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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
6E
1F
Potential for minimal harm
0A
0B
0C
July 3, 2025Standard inspection, Complaint inspection · 13 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not use the services of a Registered Nurse for at least eight (8) consecutive hours a day, seven (7) days a week. Specifically, a review of staffing revealed a Registered Nurse was not scheduled for eight (8) consecutive hours on 1/25/2025. This is evidenced by:The Facility's Policy and Procedure titled Quality of Life - Accommodation of Needs, issued 9/2024, documented, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed as needed throughout the residents stay in the facility. Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. [...]
- 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 reviews and interviews conducted during the recertification survey (NY00376034), the facility did not develop and implemented comprehensive person-centered care plans for each resident that included measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (2) (Resident #'s 5 and 27) of 28 residents reviewed for care plans. Specifically, (a.) Resident #5 was care planned for 2- person assist for when transfer. Certified Nurse Aide #1 did not follow care plan resulting in Resident #5 falling and breaking both legs; (b.) Resident #27 had difficulty hearing and had hearing aids. There was no documented evidence that a comprehensive person-centered care plan was developed and implemented for their hearing impairment. [...]
- E
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 and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) (Passport unit) of three (3) medication carts reviewed. Specifically, (a.) two (2) open multi-dose Humalog (insulin) vials were not labeled with a resident's name and (b.) one (1) open multi-dose bottle of Lantus (insulin) was not clearly marked with an open date. This is evidenced by:During an observation on 6/30/2025 at 9:07 AM, the medication cart on the Passport unit was reviewed. Two opened multi-dose vials of Humalog were found in the first draw of the medication cart. A labeled multi-dose bottle of Lantus was also found with an unclear opened date. [...]
- 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 interviews conducted during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in four (4) of four (4) resident unit nutrition rooms and the central kitchen. Specifically, the area of the main kitchen and resident kitchenettes was not clean. This is evidenced by:During the initial inspection in the central kitchen on 6/26/2025 at 11:20 AM, coffee cups, containers, pots, and trays were put away wet and contained moisture. During an inspection in the central kitchen on 7/02/2025 at 10:45 AM, the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried. Containers, pots, and trays were put away wet and contained moisture. [...]
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, record review, and staff interviews conducted during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the facility did not ensure that two (2) of five (5) trash bins were pest and rodent-proof by having damaged/broken lids. This was evidenced by:During an observation of the trash collection area on 7/02/2025 at 11:05 AM, two trash bins had broken lids and were unable to be fully closed, preventing the disposal of garbage and refuse appropriately, and were pest and rodent-proof. During an interview on 7/02/2025 at 11:30 AM, Director of Maintenance #1 stated that they usually contacted the refuse company to have them replaced periodically because they got broken. They stated that they were unsure of the last time that they had to be replaced. 10 New York Codes of Rules and Regulations 814.14(h)
- 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 and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment, and effective housekeeping and maintenance services were not maintained for four (4) of four (4) resident units. Specifically, lighting fixtures on all units were unclean and had deceased bugs within covers, and windows on units were unclean and had dirt and debris. During an observations on [DATE] at 9:45 AM, multiple lighting fixtures on the 2nd and 3rd East and [NAME] units, main corridor, and near the nursing supervisor's office had dirt, debris, and deceased bugs within the lighting covers. The windows on either end of the hallways on each unit had dirt, debris, and cobwebs on the window sills and corners of the windows. [...]
- 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 record review and interviews conducted during a recertification survey, the facility did not ensure it developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of a resident's admission for one (1) resident (Resident #248) of 28 residents reviewed for baseline care plans. Specifically, Resident #248's baseline care plan did not address resident's dialysis. [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, record review, interviews conducted during the recertification survey, the facility did not ensure dependent residents were provided with appropriate treatment and services to maintain or improve their language and communication for one (1) (Resident #7) of two (2) residents reviewed. Specifically, (a.) for Resident #7, nursing staff did not ensure there was consistent access to their communication dry/erase board so resident could use it to write down what they wanted to express as Resident #7 had difficulty speaking secondary to cerebral palsy (group of neurological conditions that affect movement and posture). [...]
- 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, the facility did not ensure that each resident received the necessary respiratory care and services that is in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preference for three (3) (Resident #'s 41, 128, and 245) of six (6) residents reviewed for oxygen administration. Specifically, (a.) for Resident #'s41 and 245, supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b.) for Residents #128 and #245, nebulizer equipment was not stored in a proper manner. This is evidenced by: The policy and procedure titled, Oxygen Concentrator Maintenance, revised 4/2023, documented tubing is to be changed weekly. [...]
- 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 conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for one (1) (Resident #120) of the 28 residents reviewed. Specifically, for Resident #120, the medical record contained documentation of wound vacuum (a wound management device that uses negative pressure that draws out excess fluid and promoting blood flow to the area) monitoring when there was no wound vacuum present. [...]
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interviews conducted during recertification and abbreviated (Case # NY00376034) survey, the facility failed to ensure residents were free from neglect for one (1) (Resident #5) of three (3) residents reviewed for neglect. Specifically, on 03/24/2025, Certified Nurse Aide #1 did not use a two-person assist for transfer mobility as required in Resident #5's Comprehensive Care Plan while transferring the resident. Certified Nurse Aide #1 attempted to transfer the resident without assistance from another staff member. Resident #5 fell onto the floor and sustained fractures (bone breaks) to both legs. This resulted in actual harm that was not Immediate Jeopardy. [...]
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview conducted during a recertification and abbreviated survey (Case # NY00344590), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for one (1) (Resident #136) of three (3) residents reviewed. Specifically, a former Certified Nurse Aide took property from Resident #136 after they had died without permission. This is evidenced by: [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview conducted during a recertification and abbreviated survey (Case # NY00344590), the facility did not ensure they reported the results of all investigations to the administrator or their designated representative, and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (1) (Resident #136) of three (3) residents reviewed. Specifically, a 5-day investigation report was not submitted to the state agency. This is evidenced by: [...]
March 18, 2022Standard inspection · 9 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 record review and interviews during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not develop and implement baseline care plans that included instructions needed to provide effective and person-centered care for 9 (Residents #'s 10, 13, 17, 68, 77, 83, 86, 89, and #104) of 18 residents reviewed. [...]
- 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 interviews during a recertification survey and abbreviated survey (Case #NY00261370) dated 3/14/2022 through 3/18/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 10 (Resident #'s 34, 43, 68, 82, 89, 101, 104, 108, 119, and #127) of 26 residents reviewed. Specifically, for Resident #34, the facility did not ensure the Activities of Daily Living (ADL) Comprehensive Care Plan (CCP) intervention to check and change the resident every 2 hours was implemented, and ensure the resident received supervision while eating in bed was implemented; [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interviews during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #'s 24, 77 and #104) of 4 residents reviewed for ADL's. Specifically, for Resident #34,who required extensive assistance of staff for ADL care, the facility did not ensure incontinence care was provided as documented in the resident's care plan; [...]
- 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 dated 3/14/2022 through 3/18/2022, the facility did not ensure each resident was free from accident hazards for 2 (Resident #'s 34 & #101) of 5 residents reviewed. Specifically, for Resident #34, who had difficulty swallowing, the facility did not ensure the resident was supervised during eating and was evaluated for the ability to chew after their dentures were broken and for Resident #101, the facility did not ensure the resident was not self-administering inhalers in their room after being assessed not to be a potential candidate for self-medication administration. This is evidenced by: Resident #34: The resident was admitted to the facility on with the diagnosis of Multiple Sclerosis, heart failure and dysphagia. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY00261370) dated 3/14/2022 through 3/18/2022, the facility did not ensure each resident maintained acceptable parameters of nutritional status for 3 (Resident #'s 17, 89, and #126) of 5 residents reviewed for nutrition. Specifically, for Resident #17, the facility did not ensure the resident was weighed upon admission and re-admission in accordance with professional standards, for Resident #89, did not ensure the resident was weighed in accordance with professional standards as documented in the Nutritional Evaluation dated 2/21/2022, the physician order and the Comprehensive Care Plan for Nutrition; and for Resident #127, did not ensure the resident was weighed in accordance with professional standards. This is evidenced by: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (1) (Resident #43) of two (2) residents reviewed. Specifically, for Resident #43, the facility did not ensure a physician's order for the prescribed flow rate for oxygen administration was followed. This is evidenced by: Resident #43: Resident #43 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease, chronic kidney disease and heart failure. The Minimum Data Set (MDS - an assessment tool) dated 3/4/2022, documented the resident was cognitively intact, could understand others and could make self-understood. [...]
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on record review and interviews during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 (Resident #68) of 4 residents reviewed for dementia care. Specifically, for Resident #68, who had a diagnosis of Alzheimer's disease, the facility did not ensure individualized, non-pharmacological approaches to care were consistently implemented to maximize the resident's dignity, autonomy, privacy, and socialization. Additionally, the facility did not ensure the Comprehensive Care Plan (CCP) for Cognition included person-centered interventions related to the resident's diagnosis of Alzheimer's disease. This is evidenced by: Resident #68: [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interviews during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #68) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #68, who received Zyprexa (anti-psychotic medication), the facility did not ensure the medical record from 2/22/2022 to 3/10/2022 included documentation that the resident was experiencing a change in behavioral symptoms or that non-pharmacological interventions were attempted prior to increasing the anti-psychotic medication from once a day to twice a day on 3/10/2022. This is evidenced by: Resident #68: [...]
- D
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 staff interview during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, food temperature thermometers were not in calibration, and equipment and floors required cleaning or repair. This is evidenced as follows: During the inspection of the main kitchen and unit kitchenettes on 03/14/22 at 9:56 AM, two (2) food temperature thermometers were found out of calibration when checked by the standard ice-bath method as follows: 35F, 38F. The floor linoleum below the dishwashing machine was separating forming a gap revealing the subfloor, and the linoleum coving was peeling away from the wall. [...]
September 9, 2019Standard inspection · 3 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 observations, record review, and interviews during a recertification survey the facility did not ensure that it developed and implemented a comprehensive person-centered care plan (CCP) for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for four (4) (Resident #'s 38, 85, 114, and #123) of twenty-six residents reviewed. Specifically: for Resident #38, the facility did not ensure that a CCP to address blepharitis (inflamation of the eye lids) was developed; that Resident #101, had a CCP developed to address a pressure sore; that Resident #114, had CCP's developed to address constipation and dermatitis (inflamation of the skin); [...]
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for the steps in the MRR process. This is evidenced by: The Facility Policy and Procedure titled, Pharmaceutical Reviews dated 8/2014, did not address the time frames for the different steps in the medication regimen review process. During an interview on 6/09/19 at 2:45 PM, the Administrator stated the policy dated 08/2014 was the current policy. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview the facility did not refer residents with newly evident mental illness for a level II review for one (Resident #93) of three residents reviewed for PASRR (Pre-admission Screening and Resident Review). Specifically, for Resident #93, the facility did not ensure the resident, who was newly diagnosed with a mental illness, received a level 1 screen to determine if a level II screen was needed. This is evidenced by: Resident #93: The resident was admitted to the nursing home on 6/18/18, with diagnoses of schizoaffective disorder, dysphagia, and hypothyroid. The Minimum Data Set (MDS-an assessment tool) dated 8/5/19, assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others and that the resident had a diagnosis of schizoeffective disorder. [...]
Fire safety inspections
15 fire safety citations on file: 8 on July 3, 2025, 1 on March 18, 2022, 6 on September 9, 2019.
Every fire safety citation15 citations
- F
Address patient/client population and determine types of services needed.
E 7 · July 3, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 18, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · September 9, 2019 · Corrected (the home has a date of correction)