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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
9D
2E
0F
Potential for minimal harm
0A
0B
0C
June 9, 2026Complaint inspection · 1 citation
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that residents are free from significant medication errors for one of four residents (Resident #94) reviewed for hospitalization. Specifically, on 05/04/2025 at 9:00 AM and 9:00 PM, the facility failed to administer Levetiracetam (Keppra: medication used to help control seizures) 750 milligrams two tablets (1500 milligrams) every 12 hours to Resident #94 as per physician order. Subsequently, Resident #94 had a seizure on 05/05/2025 at approximately 12:20 AM and was transferred to the hospital. This resulted in actual harm to Resident #94 that was not Immediate Jeopardy.
June 4, 2025Complaint inspection · 3 citations
- 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 and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure that a resident's right was supported by the facility for 1 or 3 residents reviewed. Specifically, Resident #1 filed a grievance which was reported to the Director of Nursing in January 2025 that they prefer not to receive cares from Certified Nurse Aide #1 because they were too strong in their touch and at times manhandled them. On 3/18/2025, Certified Nurse Aide #1 provided care to Resident #1 and the resident reported to their family representative that Certified Nurse Aide #1 came to their room at approximately 4:45 am, woke them out of their sleep and provided cares to them after they refused the care. Resident #1 also alleged that they were manhandled by Certified Nurse Aide #1. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure for 1 (Residents #1) of 3 residents reviewed for abuse, had the right to be free from abuse, neglect, or mistreatment. Specifically, Resident #1 was awaken at 4:45am by Certified Nurse Aide #1 to provide personal hygiene care. Resident #1 refused cares but Certified Nurse Aide #1 continued to provide cares despite Resident #1's refusal. Resident #1 reported Certified Nurse Aide #1 mishandled them. Resident #1 was very upset because thier sleep was interrupted by Certified Nurse Aide #1 and reported to their family representative.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure for 1(Residents #1) of 3 residents reviewed for abuse, that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation is made, to the State Survey Agency in accordance with State law through established procedures. [...]
October 10, 2024Standard inspection · 5 citations
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interviews and record review, conducted during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure the residents' Minimum Data Set assessments were completed not less frequently than once every 3 months. This was evident for 3 (Residents # 11,14, and 23) of 18 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments for Resident #11, Resident #14, Resident #23, were not completed within 14 days of the Assessment Reference Date.
- 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 during the recertification survey, the facility did not ensure 1 of 3 residents (Resident #16) reviewed for positioning and range of motion, had the necessary treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, Resident #16 was observed poorly positioned and their plan of care did not include interventions to address body, head, and neck positioning.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interviews during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure that each resident received necessary respiratory care including oxygen therapy that was in accordance with professional standards of practice and as ordered by the practitioner for 1 of 2 residents (Resident #312) reviewed for respiratory care. Specifically, Resident #312 had an order for oxygen therapy but there was no documented evidence of monitoring to ensure it was being administered, and there was no evidence the nasal canula tubing was changed per policy.
- 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 conducted during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, there was undated and without expiration dates food stored in the walk-in freezer and refrigerator.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview conducted during a recertification survey 10/3/24- 10/10/24, the facility did not properly establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, the facility had not updated the Water Management Plan since 12/16/19.
August 12, 2022Standard inspection · 0 citations
May 1, 2019Standard inspection · 3 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 observation, interview and record review conducted during the recertification survey, the facility did not ensure that foods were stored in accordance with professional standards for food safety practice. Specifically, for 2 of 4 nourishment refrigerators (Armonk and Canterbury units): (1) freezer thermometer readings did not reflect acceptable temperatures and no corrective action had been taken, and (2) foods stored in freezer compartments were not frozen solid. The facility's freezers must be in good working condition and must keep frozen foods frozen solid. The finding is: An Engineering policy and procedure for Temperature Logs dated October 2018 revealed the Engineering Mechanic fills out logs for refrigerators and freezers on a daily basis; [...]
- 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 a comprehensive person-centered care plan with measurable goals and interventions was developed to address the resident's diabetic needs. Specifically, 1 of 5 residents (Resident # 83) did not have a care plan in place to address his diabetic needs.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that residents received proper treatment and assistive devices to maintain hearing ability. This was evident for 1 resident reviewed for vision and hearing. ( Resident #55). The finding is: Resident #55 was admitted with diagnoses that included Hypertension, Diabetes Mellitus and Depression. Review of the Quarterly Minimum Data Set (MDS-a resident assessment tool) dated 03/01/2019 documented that the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 indicating severe cognitive impairment. The MDS further documented that the resident had minimal hearing difficulty with no hearing aid. Review of the Annual MDS dated [DATE] documented that the resident had minimal hearing difficulty and used a hearing aid. [...]
Fire safety inspections
13 fire safety citations on file: 1 on October 10, 2024, 9 on August 12, 2022, 3 on May 1, 2019.
Every fire safety citation13 citations
- E
Have simulated fire drills held at unexpected times.
K 712 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 12, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 12, 2022 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 12, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 12, 2022 · Corrected (the home has a date of correction)
- D
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
K 224 · August 12, 2022 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · August 12, 2022 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 12, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 12, 2022 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · August 12, 2022 · Corrected (the home has a date of correction)
- E
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 · May 1, 2019 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · May 1, 2019 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 1, 2019 · Corrected (the home has a date of correction)