from an uncovered linen cart.
August 21, 2019Standard inspection · 6 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 and interview conducted during a recertification survey, the facility did not ensure specicific food items were maintained in accordance with professional standards for food safety. Specifically, opened and outdated potentially hazardous foods (meat, fish, eggs and dairy products) were observed in one of the refrigerators.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview and record review conducted during a recent recertification survey, it cannot be ensured that the facility is adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or to a centralized work area for 3 of 3 occupied resident bathrooms, 211, 234, and 240.
- 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 interviews conducted during the recertification survey, the facility did not ensure that the comprehensive person-centered care plan for each resident was implemented. This was evident for 1 of 4 residents reviewed for nutrition. Specifically, Resident #47 had a Physician's (MD) order for a 1000 cc fluid restriction in 24 hours which was not consistently 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 conducted during the recertification survey the facility did not ensure that necessary assistance and care were provided to carry out activities of daily living (ADLs). This was evident for 1 of 6 residents (Resident # 48).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that a resident received the necessary treatment to meet skin care needs. Specifically, 1 resident (Resident # 39) reviewed for non-pressure-related skin issues did not receive the treatment prescribed by a Dermatologist.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review conducted during a recertified survey, the facility did not ensure that facility staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 1 of 5 residents (Resident # 99) reviewed for pressure ulcer, and during a random room observation on 1 North and 2 North units.
Fire safety inspections
23 fire safety citations on file: 7 on November 20, 2025, 1 on May 9, 2024, 7 on March 30, 2023, 8 on August 21, 2019.
Every fire safety citation23 citations
- F
Provide properly protected cooking facilities.
K 324 · November 20, 2025 · Corrected (the home has a date of correction)
- E
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 · November 20, 2025 · 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 · November 20, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 20, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · November 20, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 20, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 20, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Meet Health Care Facilities Code mechanical requirements.
K 900 · March 30, 2023 · Waiver
- E
Provide properly protected cooking facilities.
K 324 · March 30, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · March 30, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 30, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 30, 2023 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 30, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 21, 2019 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 21, 2019 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 21, 2019 · 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 · August 21, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 21, 2019 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 21, 2019 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 21, 2019 · Corrected (the home has a date of correction)
- C
Develop a communication plan.
E 29 · August 21, 2019 · Corrected (the home has a date of correction)