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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
1E
0F
Potential for minimal harm
0A
2B
3C
March 13, 2026Standard inspection · 7 citations
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on observation, interview and record review conducted during the recertification survey from 03/08/2026 to 03/13/2026, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for one (1) (Resident #29) of two (2) residents reviewed for personal funds. Specifically, the facility restricted Resident #29 to receiving money on two (2) days a week and in an amount lower than the resident wanted.
- 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 reviews during the recertification survey, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment for two (2) of eight (8) residents (Resident #126 and Resident #170) reviewed for the environment. Specifically, 1) Resident #126 was observed sitting in a wheelchair that was visibly soiled on the frame, cushion, and protective gauze; 2) Resident #170 was observed sitting in a wheelchair that was visibly soiled on the frame, body, and back of wheelchair.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record reviews during the recertification survey, the facility did not ensure that residents unable to carry out activities of daily living received the necessary assistance with eating for one (1) of six (6) residents (Resident #128) reviewed for nutrition and one (1) of 19 residents (Resident #140) reviewed for dining. Specifically, 1) Resident #128, who had significant weight loss and required maximal assistance with eating was observed receiving only set up assistance during meals; 2) Resident #140, who had a history of weight loss and required moderate assistance with eating was observed receiving mostly only set up assistance during meals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record reviews during the recertification survey, the facility did not ensure that the residents' environment remained as free of accident hazards as possible for one (1) of two (2) residents (Resident #72) reviewed for Accidents. Specifically, Resident #72 had a history of falls and multiple safety interventions in place including keeping the environment well lit and clutter free. Floor mats were determined to be a tripping hazard and not included as an intervention for their safety; however, floor mats were observed in the room and staff reported that they were in use.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility did not ensure care consistent with professional standards of practice, and the comprehensive person-centered care plan was provided for one (1) of two (2) residents (Resident #69) reviewed for Respiratory Care. Specifically, Resident #69 was administered oxygen at a liter flow greater than the current physician's order.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interviews and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure a resident received behavioral health services to attain their highest practicable well-being, in accordance with the comprehensive assessment and plan of care. This was evident for one (1) (Resident #9) of one (1) resident reviewed for Behavioral/Emotional Status. Specifically, Resident #9 had a physician order for a psychiatry and psychology consultation after making an inappropriate sexual comment to another resident on [DATE]. Resident #9 was not evaluated by a psychiatrist or psychologist in accordance with the physician order.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews during a recertification survey from 3/08/2026 to 3/13/2026, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, six (6) food items were not properly identified in the kitchen refrigerators, freezers, and food storage areas and one dietary cook was not wearing a beard net while actively preparing food.
October 24, 2025Complaint inspection · 2 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, and interviews conducted during the abbreviated Survey #2637567, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one (1) of three (3) residents (Resident #1) reviewed for neglect. Specifically, Certified Nurse Aide #1 did not provide Resident #1 with staff assistance for meeting their activities of daily living needs during the evening shift on 10/06/2025, despite documenting such care was given. Subsequently, Resident #1 was last seen on 10/06/2025 at 9:12 PM in their room sitting fully clothed in their wheelchair and at 11:51 PM, Resident #1 was found in their room lying face down on the floor between the bed and wheelchair, with their head under the bed and their oxygen nasal cannula dislodged. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview during abbreviated survey #2637567, the facility did not ensure accurate documentation of medical records in accordance with accepted professional standard and practice were maintained for one (1) (Resident #1) of three (3) residents reviewed for activity of daily living care. Specifically, Certified Nurse Aide #1 documented in the electronic medical record activity of daily living cares on [DATE] that had not been provided. Additionally, although Resident #1 expired on [DATE] at 12:20 AM and their remains were removed from the facility at approximately 3:00 AM, Licensed Practical Nurse #10 documented hourly rounding was completed for Resident #1 on [DATE] from 11:45 PM-6:45 AM.
July 24, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record review completed during a complaint investigation (NY00374056) the facility did not maintain infection prevention and control practices in accordance with guidelines for enhanced barrier precautions for one (Resident #2) of three residents reviewed for infection control practices. Specifically, Resident #2 was on enhanced barrier precautions, as indicated by signage posted on the wall outside of their room. On three separate occasions, staff provided hands-on care without wearing gowns. Record review:The facility policy titled Enhanced Barrier Precautions, dated 1/28/25 documented that enhanced barrier precautions are utilized to reduce the transmission of multi-drug-resistant organisms to residents. [...]
March 4, 2025Complaint inspection · 1 citation
- 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 abbreviated survey (NY00331188) the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1(Resident #2) of 4 residents reviewed for Abuse. Specifically, Resident #2's Behavior Care Plan initiated 4/22/22 documented that they were two assists with cares due to history of accusatory behaviors and the care plan was not reviewed and revised to populate these interventions onto Certified Nurse Aides tasks/documentation. Certified Nurse Aide #2 was unaware of Resident #2's plan of requiring two person assists and they provided care to Resident #2 without another staff member present. Resident #2 accused Certified Nurse Aide #2 of alleged abuse after cares were provided.
November 17, 2023Standard inspection, Complaint inspection · 7 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 observations and interviews conducted during the recent recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. Cold foods were stored in a soiled, unsanitary refrigerated unit, 2. Cold foods to be served at activities events were stored in an unsanitary manner in a refrigerated unit, 3. Unlabeled, defrosted, uncooked, ground beef was stored in a refrigerated unit, 4. cooling logs were being utilized to ensure that foods were cooled in a safe and timely manner, 5. 2 of 7 nourishment refrigerators were not maintained at safe temperatures for food safety, and 5. Two food service staff did not follow safe food handling practices while recording food temperatures.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY 309477) conducted from 11/8/2023 through 11/17/2023, the facility did not ensure a thorough and complete investigation was conducted for 1 of 3 residents (Resident #70) reviewed for abuse/neglect. Specifically, for Resident #70 the facility did not conduct a complete and thorough investigation, including a root cause analysis to determine why physician recommended magnesium citrate scheduled for 1/10/2023 and 1/11/2023 was not administered for management of the residents' constipation. Subsequently on 1/12/2023 Resident #70 required manual dis-impaction.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 11/8/23 to 11/17/23, the facility did not provide an ongoing program of activities for 1 of 4 residents (Resident #39) reviewed for activities. Specifically, Resident #39 was not provided opportunities to consistently participate in independent activities of their choice and to be regularly reassessed for their preferences.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (#NY00326212 and NY00309477) from 11/8/23 to 11/17/23, the facility did not ensure 1 of 3 residents (Resident #70) reviewed for abuse/neglect and 1 of 3 (Resident #63) reviewed for medications, received care and treatment in accordance with professional standards. Specifically, 1) Resident #70's medications for constipation was not given timely, the physician and pharmacy were not notified when the medication was unavailable; and 2) Resident #63 was not provided their medication with meals as ordered.
- 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 interview conducted during the recertification survey, the facility did not ensure that residents were provided the appropriate treatment to improve and/or prevent a further decline in range of motion (ROM) for 1 of 2 residents, (Resident #120) reviewed for positioning and limited mobility. Specifically, Resident # 120 was not provided soft booties as per physical therapy recommendations. Resident #120 was admitted with diagnoses and medical conditions including but not limited to encephalopathy, cerebral vascular accident (Stroke), and generalized muscle weakness. The 11/05/2020 risk for chronic pain related to contractures and impaired mobility care plan, revised 11/10/23, did not include use of soft booties or monitoring the effect(s) of their use. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey conducted from 11/8/2023 to 11/17/2023, it was determined that for one of four (Resident #82) reviewed for respiratory care, the facility did not ensure that the resident received proper respiratory treatment and care consistent with professional standards of practice, and the comprehensive person-centered care plan. Specifically, Resident #82 did not receive continuous oxygen 3L/min via nasal cannula as per physician order.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observation and interview during the 11/8/2023 -11/17/2023 recertification survey, it could not be ensured that for 3 of 3 residents (Resident # 35, #126 and #129) reviewed for dignity that the residents' rights and/or that care was provided in a dignified manner. Specifically, Residents #35, #126 and #129 were not provided a dignified dining experience.
April 18, 2019Standard inspection · 12 citations
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not determine there had been a significant change in the residents mental or physical condition within 14 days for 1 resident (#104) reviewed for decline in Activities of Daily Living (ADLs). Specifically, a significant change Minimum Data Set (MDS: a resident assessment tool) was not completed to ensure all appropriate interventions were in place after a decline from extensive assist to total dependence was identified in two areas of ADLs. Specifically, the resident declined from extensive assistance to total dependence for toilet use and personal hygiene.
- 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 survey, the facility did not ensure that comprehensive person-centered care plans with measurable goals and interventions were developed to address the residents' respiratory and diabetic needs. Specifically, 1) 1 resident (Resident #28) reviewed for respiratory care did not have care plans in place to address her respiratory needs; and 2) 1 of 5 residents (Resident # 28) reviewed for unnecessary medications did not have care plans in place to address her diabetic needs.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that staff followed protocol for the care of a BI-PAP machine (a device to treat sleep apnea) for 1 resident (Resident # 28) who required respiratory support.
- D
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 interviews and record review conducted during the recertification survey, it was determined that for one of five residents reviewed for unnecessary medications, the facility did not ensure that the resident's drug regimen was reviewed at least once a month by a licensed pharmacist. Specifically, no drug regimen review was completed for Resident #104 for the month of February 2019. (Resident #104).
- 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 interview and record review conducted during a recertification survey, the facility did not ensure that each residents' medication regimen was free from unnecessary medications. Specifically, the Psychiatrist's recommendation to discontinue Cymbalta (antidepressant) was not communicated to the resident's primary medical doctor concurrent with a new order for a different antidepressant, resulting in the administration of duplicate medication therapies to the resident for a period of 12 days (4/4/19 to 4/15/19). This was evident for 1 of 5 residents reviewed for unnecessary medications (Resident #104). Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking. The finding is: [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review conducted during a recent recertification survey, the facility did not ensure that its medication error rate 5% or less. This was evident for 1 of 5 residents observed during a medication pass (Resident # 4). This resulted in an error rate of 12% out of total of 25 opportunities observed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that the facility staff followed proper hand hygiene, gloving, and proper cleansing of a blood glucose monitoring device to prevent the spread of infection. This was evident for 1 of 7 residents reviewed for pressure ulcer wound care (Resident #119) and 3 of 5 residents observed during medication administration (Resident #s 4, 98 and 105).
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview conducted during the recertification survey it was determined that residents were not aware of the location of the results of the most recent survey. Specifically, the signage indicating the location of the most recent survey and the actual survey results were placed together in an area not readily available to the public.
- C
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, the facility did not ensure that for 2 of 2 residents (Resident #119 and #183), reviewed for hospitalization, that the resident and/or their representatives received written notification of the facility bed hold policy.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interviews conducted during the recent recertification survey, the facility did not ensure that garbage and refuse were contained and disposed of in an appropriate manner. Specifically, the area surrounding the trash compactor was not maintained in a sanitary condition.
- B
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased upon observations, interview and record review conducted during the recertification survey, the facility did not ensure that advance directives formulated for one resident (#104) were effectively implemented according to facility policy to identify the residents' written consent for Do Not Resuscitate (DNR). Specifically, an identifier (orange dot) indicating DNR was not found on the resident's identification (ID) band and on the paper chart spine. The facility is required to establish, maintain, and implement written policies and procedures regarding the residents' right to formulate an advance directive, refuse medical or surgical treatment. In addition, the facility management is responsible for ensuring that staff follow those policies and procedures. The finding is: [...]
- B
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 interview conducted during the recertification survey, the facility did not ensure that 1 of 6 residents (#62) was consistently invited to care plan meetings. Specifically, Resident # 62 stated during an interview that she attended one care plan meeting soon after admission but has not been invited to any further care plan meetings. Review of the Comprehensive Care Plan (CCP) Policy dated 02/19/2019 revealed that to ensure resident and family participation in the interdisciplinary treatment plan, residents (as they are able to) and families are invited to attend during an initial, annual or significant change CCP meetings.
Fire safety inspections
25 fire safety citations on file: 8 on March 13, 2026, 10 on November 17, 2023, 7 on April 18, 2019.
Every fire safety citation25 citations
- F
Install proper backup exit lighting.
K 281 · March 13, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 13, 2026 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 13, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · November 17, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 17, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 17, 2023 · Corrected (the home has a date of correction)
- D
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 17, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · November 17, 2023 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · November 17, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 17, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 17, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 17, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 17, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · April 18, 2019 · Corrected (the home has a date of correction)
- D
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 · April 18, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 18, 2019 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 18, 2019 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 18, 2019 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · April 18, 2019 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · April 18, 2019 · Corrected (the home has a date of correction)