5 Reports
Inspection Report — Nov 20, 2025
Complaint Investigation CMS
Date: Nov 20, 2025
Visit Reason
The inspection was conducted as an abbreviated survey triggered by complaint #2633955 regarding failure to provide appropriate treatment and care to Resident #1 after a fall.
Complaint Details
The complaint investigation found that Resident #1 fell on 09/30/2025 but the fall was not documented or reported timely by Registered Nurse Supervisor #1. The resident developed bruising and a fractured femur two days later. The nurse was suspended and received in-service training. The Director of Nursing and Medical Doctor confirmed the failure to report and document the fall as required.
Findings
The facility failed to ensure Resident #1 received proper treatment and care following a fall on 09/30/2025. Registered Nurse Supervisor #1 did not document the fall, notify the physician or family, or complete required reports, resulting in delayed medical intervention and actual harm to the resident.
Violations (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences. Registered Nurse Supervisor #1 did not document Resident #1's fall, notify the physician or family, or complete an Occurrence Report, leading to delayed detection of a fractured femur.
Report Facts
Residents affected: 3
Suspension duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Named in failure to document and report Resident #1's fall and subsequent suspension | |
| Director of Nursing | Provided statements regarding the incident and disciplinary actions | |
| Medical Doctor #1 | Provided medical assessment and comments on the fall and injury |
Inspection Report — Feb 21, 2025
Renewal State
Date: Feb 21, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from April 2022 to March 2026 with deficiency history and enforcement actions.
Complaint Details
Five of the seven inspections were complaint surveys, with violations cited in four of those complaint investigations.
Findings
Across 7 inspections, 5 found violations totaling 12 citations primarily related to resident services, disaster planning, food service, and resident protections. The most recent relicensure survey in February 2025 found 4 violations, all with approved plans of correction.
Violations (8)
Food service: Regulation cited CFR 487.8 (d) (1-2) with violations noted in two inspections.
Personnel: Regulation cited CFR 487.9 (e) (3) with violations found in the most recent relicensure survey.
Disaster and emergency planning: Regulations cited CFR 487.12 (g) and CFR 487.12 (h) with violations in the latest relicensure survey.
General provisions: Regulation cited CFR 487.3 (d) with violations found in a complaint survey.
Resident protections: Regulation cited CFR 487.5 (a) (3) (xi) with violations found in a complaint survey.
Consumer and resident protections: Regulation cited CFR 1001.8 (b) (2) (viii) with one violation in a complaint survey.
Resident services: Regulations cited CFR 487.7 (f) (5), CFR 487.7 (f) (8), and CFR 1001.10 (i) (5-8) with multiple violations in a complaint survey.
Resident services: Regulation cited CFR 487.7 (d) (6) (ii) with violations in a relicensure survey.
Report Facts
Inspections on page: 7
Total violations cited: 12
Inspections with violations: 5
Inspections without violations: 2
Enforcement actions: 1
Inspection Report — Nov 26, 2024
Annual Inspection CMS
Date: Nov 26, 2024
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements and ensure the facility meets standards for resident care and safety.
Findings
The facility was found deficient in accurately assessing residents' needs, providing appropriate pressure ulcer care, pharmaceutical services, food safety, and infection prevention and control practices. Several minimal harm deficiencies were identified related to inaccurate Minimum Data Set assessments, improper wound care treatment application, mislabeled wound care products, unsafe food temperatures, and breaches in aseptic technique during wound care.
Violations (5)
F 0641: The facility did not ensure the Minimum Data Set assessment accurately reflected the use of hearing aids for Resident #190, despite physician orders and care plans indicating hearing aid use.
F 0686: Licensed Practical Nurse #1 did not apply physician-ordered treatment to Resident #19's pressure ulcer and peri-wound area, and the wound care product used did not contain silver as ordered.
F 0755: The facility failed to provide pharmaceutical services meeting residents' needs when the wound care product delivered lacked the silver ingredient specified in the physician's order for Resident #19.
F 0812: The facility did not store and serve food at safe temperatures; tuna salad was outdated and egg, potato, and macaroni salads were served above safe temperature limits.
F 0880: Licensed Practical Nurse #1 breached infection control by placing normal saline-soaked gauze pads on Resident #19's hip and then using the same pads to cleanse the pressure ulcer wound, failing to maintain aseptic technique.
Report Facts
Deficiencies cited: 5
Food temperature: 68
Food temperature: 65
Food temperature: 62
Date of tuna salad: Nov 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in findings related to improper wound care application and infection control breach. | |
| Registered Nurse #1 | Reviewed wound care product packaging and confirmed lack of silver ingredient. | |
| Pharmacist #1 | Interviewed regarding mislabeled wound care product supplied by pharmacy. | |
| Director of Nursing Services | Provided statements on expectations for accurate MDS coding, wound care, and medication administration. | |
| Registered Nurse Infection Preventionist/Nurse Educator | Commented on infection control breach during wound care. | |
| Registered Nurse Wound Care Nurse | Provided expert opinion on wound care aseptic technique breach. | |
| Dietary Aide #1 | Observed serving food without checking cold food temperatures. | |
| Executive Chef | Measured unsafe food temperatures and acknowledged the issue. | |
| Food Service Director | Discussed food safety practices and temperature monitoring deficiencies. |
Inspection Report — Feb 15, 2023
Annual Inspection CMS
Date: Feb 15, 2023
Visit Reason
The survey was a Recertification Survey and Abbreviated Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in timely reporting of injuries of unknown origin, implementation of comprehensive care plans, professional standards in insulin administration, adequate supervision to prevent accidents, accurate resident record documentation, and infection prevention and control practices.
Violations (6)
10NYCRR 415.4 (b) (1) (ii): The facility failed to timely report an injury of unknown origin involving Resident #368 to the New York State Department of Health within 24 hours.
The facility did not implement a comprehensive person-centered care plan for Resident #368, resulting in Certified Nursing Assistants not following the plan of care for two-person assistance during bed mobility.
The facility failed to document the site and amount of insulin administered for Resident #565 on multiple occasions, not meeting professional standards of quality.
The facility did not ensure adequate supervision for residents at risk for aspiration, including Residents #10 and #140, resulting in unsafe eating conditions without staff monitoring.
The facility failed to accurately document colostomy care for Resident #72 as per facility protocol, with multiple instances of missing documentation on the Treatment Administration Record.
The facility failed to ensure proper infection prevention during wound care for Resident #315, as RN #8 did not perform hand hygiene after cleansing the wound and prior to donning clean gloves.
Report Facts
Insulin injection site undocumented: 112
Insulin amount undocumented: 32
Insulin injection site undocumented: 49
Insulin amount undocumented: 7
Colostomy care undocumented: 22
Colostomy care undocumented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Risk Manager/Assistant Director of Nursing Services | Interviewed regarding failure to report injury and care plan violation for Resident #368. |
| Director of Nursing Services | Interviewed regarding reporting procedures and care plan violations for Resident #368 and insulin administration expectations. | |
| CNA #1 | Certified Nursing Assistant | Interviewed about care provided to Resident #368 and failure to follow two-person assistance plan. |
| CNA #2 | Certified Nursing Assistant | Interviewed about care provided to Resident #368 and failure to follow two-person assistance plan. |
| CNA #3 | Certified Nursing Assistant | Interviewed about care provided to Resident #368 and failure to follow two-person assistance plan. |
| RN #7 | Unit Nurse Manager | Interviewed about insulin administration documentation for Resident #565. |
| LPN #6 | Licensed Practical Nurse | Interviewed about insulin administration practices for Resident #565. |
| LPN #7 | Licensed Practical Nurse | Interviewed about insulin administration documentation for Resident #565. |
| RN #4 | Nurse Manager | Interviewed about supervision and feeding of Resident #10. |
| CNA #5 | Certified Nursing Assistant | Interviewed about feeding and supervision of Resident #10. |
| CNA #6 | Certified Nursing Assistant | Interviewed about feeding and supervision of Resident #140. |
| RN #8 | Registered Nurse | Observed and interviewed regarding improper hand hygiene during wound care for Resident #315. |
| LPN #1 | Licensed Practical Nurse | Interviewed about colostomy care documentation for Resident #72. |
| LPN #2 | Licensed Practical Nurse | Interviewed about colostomy care documentation for Resident #72. |
| LPN #3 | Licensed Practical Nurse | Interviewed about colostomy care documentation for Resident #72. |
| RN #6 | Registered Nurse Supervisor | Interviewed about colostomy care documentation for Resident #72. |
| In-service Coordinator/Infection Control Preventionist | Interviewed regarding hand hygiene education for RN #8. |
Inspection Report — Nov 9, 2020
Annual Inspection CMS
Date: Nov 9, 2020
Visit Reason
The inspection was conducted as a recertification (annual) survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in ensuring the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team to meet resident needs, specifically lacking documentation for use and monitoring of a midline catheter for one resident. Additionally, pharmaceutical services were deficient as medication administration did not match physician orders for Tramadol, and the pharmacy had not received prescriptions to provide correct blister packs.
Violations (2)
F 0657: The facility failed to update the Comprehensive Care Plan to include goals and interventions for the use and monitoring of a left arm midline catheter for Resident #46 with a bacterial infection.
F 0755: The facility did not ensure pharmaceutical services met resident needs, as medication administration for Resident #189 did not match physician orders and the pharmacy had not received prescriptions to provide correct medication blister packs.
Report Facts
Residents reviewed for infection: 4
Residents observed during medication administration: 6
Physician's order dates: 4
Tablets remaining in blister pack: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Manager | Interviewed regarding CCP updates for Resident #46. | |
| Director of Nursing Services (DNS) | Interviewed regarding responsibility for CCP updates and pharmaceutical services. | |
| RN Unit Manager | Interviewed about medication orders and pharmacy communication. | |
| Pharmacist | Interviewed about prescription receipt and blister pack preparation. | |
| Nurse Practitioner (NP) | Interviewed about writing prescriptions for Tramadol orders. |
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