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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
9E
0F
Potential for minimal harm
0A
1B
0C
August 11, 2025Standard inspection · 9 citations
- K
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, and interviews, during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility failed to ensure that a resident requiring respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for two (2) (Resident #74 and Resident #119) of four (4) residents reviewed for Respiratory Care. Specifically, Resident #74 with a diagnosis of Chronic Obstructive Pulmonary Disease had a physician's order for supplemental oxygen and did not receive it. On 07/25/2025, the resident was in respiratory distress and was utilizing accessory muscles, appeared pale with gray lips, and verbalized I need air. [...]
- 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, interviews, and record review conducted during the Recertification Survey, initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen Task observation. Specifically, 1) the walk-in freezer, the storage shelf in the kitchen, and the two-door reach-in freezer had one opened and undated food or food packages. 2) The cooked poultry meal temperatures were not maintained within the required range (above 135 degrees).
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record review and staff interviews, during the re-certification survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for two (2) (Resident #74 and Resident #119) of (4) four residents reviewed for Respiratory care. Specifically, the facility was not effectively administered to ensure two (2) (Resident #74 and Resident #119) of (4) four residents were monitored for respiratory care. On 07/25/2025 and 07/28/2025, Resident #74 was observed without Oxygen in their portable Oxygen tank, and on 08/08/2025, Resident # 119 was observed without oxygen in their portable Oxygen tank. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, record reviews, and staff interviews, during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that each resident had the right to receive services in the facility with reasonable accommodation of resident needs and preferences. This was identified for one (Resident #40) of seven residents reviewed for Activities of Daily Living. Specifically, during the Resident Council meeting on 07/21/2025, Resident # 40 stated they were not getting their showers as per their preference. A review of the record documented that Resident # 40 was receiving bed baths and not receiving showers as per the resident's care plan and preference. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record reviews, and staff interviews, during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for two (Resident # 74 and Resident #119) of four residents during the Respiratory Care. Specifically, Licensed Practical Nurse #4 did not provide respiratory care to Resident #74 when the resident's oxygen tank was observed to be empty. The resident complained of difficulty breathing. Licensed Practical Nurse #4 dismissed the resident's complaint as a panic attack and that the resident was exaggerating their distress and proceeded to complete the medication administration to other residents. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation record review and staff interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition. This was identified for one (Resident #7) of five residents reviewed for Limited Range of Motion. Specifically, during an observation on 07/22/2025 at 11:20 AM, Resident #7's breakfast tray was observed unopened and untouched on the overbed table. Resident #7 required setup help and was not assisted with their breakfast meal. The finding is: The facility's policy and procedure titled Assisting the Resident With In-Room Meals, revised on 2/14/2025, documented placing the (meal) tray on the overbed table or serving area. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/112025, the facility did not ensure that each resident with a Pressure Ulcer or potential for a Pressure Ulcer received the necessary treatment and service consistent with professional standards of practice to promote healing, prevent infections, and prevent new ulcers from developing. This was identified for one (Resident #112) of three residents reviewed for Pressure Ulcers. Specifically, Resident #112, with a history of Stage 4 pressure ulcer, was observed on multiple occasions in bed on an air mattress that was set to 450 pounds and had a history of pressure ulcers and currently weighs 167 pounds. [...]
- 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 observations, record review, and interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that all drugs were labeled in accordance with currently accepted professional principles, including the expiration dates. This was identified for one (Resident #66) of seven residents reviewed during medication pass observation, one (2 North medication cart) of two medication carts observed during the medication storage and labelling task, and for one (Resident #83) of three residents reviewed for Accidents. Specifically, 1) during medication pass observation, Resident #66's nebulizer treatment medication, Budesonide Inhalation, was not dated. 2) Unit 2 North medication cart was observed with a souffle cup containing three prepoured unlabeled medication tablets. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #112) of one resident reviewed for infection control and one (Resident #19) of seven residents reviewed for Medication Pass Observation. Specifically, Resident #112 had a physician's order for Enhanced Barrier Precautions secondary to the use of an indwelling Foley Catheter. There was no Enhanced Barrier Precaution signage posted outside the resident's door to alert staff and visitors regarding the resident's precaution status. [...]
February 21, 2025Complaint inspection · 4 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and closed record reviews , during an abbreviated survey (NY00370917), the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice for one (1) out of three (3) residents. Specifically, on [DATE] at 8:01 PM, Resident #2 was evaluated for symptoms including fever and tachycardia. Nurse Practitioner #1 was notified on [DATE] at 6:30 PM of critical lab values and ordered to send Resident #2 to the hospital for an emergent blood transfusion. Registered Nurse Supervisor #1 documented Resident #2 would be sent to the hospital in the morning. Subsequently, on [DATE] at 1:20 AM, Resident #2 was found to be unresponsive, pulseless, and without respirations. Resident #2 expired at 2:01 AM. This resulted in Immediate Jeopardy with the likelihood for serious injury, serious harm, or death for all residents.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review conducted during an abbreviated survey (NY00370917), the facility did not provide person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being for three of six residents (Resident #2 #3 #5) reviewed for Accidents. Specifically, (1) Resident #2 was identified as high risk for aspiration (choking) and was to be fed via percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that allows nutrition directly through your stomach.) Resident #2 physician orders documented medications to be administered by mouth. (2) Resident #3 was evaluated by speech and deemed to be at risk for aspiration, a physician's order indicated a puree diet. Resident #3 was given a dog biscuit which Resident #3 ate and subsequently began coughing and noted with abnormal lung sounds (stridor). [...]
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00370917) the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit and a decision about the continued appropriateness of the resident's current medical regimen for 2 out of 6 residents (Resident #5, #2) reviewed for Quality of Care. Specifically, (1) Resident #2 was admitted to the facility with orders for nothing to be administered by mouth and a feeding tube the facility did not address Resident #2 ability to receive oral medication or include an order for nothing by mouth (NPO) on the admission orders. Additionally, Physician Assistant #1 ordered Tylenol 325mg by mouth every 8 hours and Tamiflu capsules 30mg daily by mouth. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews during the Abbreviated Survey (NY00370917) the facility did not ensure that each resident's representative was immediately informed when a resident had a change in condition or the potential for change of condition requiring physician intervention. This was identified for one (Resident #1) of six residents reviewed for Quality of Care. Specifically, on 1/26/2025 and 1/27/2025 Resident #1 presented with fever, tachycardia (increased heart rate) hypotension (low blood pressure) and critical lab results including a HGB (hemoglobin) 4.9g/dl (normal range is 13.0-17.0g/dl). The resident's representative was not informed of the change in condition, or the interventions provided. The finding is: [...]
January 22, 2025Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and staff interviews during the Abbreviated Survey case #NY00369007 and initiated on 1/21/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. This was identified for six (Resident #1, Resident #2, and Resident #3, Resident #4, Resident #5, and Resident #6) of eighteen residents reviewed for Quality of Care and Treatment. Specifically, 1) Resident #1 had no documented bowel movement for eight consecutive days. 2) Resident #2 had no documented bowel movement for five consecutive days. 3) Resident #3 had no documented bowel movement for five consecutive days. The finding is: The facility's policy titled, Bowel Protocol dated 12/23/2024 documented the nurses shall assess and document/report the following: [...]
February 15, 2024Standard inspection, Complaint inspection · 3 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, record review, and staff interviews during the Recertification and Abbreviated Survey (Complaint # NY00311574, NY00324554, NY00316227, and NY00331727) initiated on 2/07/2024 and completed on 2/15/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified during a review of the Payroll-Based Journal (PBJ) Staffing Data Report; a review of the Facility Assessment; and an observation during the Medication Administration. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report and the Facility Assessment (FA) identified that the facility did not ensure adequate staffing was available to meet the residents' needs on multiple days. [...]
- E
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, conducted during the Recertification Survey initiated on 2/07/2024 and completed on 2/15/2024, the facility did not ensure that pharmaceutical services including administration of all medications was provided to meet the needs of all residents. This was identified for four (Resident #35, Resident #164, Resident #15, and Resident# 99) of four residents observed during the medication pass observation. Specifically, 1) Resident #35 did not receive five of the 9:00 AM Physician ordered medications until 10:45 AM on 2/9/2024. 2) Resident #103 did not receive eight of the 9:00 AM Physician ordered medications until 11:00 AM on 2/9/2024, 3) Resident #99 did not receive nine of the 9:00 AM Physician ordered medications until 10:42 AM 2/7/2023. [...]
- E
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 during the Recertification Survey initiated 2/07/2024 and completed 2/15/2024 the facility did not ensure that it maintained medical records that are complete and accurately documented in accordance with professional standards of practice. This was identified for 1) one (Resident #77) of three residents reviewed for Hydration, and 2) one (Resident #31) of one resident reviewed for Bladder and Bowel. Specifically, 1) Resident #77, had a Physician's order to check the Peripheral Intravenous Catheter insertion site for redness and infiltration every shift. There was no documented evidence that the Peripheral Intravenous Catheter was assessed for redness and infiltration as per the Physician's order. 2) Resident #31, had a Physician's order to flush the Nephrostomy tube. [...]
February 28, 2022Standard inspection · 6 citations
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 2/28/2022 the facility failed to ensure that each resident received care, consistent with professional standard of practice to prevent Pressure Ulcer (PU) development and to promote healing. This was identified for one (Resident #66) of three residents reviewed for PU. Specifically, Resident #66 was admitted with no PUs. The resident utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity. On 12/10/2021 Resident #66 was identified with a PU to the right heel. The facility staff did not consistently conduct weekly assessments. Timely assessments by the Physician were not completed. Resident #66's was identified with skin impairment and was not referred to the wound care team until 18 days after the PU was first identified. The finding is: [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00253069) completed on 2/28/2022, the facility did not ensure that each resident representative was notified timely of a resident's transfer from the facility. This was identified for one (Resident #307) of two residents reviewed for Notification of Change. Specifically, Resident #307 was transferred to the hospital on 2/9/2020 to rule out Gastrointestinal Bleeding, however, there was no documented evidence that the resident's representative was notified of the change in the resident's condition resulting in a transfer to the hospital. The finding is: The facility policy and procedure dated 2/22/2021 for Acute Change in Condition documented nursing staff are responsible to notify the resident representative following the resident's transfer to the hospital. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00278230) completed on 2/28/2022, the facility did not ensure that a thorough investigation was completed to rule out neglect following a report of an incident. This was identified for one (Resident #303) of two residents reviewed for Accidents. Specifically, Resident #303 was found on the floor of their room on 6/20/2021, however, there was no documentation that an Occurrence Report investigation was completed. The finding is: The facility's policy titled Accident/Incident/Occurrence Reports (Patients/Residents) dated 9/2016 documented that all falls and/or lowered to the floor are to have an Occurrence Report completed for investigation and Quality Assurance (QA) review. Resident #303 was admitted with diagnoses which include Hydrocephalus and Bipolar Disorder. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey completed on 2/28/2022 the facility did not ensure that services provided met professional standards. This was identified for one (Resident #17) of 5 residents reviewed for medication administration. Specifically, Licensed Practical Nurse (LPN) #1 administered a crushed Potassium Chloride (supplement) Extended-Release tablet to Resident #17. The Manufacturer's specifications for the Potassium supplement specified that the medication should not be crushed. The finding is: The undated facility policy and procedure for Crushing of Medications documented the Physician should order the crushing of medications. The physician must document the rationale why a medication must be crushed. [...]
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on record review and interviews during the Recertification Survey completed on 2/28/2022, the facility did not ensure that the medical care of each resident was supervised by a Physician. This was identified for one (Resident #66) of three residents reviewed for Pressure Ulcer (PU). Specifically, Resident #66 utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity due to paralysis. On 12/10/21 the resident was identified with an open area to the right heel and there was no documented evidence that the resident's change in skin condition was evaluated or addressed by the attending Physician until 1/7/2022 after the wound had declined to a Stage 3 pressure ulcer. Additionally, there was no documented evidence in the Physician's monthly notes that the progress of the wound was monitored by the attending Physician. The finding is: [...]
- 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 staff interviews during the Recertification Survey completed on [DATE], the facility did not ensure that Minimum Data Set (MDS) assessment was encoded and transmitted timely for each resident including a subset of items upon a residents' transfer, reentry, discharge and or death. This was identified for one (Resident #1) of one resident reviewed for the Resident Assessment Task. Specifically, after Resident #1 expired on [DATE] there was no documented evidence that the MDS was encoded and transmitted to the Centers for Medicare & Medicaid Services (CMS) System. The finding is: Resident #1 was admitted with diagnoses including Hypertension, Chronic Obstructive Pulmonary Disease, and Compression Fracture of T5-T6 Vertebrae. The Entry MDS assessment dated [DATE] was in place and documented accepted in the CMS System. [...]
Fire safety inspections
13 fire safety citations on file: 2 on August 11, 2025, 9 on February 15, 2024, 2 on February 28, 2022.
Every fire safety citation13 citations
- F
Use approved construction type or materials.
K 161 · August 11, 2025 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · August 11, 2025 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · February 15, 2024 · fire safety evaluation s
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · February 15, 2024 · 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 15, 2024 · 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 · February 15, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · February 15, 2024 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · February 15, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 15, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · February 15, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 15, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · February 28, 2022 · Waiver
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · February 28, 2022 · Corrected (the home has a date of correction)