Citations (last 4 years)
Citations (over 4 years)
9.3 citations/year
Citations are regulatory findings recorded during state inspections.
82% worse than New York average
New York average: 5.1 citations/yearCitations per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 12
Date: Mar 7, 2025
Visit Reason
Inspection identified multiple Level 2 deficiencies related to quality of care and life safety code issues, all corrected by May 2025.
Findings
Inspection identified multiple Level 2 deficiencies related to quality of care and life safety code issues, all corrected by May 2025.
Citations (12)
Accuracy of assessments
Baseline care plan
Drug regimen review
Free of medication error rates
Increase/prevent decrease in ROM/mobility
Label/store drugs and biologicals
Quality of care
Right to refuse certain transfers
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Discharge from exits
Vertical openings - enclosure
Inspection Report
Annual Inspection
Citations: 5
Date: Apr 12, 2023
Visit Reason
The inspection was conducted as a Recertification Survey from 04/03/2023 to 04/12/2023 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in timely reporting of suspected abuse, accuracy of Minimum Data Set (MDS) assessments, comprehensive care plan reviews, pain management, and food storage practices. Specific issues included failure to report an unwitnessed fall with injury within 2 hours, inaccurate MDS documentation for multiple residents, failure to update care plans quarterly, inadequate pain medication administration, and storage of expired food items.
Citations (5)
Failure to timely report suspected abuse or injuries of unknown source to the New York State Department of Health within 2 hours, specifically for Resident #26's unwitnessed fall with a laceration.
Inaccurate Minimum Data Set (MDS) assessments for 4 residents, including failure to document continuous oxygen use, incorrect diagnosis of schizophrenia, failure to document vision impairment, and failure to document use of wander alert device.
Failure to review and revise Resident #230's Comprehensive Care Plan related to elopement risk upon each quarterly assessment.
Failure to provide pain management as ordered for Resident #217, including not administering pain medications despite resident complaints and physician orders.
Food safety violations including storage of expired half and half creamers and expired saltine crackers in the kitchen and dry storage room.
Report Facts
Residents reviewed for Falls: 3
Residents sampled for MDS accuracy: 35
Residents investigated for Accidents: 5
Residents reviewed for pain management: 9
Expired food items observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #2 | Interviewed regarding Resident #26's fall and reporting procedures. | |
| Director of Nursing (DON) | Interviewed regarding reporting decisions and pain management policies. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding reporting procedures and MDS oversight. | |
| Administrator | Interviewed regarding video review and incident conclusions for Resident #26. | |
| MDS Coordinator | Interviewed regarding MDS scheduling and accuracy oversight. | |
| MDS Assessor (MDSA) | Interviewed regarding MDS assessment errors and diagnosis documentation. | |
| Certified Nursing Assistant (CNA) #5 | Interviewed regarding Resident #230's behavior and monitoring. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding pain medication administration for Resident #217. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding pain medication administration and Resident #230's wanderguard. | |
| Registered Nurse (RN) #1 | Interviewed regarding pain assessment and medication administration. | |
| Dietary Aide | Interviewed regarding expired food items in dry storage. | |
| Dietary Supervisor (DS) #1 | Interviewed regarding food storage and expiration checks. | |
| Dietary Supervisor (DS) #2 | Interviewed regarding food storage rounds and expired items. | |
| Food Service Director (FSD) | Interviewed regarding food storage oversight and expired items. | |
| Physician Assistant (PA) | Interviewed regarding Resident #45's mental health diagnoses. | |
| Medical Doctor (MD) | Interviewed regarding Resident #45's diagnoses and pain management. | |
| Psychologist | Interviewed regarding Resident #45's mental health status. |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 18
Date: Apr 12, 2023
Visit Reason
Inspection found multiple Level 1 and Level 2 deficiencies related to quality of care and life safety code issues, all corrected by June 2023.
Findings
Inspection found multiple Level 1 and Level 2 deficiencies related to quality of care and life safety code issues, all corrected by June 2023.
Citations (18)
Accuracy of assessments
Care plan timing and revision
Food procurement/store/prepare/serve-sanitary
Free from abuse and neglect
Pain management
Reporting of alleged violations
Alcohol based hand rub dispenser
Corridor - doors
Corridors - construction of walls
Electrical systems - essential electric system
Means of egress - general
Physical environment
Portable fire extinguishers
Soiled linen and trash containers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke compartment
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: May 12, 2022
Visit Reason
Inspection identified a Level 2 deficiency related to reporting of alleged violations, corrected by June 2022.
Findings
Inspection identified a Level 2 deficiency related to reporting of alleged violations, corrected by June 2022.
Citations (1)
Reporting of alleged violations
Inspection Report
Annual Inspection
Citations: 1
Date: Mar 6, 2020
Visit Reason
The inspection was conducted as a Recertification survey to assess the facility's compliance with infection prevention and control practices.
Findings
The facility failed to ensure proper infection control practices, specifically a Certified Nursing Assistant (CNA) was observed not performing hand hygiene after contact with a trash bin and after exiting the soiled utility room before interacting with residents. Interviews with staff confirmed expectations and training on hand hygiene.
Citations (1)
Failure to provide and implement an infection prevention and control program, specifically inadequate hand hygiene by a Certified Nursing Assistant.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | CNA | Observed failing to perform hand hygiene after contact with trash bin and soiled utility room. |
| Registered Nurse | RN | Interviewed regarding hand hygiene expectations for staff. |
| Assistant Director of Nursing Services | ADNS / Facility Infection Control Representative | Interviewed regarding hand hygiene policies and education. |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 0
Visit Reason
Six inspections during the reporting period resulted in no citations.
Findings
Six inspections during the reporting period resulted in no citations.
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