4 Reports
Inspection Report — Dec 8, 2025
Original Licensing State
Date: Dec 8, 2025
Visit Reason
State-compiled facility profile showing 12 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
The state logged 178 complaints about this facility; 8 led to on-site inspections. No citations resulted from those complaints during the reporting period.
Findings
Across 12 inspections, 7 resulted in citations totaling 41 deficiencies primarily related to standard health and life safety code issues. The facility had 2 enforcement actions with fines totaling $36,000 and multiple citations were corrected by early 2026.
Citations (28)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient.
Standard Health Citation — quality of care: Infection Prevention & Control was deficient.
Standard Health Citation — quality of care: Resident Records - Identifiable Information was deficient.
Standard Health Citation — quality of care: Right To Be Free From Chemical Restraints was deficient.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment was deficient.
Standard Health Citation — quality of care: Safe/functional/sanitary/comfortable Environ was deficient.
Standard Health Citation — quality of care: Services Provided Meet Professional Standards was deficient.
Standard Health Citation — quality of care: Tube Feeding Mgmt/restore Eating Skills was deficient.
Life Safety Code Citation — NFPA requirements: Exit Signage was deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Physical Environment was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Standard Health Citation — quality of care: Choose/be Notified Of Room/roommate Change was deficient.
Standard Health Citation — quality of care: Criminal History Record Check Process was deficient.
Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary was deficient.
Standard Health Citation — quality of care: Infection Prevention & Control was deficient.
Standard Health Citation — quality of care: Menus Meet Resident Nds/prep In Adv/followed was deficient.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was deficient.
Standard Health Citation — quality of care: Required Postings was deficient.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notif was deficient.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was deficient and not yet corrected.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was deficient and not yet corrected.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was deficient and not yet corrected.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was deficient and not yet corrected.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was deficient and not yet corrected.
Report Facts
Inspections on page: 12
Total violations/deficiencies cited: 41
Inspections with violations: 7
Inspections without violations: 5
Total complaints: 178
On-site complaint inspections: 8
Enforcement actions: 2
Total fines: 36000
Inspection Report — Nov 15, 2023
Annual Inspection CMS
Date: Nov 15, 2023
Visit Reason
The inspection was conducted as a Recertification survey from 11/08/2023 to 11/15/2023 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in several areas including failure to provide appropriate notice before room changes, lack of posting of State Agency complaint information, failure to timely report suspected abuse, failure to follow menus according to resident preferences, unsafe food storage practices, and inadequate infection control practices including improper hand hygiene and equipment sanitization.
Citations (6)
Failure to ensure a resident received appropriate notice before a room change, including opportunity to view the new room and meet roommates.
Failure to post pertinent State Agency information including the New York Department of Health Complaint Hotline on resident units.
Failure to timely report suspected abuse, neglect, or injuries of unknown origin to the New York State Department of Health within two hours.
Failure to ensure menus were followed according to resident food preferences and allergies.
Failure to ensure safe food storage and infection control; specifically, use of cottage cheese with broken seal and mold present.
Failure to maintain infection control practices including inadequate hand hygiene and failure to sanitize shared equipment between residents, and improper hand hygiene during wound care treatment.
Report Facts
Residents reviewed: 38
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 1
Containers of cottage cheese: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Conducted investigation of Resident #54 injury and reported findings |
| Social Work Assistant | Provided notification letter for room change and interviewed about notification timing | |
| Director of Social Work | Director of Social Work | Interviewed regarding room change notification procedures |
| Facility Administrator | Facility Administrator | Interviewed about room change notification and resident viewing of new room |
| Food Service Director / Registered Dietitian | Food Service Director / Registered Dietitian | Interviewed about menu compliance and food preferences for Resident #18 |
| Dietary Aide #2 | Dietary Aide | Interviewed about tray preparation and meal ticket reading |
| Registered Nurse #3 | Registered Nurse | Observed using shared equipment without sanitizing and inconsistent hand hygiene |
| Wound Care Nurse (Registered Nurse #4) | Registered Nurse | Observed not performing proper hand hygiene during wound care treatment |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control rounds and staff compliance |
| Director of Nursing | Director of Nursing | Interviewed about infection control policies and staff education |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed about infection control rounds and wound care competencies |
Inspection Report — Oct 25, 2021
Annual Inspection CMS
Date: Oct 25, 2021
Visit Reason
The inspection was conducted as a Recertification and Abbreviated survey to assess compliance with regulatory requirements and investigate complaints and concerns related to resident care, safety, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including maintenance of a safe and homelike environment, appropriate care for residents with limited range of motion, medication security and administration, respiratory care without physician orders, infection prevention and control during a COVID-19 outbreak, call bell system functionality, and pest control. Several residents were exposed to accident hazards, medication errors occurred, and infection control protocols were not fully followed during the COVID-19 outbreak.
Citations (8)
Resident's chest of drawers was in disrepair with rot and holes, not providing a safe and comfortable environment.
Resident with hand contractures was not wearing ordered splint devices, risking further decrease in range of motion.
Controlled substances were left unlocked and unattended on medication cart, leading to resident ingestion of narcotics.
Residents received oxygen therapy without physician orders or comprehensive care plans.
Schedule II controlled substances were not securely locked, allowing unauthorized access.
Facility failed to maintain an infection prevention and control program to prevent COVID-19 transmission during an outbreak, including inadequate quarantine and visitation controls.
Resident call bell system was not functioning, leaving resident unable to summon assistance.
Facility did not maintain an effective pest control program; multiple flies observed in resident rooms and hallways.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 42
COVID-19 positive residents: 66
Visitors: 183
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Reported missing narcotics and investigated medication incident |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication security, oxygen therapy, infection control, and call bell system |
| Licensed Practical Nurse #3 | Licensed Practical Nurse Charge Nurse | Left medication cart unattended leading to narcotics missing |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about splint device not being applied to resident |
| Occupational Therapist #8 | Occupational Therapist | Provided in-service about splints to nursing staff |
| Director of Facility | Director of Facility | Interviewed about maintenance issues and pest control |
| Administrator | Administrator | Interviewed about infection control, visitation policies, and outbreak management |
| Medical Director | Medical Director | Interviewed about COVID-19 protocols and resident care |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported call bell malfunction and communication with maintenance |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported knowledge of call bell malfunction and maintenance notification |
| Licensed Practical Nurse #2 | Licensed Practical Nurse Charge Nurse | Interviewed about visitor protocols and infection control |
| Housekeeper | Housekeeper | Reported presence of flies and pest control efforts |
| Director of Recreation | Director of Recreation | Interviewed about visitation scheduling and compassionate care plans |
Inspection Report — Apr 5, 2019
Annual Inspection CMS
Date: Apr 5, 2019
Visit Reason
The inspection was conducted as part of a recertification survey to assess compliance with federal regulations for nursing homes, including resident care, assessment, infection control, and social services.
Findings
The facility was found deficient in multiple areas including improper resident transfers without adequate documentation or options for long-term care, untimely completion of Minimum Data Set (MDS) assessments, incomplete and non-measurable care plans, failure to follow physician orders, missed medical appointments due to staffing issues, and lapses in infection control protocols such as improper use of personal protective equipment and food handling.
Citations (6)
Failure to ensure residents were permitted to remain in the facility for long term care after completing short-term rehabilitation and inadequate documentation of transfer reasons.
Admission Minimum Data Set (MDS) assessments were not completed within 14 calendar days after admission for 2 residents.
Care plans were not comprehensive, lacked measurable objectives and time frames, and were not developed or implemented timely for 5 residents.
Failure to follow a physician's order to repeat a laboratory test for one resident.
Missed medical appointment for a resident due to non-availability of staff escort.
Infection control lapses including staff entering contact isolation rooms without proper PPE and handling food with bare hands.
Report Facts
Residents reviewed: 43
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse Discharge Planner | Interviewed regarding admission and discharge policies and family communication |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding facility policies, care plans, and infection control |
| DSW | Director of Social Work | Interviewed regarding resident insurance coverage and transfer decisions |
| RN #5 | Registered Nurse Manager | Interviewed regarding care plan development and infection control |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding infection control lapses |
| RN #1 | Registered Nurse | Interviewed regarding missed lab order |
| RN #7 | Charge Nurse | Interviewed regarding care plan completion |
| RN #5 | Registered Nurse | Interviewed regarding missed medical appointment complaint |
| LPN #6 | Licensed Practical Nurse, Staffing Coordinator | Interviewed regarding scheduling and missed escort for medical appointment |
| CNA #4 | Certified Nursing Assistant | Observed and interviewed regarding improper food handling |
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