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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
3K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
11E
5F
Potential for minimal harm
0A
0B
0C
February 23, 2026Standard inspection · 3 citations
- 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 observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of four (4) medications carts (Unit 3 South and Unit 4 North) and one (1) of two (2) medications rooms (Unit 4) reviewed. Specifically, the Unit 3 South medication cart had expired eye drops and nasal spray; the Unit 4 North medication cart had opened unlabeled inhalers, expired or unlabeled eye drops, one insulin pen was missing the pharmacy label, the resident's name, and date opened and one insulin pen was not labeled with an opened date; and the Unit 4 medication room refrigerator was not maintained at an appropriate temperature.
- D
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 on record review and interviews during the recertification survey (complaint #2738777) the facility failed to honor advance directive wishes for one (1) of one (1) resident (Resident #14) reviewed. Specifically, Resident #14 had a Medical Order for Life-Sustaining Treatment documenting do not resuscitate (do not attempt resuscitation, allow natural death). Cardiopulmonary resuscitation (chest compressions) was initiated, and an automated external defibrillator (a device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock, to help the heart re-establish an effective rhythm) was used when Resident #14 did not have a pulse.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews and interviews during the recertification survey, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for two (2) of five (5) residents (Residents #25 and #56) reviewed. Specifically, Resident #25 was on contact precautions and Activities Aide #14, and Certified Nurse Aides #15 and #16 entered the room without appropriate personal protective equipment; and Resident #56 was on enhanced barrier precautions and Licensed Practical Nurse #7 performed wound care without appropriate personal protective equipment.
February 11, 2025Standard inspection · 13 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/3/2025- 2/11/2025, the facility failed to ensure the resident environment was free of accident hazards for three (3) of eight (8) residents (Residents #72, #75, and #98) reviewed. Specifically, Residents #72, #75, and #98 were served and Residents #72 and #98 consumed a cleaning solution stored in the kitchenette refrigerator in an unlabeled pitcher. This resulted in physical and psychosocial harm to Resident #72 that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury, or death to Residents #72, #75, and #98 and the additional 107 residents in the facility.
- F
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observations and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups were posted in a form and manner accessible to residents and resident representatives. Specifically, 13 out of 13 anonymous residents present at the resident group meeting stated they did not know where to find the Ombudsman and New York State Nursing Home Complaint Hotline information. Additionally, there were no posted Ombudsman program or New York State Nursing Home Complaint Hotline numbers or posters observed in the facility.
- F
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observations and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure the results of the most recent Federal and State surveys were posted in a place readily accessible where individuals who wished to examine the survey results did not have to ask for them. Specifically, the facility state inspection binder located in the front lobby did not include the most recent (3/3023) standard health survey results and any subsequent complaint survey results, and there was no posted notification of the availability of the previous 3 years of survey reports. Findings Include: [...]
- F
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure a process was in place for residents to have their grievances addressed for 13 of 13 anonymous residents present at the resident group meeting. Specifically, all 13 residents stated they did not know who the grievance officer was or how to file a grievance.
- F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/3/2025 - 2/11/2025, the facility did not ensure a system of records and accounts of all controlled drugs was maintained for 1 of 3 nursing units (Unit 3) reviewed. Specifically, a controlled substance reconciliation (a system of recordkeeping that ensures an accurate inventory by accounting for controlled medications that were received, dispensed, and administered) was not performed between the oncoming and outgoing nurse; the narcotic count log form was completed and signed without a count being performed; narcotic keys were not transferred between nurses in a secured manner; and Resident #65's Controlled Substance Record was not accurately reconciled after the medication was administered to the resident.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, 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 2 of 2 units (Units 2 and 3) observed. Specifically, Units 2 and 3 floors did not have proper signage for transmission based precautions, and personal protective equipment was not readily accessible. Additionally, Licensed Practical Nurse #37 performed gastrostomy tube (feeding tube) care without wearing required personal protective equipment, and Resident#31's suction equipment was not maintained or stored in a sanitary manner.
- 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 review and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 3 of 5 residents (Residents #59, #88, and #100) reviewed. Specifically, Resident #59's person-centered comprehensive care plan did not include the diagnoses of type 2 diabetes mellitus (the body does not use insulin properly causing high blood sugars) or the use of insulin (used to treat high blood sugars); Resident #88's person-centered comprehensive care plan did not include use of an anticoagulant (blood thinner); [...]
- 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 observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 3 of 4 medication carts (4th floor North, 4th floor South, and 3rd floor North medication carts). Specifically, the 4th floor medication carts (North and South carts) and the 3rd floor North medication cart had expired stock medications and insulin.
- 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, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 2 of 3 unit kitchenettes (Units 3 and 4) and the main kitchen. Specifically, there were unclean surfaces in the Units 3 and 4 floor kitchenettes and main kitchen; moldy bread in the 4th floor kitchenette; and inaccurate thermometers in the walk-in cooler off the kitchen and the economy refrigerator in the main kitchen.
- 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, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 5 resident units (Units 2 North, 2 South, and 3 South) reviewed. Specifically, the stove/oven in Unit 2's activity room had accessible and operational knobs; Resident #31 on Unit 3 had an unclean tube feeding pole; and Resident #6 on Unit 4 had an improperly secured enabler bar (a device attached to the bed to aid in positioning).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record reviews, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for 2 of 3 residents (Residents #6 and #31) reviewed. Specifically, clinical nutrition staff did not assess Resident #6 following significant weight changes; and Resident #31's ordered enteral feeding (a feeding tube) water flushes were not provided as ordered.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not post daily current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent location readily accessible to residents and visitors for 6 of 6 days reviewed. Specifically, daily nurse staffing was not posted daily at the beginning of the shift as required on 2/3/2025, 2/4/2025, 2/5/2025, 2/6/2025, 2/7/2025 and 2/10/2025 as required.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did provide each resident with a nourishing, well-balanced diet that considered the preferences of each resident for 1 of 2 residents (Resident #24) reviewed. Specifically, Resident #24 was not provided their preferred meal choices.
January 14, 2025Complaint inspection · 2 citations
- K
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, observation, and interviews during an abbreviated survey (NY00367007), the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #1) reviewed. Specifically, Dietary Aide #4 witnessed Certified Nurse Aide #8 abuse Resident #1 and did not report the incident for three days. Additional staff were identified as having knowledge of the incident and failed to report to facility Administration timely. The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 104 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death.
- K
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00367007), the facility failed to ensure an incident of staff abuse toward a resident was reported to the State Agency and to law enforcement for 1 of 3 residents (Resident #1). Specifically, Dietary Aide #4 witnessed Certified Nurse Aide #8 abuse Resident #1 and did not report the incident to Administration for three days. Multiple staff were identified who were made aware of the abuse allegations and did not report to Administration. Upon receipt of the reported incident, the facility did not report the allegation of abuse to the State Agency or law enforcement as required. Additionally, Certified Nurse Aide #8 continued to have access to residents following the witnessed abuse. [...]
October 7, 2024Complaint inspection · 6 citations
- K
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 during the abbreviated survey (NY00330966), the facility failed to ensure that residents were free from sexual abuse and failed to protect residents from further abuse for 1 of 7 residents (Residents #4) reviewed. Specifically, Resident #5 had intact cognitive function, a history of sexually inappropriate behaviors, and continued to exhibit sexually inappropriate behaviors, including making verbal sexual requests to residents. There were no documented interventions to address the resident's ongoing behaviors or to protect other residents from abuse. Resident #4, a cognitively impaired resident, was found in Resident #5's room engaging in a sexual act. [...]
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview during the abbreviated survey (NY00340854, NY00335730, NY00340963, NY00330996, and NY00344094), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 6 of 12 residents reviewed (Residents #1, #2, #3, #4, #5, and #6). -Resident #3, had episodes of vaginal/rectal bleeding, was not assessed by a qualified professional, and the medical provider was not notified timely of the bleeding (8 hours and 15 minutes following onset of bleeding). The provider ordered STAT (immediate) labs, the blood specimen could not be obtained from the resident, and the provider was not notified timely. - Resident #2 had an intact left heel blister and a treatment was ordered. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews during abbreviated surveys (NY00330966, NY00344094, and NY00344130), the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 4 of 6 residents (Residents #4, #5, #6, and #9) reviewed, and an additional 6 unidentified residents. Specifically, facility investigations did not identify concerns related to: - Resident #4, a cognitively impaired resident, was found in Resident #5's room engaging in a sexual act and was not assessed by a qualified professional timely, protective interventions were not implemented timely, police, family, and the medical provider were not notified timely, and a staff member left the residents after discovering them engaged in a sexual act. Cross referenced in F 600 Free from Abuse and Neglect and F 684 Quality of Care. [...]
- E
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 during the abbreviated survey (NY00330966) the facility did not ensure that Comprehensive Care Plans were reviewed and revised to meet the needs of each resident for 3 of 12 residents (Residents #4, #5, and #13) reviewed. Specifically, Resident #5 exhibited sexually inappropriate behaviors and did not have an individualized care plan to address their behaviors. When their behaviors continued, the care plan was not updated to ensure protection of other residents. Residents #4 and #13 were at risk of being sexually abused and their care plans were not updated to prevent abuse.
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on record review and interviews during the Abbreviated Survey (NY00330966), the facility did not ensure medically related social services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 7 residents (Residents #4, #5, and #13) reviewed. Specifically: - Resident #5 had intact cognitive function, a known history of sexually inappropriate behaviors, was at risk for sexually abusing cognitively impaired residents, and was moved to a unit with cognitively impaired residents. The resident did not have person-centered mental/behavioral health interventions, responses to inappropriate behaviors were ineffective and punitive in nature, and the licensed psychologist's recommendations were not implemented into the resident's plan of care. [...]
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record review, and interview during the abbreviated survey (NY00330966, NY00335730, NY00340854, NY00340963, NY00344094, and NY00344130), the facility failed to ensure it was administered in a manner that ensured residents received appropriate quality of care, allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F 684 Quality of Care and F 600 Free from Abuse and Neglect. Specifically, facility Administration, including the Director of Nursing and Director of Social Services did not ensure: - residents were free from sexual abuse and did not ensure residents were protected from further abuse and all alleged violations were thoroughly investigated; - Comprehensive Care Plans were reviewed and revised to meet the needs of each resident; [...]
October 23, 2023Complaint inspection · 1 citation
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on record review, observation, and interview during the abbreviated survey (NY00325469), the facility did not maintain an effective pest control program so that the facility was free of pests for 1 of 3 units (2nd floor kitchenette and 2nd floor Teresian room). Specifically, fruit flies were observed in the 2nd floor kitchenette and the 2nd floor Teresian room.
March 8, 2023Standard inspection · 13 citations
- E
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 record review, observation, and interview during the recertification and abbreviated surveys (NY00278700, NY00277501, and NY00284096) conducted 3/1/23-3/7/23, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 3 nursing units (second, third, and fourth floors), for 5 resident rooms (rooms 315, 316, 324, 423, and 421), and for 16 resident common areas (hall wall near room [ROOM NUMBER], hall walls between rooms [ROOM NUMBERS], fourth floor sun room, fourth floor housekeeping door frame, hall walls between rooms [ROOM NUMBERS], hall wall near room [ROOM NUMBER], fourth floor north fire barrier door frame, third floor shower room, third floor tub room, third floor nursing station, second floor staff bathroom, second floor shower room, second floor tub room, hall wall behind the south unit fire barrier door, second floor kitchenette, and [...]
- 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, interview, and record review during the recertification survey conducted 3/1/23-3/8/23, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, soup in the walk-in cooler was not cooled properly; there was unclean equipment and unclean surfaces; the faucet for the three bay sink was in disrepair; and dented cans were available for use in storage areas.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00284096) surveys conducted 3/1/23-3/7/23, the facility failed to maintain an effective pest control program so that the facility was free of pests for five isolated areas (the main kitchen, the fourth floor kitchenette, resident room [ROOM NUMBER], the second floor nursing station, and the second floor hallway between resident rooms [ROOM NUMBERS]). Specifically, there was fruit fly infestation observed in the main kitchen, the fourth floor kitchenette, resident room [ROOM NUMBER], the second floor nursing station, and the second floor hallway between resident rooms [ROOM NUMBERS].
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 3/1/23-3/8/23, the facility failed to protect and promote the rights of the resident including protecting residents' private space for 3 of 3 residents (Residents #34, 44, and 83) reviewed. Specifically, Residents #34, 44, and 83 requested a key for their room's locked drawer and the key was not provided.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 3/1/23-3/8/23, the facility failed to ensure self-administration of medications was determined to be clinically appropriate for 1 of 8 residents (Resident #46) reviewed. Specifically, Resident #46 had 6 medications left on their bedside table and was not assessed for the ability to safely self-administer medications and did not have a medical order to self-administer medications.
- D
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 on observation, interview, and record review during the recertification and abbreviated (NY00310048) surveys conducted [DATE]-[DATE], the facility failed to ensure the resident's right to formulate an advance directive for 1 of 1 (Resident #94) reviewed. Specifically, Resident #94's Medical Orders for Life-Sustaining Treatment (MOLST) documented that Resident #94 consented to a Do Not Resuscitate (DNR, allow natural death) and the physician's order in the electronic medical record (EMR) documented Cardiopulmonary Resuscitation (CPR, perform chest compressions to restart the heart).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview during the recertification survey conducted 3/1/23-3/8/23 the facility failed to inform each resident and/or their designated representative of changes to services covered by Medicare and potential financial liability for services provided during a non-covered stay for 2 of 3 residents (Residents #11 and 105) reviewed. Specifically, Residents #11 and 105 had facility-initiated discharges from Medicare Part A services when benefit days were not exhausted and they remained in the facility, and were not provided with the SNF (Skilled Nursing Facility) ABN(Advanced Beneficiary Notice), CMS (Centers for Medicaid and Medicare Services) Form 10055 as required.
- 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 observation, record review, and interview during the recertification and abbreviated (NY00275812) surveys conducted 3/1/23-3/8/23, the facility failed to review and revise the comprehensive care plan (CCP) for 2 of 5 (Residents #74 and 84) residents reviewed. Specifically, Resident #74 was a victim in multiple resident to resident abuse incidents and there were no care planned interventions to prevent further abuse; and Resident #84 had a physician order for protective boots to prevent heel pressure and they were not included in the CCP.
- 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 during the recertification and abbreviated (NY00275411, NY00278832, NY00284096, NY00278700, NY00290397 and NY00287038) surveys conducted 3/1/23-3/8/23, the facility failed to 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 of 6 residents (Residents #46, 74 and 108) reviewed. Specifically, Resident #46 was not repositioned and set up at 2 meals as planned; Resident #74 was observed on multiple occasions with food on their clothing and face, and their hair appeared greasy and unwashed; and Resident #108 was left in bed for meals and not set up as care planned.
- 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, interview, and record review during the recertification survey conducted 3/1/23-3/8/23, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dates when applicable for 1 of 6 medication carts (2 South) reviewed. Specifically, the 2 South medication cart had 1 insulin pen that was not labeled with a date opened or when it would expire.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00277501) surveys conducted from 3/1/23-3/7/23, the facility failed to ensure each resident receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals reviewed (3/2/23 and 3/3/23 lunch meals). Specifically, food was not served at palatable and appetizing temperatures.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted from 3/1/23 to 3/8/23, the facility failed to ensure each resident received food that accommodated resident allergies, intolerances, and preferences for 2 of 7 (Resident #59 and 108) reviewed. Specifically, Residents #59 and 108 were served foods they were allergic to.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview during the recertification survey and abbreviated surveys (NY00310048 and NY00284096) conducted 3/1/23-3/8/23, 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 1 resident (Resident #84) reviewed. Specifically, during Resident #84's wound and gastrostomy (a surgical opening into the stomach for a feeding tube) treatment observation, licensed practical nurse (LPN) #8 did not remove soiled gloves or perform hand hygiene after the removal of soiled dressings and application of a treatment and a clean dressing.
Fire safety inspections
43 fire safety citations on file: 6 on February 23, 2026, 23 on February 11, 2025, 1 on February 27, 2024, 13 on March 8, 2023.
Every fire safety citation43 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 23, 2026 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · February 23, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 23, 2026 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 23, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 23, 2026 · Corrected (the home has a date of correction)
- C
Provide emergency officials' contact information.
E 31 · February 23, 2026 · Corrected (the home has a date of correction)
- F
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · February 11, 2025 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · February 11, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 11, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 11, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · February 11, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · February 11, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · February 11, 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 · February 11, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 11, 2025 · 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 · February 11, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 11, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Install properly constructed windows in hallway walls or doors.
K 364 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · February 11, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 11, 2025 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · February 11, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · February 27, 2024 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · March 8, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · March 8, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 8, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 8, 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 8, 2023 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · March 8, 2023 · 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 · March 8, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 8, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 8, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 8, 2023 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · March 8, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 8, 2023 · Corrected (the home has a date of correction)