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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
1E
0F
Potential for minimal harm
0A
1B
0C
August 28, 2024Standard inspection, Complaint inspection · 5 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey from 8/21/2024 to 8/28/2024, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review and revision of the comprehensive care plan. Specifically, Resident #54 and/or Designated Representative were not afforded the opportunity to participate in quarterly care plan meetings. This was evident in 1 out of 1 residents reviewed for Resident Assessment (Resident #54).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, record review, and interviews conducted during the Abbreviated survey (NY00320628 and NY00346784) and Recertification survey from 8/21/24 to 8/28/24, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made. This was evident in 3 out of 38 residents sampled (Residents #22, #147, and #44). Specifically, on 07/21/2023 approximately 5 minutes apart, Resident #22 and Resident #147 (who are roommates) reported that they were rough handled and hit by Certified Nursing Assistant #1. The facility did not report the allegations of abuse within 2 hours to New York State Department of Health. 2) Resident #44 reported an allegation of abuse that was not reported within 2 hours to the New York State Department of Health. [...]
- 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 conducted during the recertification survey from 08/21/2024 to 08/28/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This was evident for 1 (Resident #190) of 2 residents reviewed for Activities of Daily Living out of 38 sampled residents. Specifically, Resident #190 was not provided hand rolls for bilateral hand contractures in accordance with physician's orders.
- 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 the Abbreviated (NY#00339083) and Recertification survey from 8/21/2024 to 8/28/2024, the facility did not ensure resident was free from accidents. This was evident in 1 (Resident #26) of 7 residents reviewed for Accident. Specifically, Resident #26 sustained 2 cm skin cut to the eyebrow during toileting when staff assisted without a second staff member.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 8/21/2024 to 8/28/2024, the facility did not ensure Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system timely. This was evident in 1 (Resident #54) out of 1 resident reviewed for Resident Assessment. Specifically, the quarterly Minimum Data Set 3.0 assessment for Resident #54 was not submitted and transmitted within 14 calendar days from the assessment complete date.
March 28, 2023Standard inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review conducted during the Recertification survey from 03/21/23 to 03/28/23, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health (NYSDOH), if the events that cause the allegation involve abuse or result in serious bodily injury. This was evident for 1 (Resident #224) of 4 residents reviewed for Accidents out of 40 total sampled residents. Specifically, the facility did not report an incident where Resident #224 was found on the floor with rib fractures to NYS DOH.
March 11, 2020Standard inspection · 3 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interview conducted during the recertification and abbreviated survey, the facility did not ensure needed care and services that are in accordance with the resident's preferences, goals for care and professional standards of practice were provided. Specifically, 1). a resident was administered a dose of insulin without a physician's order and 2). a resident ordered to receive medication every other day received medication on a daily basis. This was evident for 2 of 9 residents reviewed for Unnecessary Medications out of a sample of 35 residents (Resident # 401-Complaint #NY 00226392 and Resident # 245)
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observations, record review, and staff interviews conducted during the re-certification survey, the facility did not ensure a resident received and consumed foods in the appropriate form as prescribed by a physician. Specifically, the CNA did not provide the resident the correct consistency diet as prescribed. This was evident for 1 of 3 residents reviewed for Nutrition out of an investigation sample size of 38 residents. (Resident#171) The finding is: The most recent Minimum Data Set, dated [DATE] documented resident has a diagnosis of dysphagia and requires nectar thick liquids. On 3/2/2020 at 12:45 PM, resident was observed coughing in the dining room during lunch service. CNA #1 walked over to resident and held a cup of thin water to the resident while she drank. Tray ticket for the resident documented nectar thick liquids. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview conducted during the Recertification survey, the facility did not ensure that an infection prevention and control program was established and maintained a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, oxygen tubing connected to resident from a Bi-pap machine was observed touching the floor and a resident's nasal cannula was found attached to a portable oxygen tank uncovered and touching the floor. This was evident in 1 of 3 residents reviewed for Infections out of sample size of 38 residents. (Resident # 304) The finding is: The undated policy titled Oxygen Therapy documented if oxygen is to be used for greater than 24 hours, the mask and or cannula and humidifier will be replaced weekly. [...]
Fire safety inspections
12 fire safety citations on file: 4 on August 28, 2024, 6 on March 28, 2023, 2 on March 11, 2020.
Every fire safety citation12 citations
- E
Install an approved automatic sprinkler system.
K 351 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 28, 2023 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · March 28, 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 28, 2023 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · March 28, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 28, 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 28, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 11, 2020 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 11, 2020 · Corrected (the home has a date of correction)