4 Reports
Inspection Report — Dec 19, 2025
Complaint Investigation State
Date: Dec 19, 2025
Visit Reason
State-compiled facility profile showing 16 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 51 complaints about this facility; 16 led to on-site inspections. Four citations resulted from those complaints.
Findings
Across 16 inspections, 9 had no citations while 7 resulted in 32 citations mostly related to standard health and life safety code issues. The facility had 51 complaints with 16 on-site inspections and no formal enforcement actions.
Citations (19)
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices found deficient with pattern scope.
Standard Health Citation — quality of care: Infection Prevention & Control deficiencies noted with isolated scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals found deficient with isolated scope.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights deficiencies with isolated scope.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors found deficient with isolated scope.
Standard Health Citation — quality of care: Right To Be Free From Chemical Restraints deficiencies with pattern scope.
Standard Health Citation — quality of care: Services Provided Meet Professional Standards found deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage found deficient with isolated scope.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies with pattern scope.
Standard Health Citation — quality of care: Reporting - National Health Safety Network deficiencies noted as widespread and not yet corrected.
Standard Health Citation — quality of care: Develop/implement Abuse/neglect Policies found deficient with pattern scope.
Standard Health Citation — quality of care: Essential Equipment, Safe Operating Condition deficiencies with isolated scope.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility found deficient with isolated scope.
Standard Health Citation — quality of care: Infection Prevention & Control deficiencies with pattern scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals found deficient with isolated scope.
Standard Health Citation — quality of care: Tube Feeding Mgmt/restore Eating Skills deficiencies with isolated scope.
Life Safety Code Citation — NFPA requirements: Aisle, Corridor, Or Ramp Width deficiencies with pattern scope.
Life Safety Code Citation — NFPA requirements: Corridor - Doors found deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenance deficiencies with pattern scope.
Report Facts
Inspections on page: 16
Total violations/deficiencies cited: 32
Inspections with violations: 7
Inspections without violations: 9
Total complaints: 51
On-site complaint inspections: 16
Citations from complaints: 4
Total fines: 0
Enforcement actions: 0
Inspection Report — Dec 26, 2023
Annual Inspection CMS
Date: Dec 26, 2023
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home operations, including employee screening, resident care, medication management, infection control, and equipment maintenance.
Findings
The survey identified multiple deficiencies including failure to document nurse aide registry abuse screenings prior to employee hire, inadequate care for a resident with limited range of motion, incomplete documentation of tube feeding intake, improper medication storage with expired and unlabeled medications, lack of ongoing infection surveillance and antibiotic stewardship, unqualified infection preventionist, and failure to maintain proper sanitization temperature in the kitchen dish machine.
Citations (7)
Failure to implement written policies and procedures to prevent abuse, neglect, and theft related to screening prospective employees; nurse aide registry abuse screenings were not documented prior to hire for four employees.
Failure to provide appropriate care to maintain or improve range of motion for a resident with contractures; resident was not provided hand devices per plan and no documented evidence of range of motion performed.
Failure to provide appropriate care for a resident with a feeding tube; no documented evidence that resident received correct tube feeding and water intakes as ordered.
Failure to ensure all drugs and biologicals were properly stored; expired medications and loose unlabeled pills found in medication carts, and medication drawer contained debris.
Failure to maintain an infection prevention and control program; no evidence of ongoing infection surveillance or antibiotic stewardship since June 2023.
Designated Infection Preventionist had not completed specialized infection prevention and control training.
Failure to keep essential equipment working safely; high-temperature mechanical dish machine did not reach required final rinse temperature to properly sanitize dishes.
Report Facts
Shifts with no documented tube feeding intake: 42
Shifts with no documented tube feeding intake: 32
Tube feeding volume: 960
Water flush volume: 200
Water flush volume: 30
Water flush volume: 10
Medication expiration dates: 2
Dish machine rinse temperatures: 140
Boiler supply temperature range: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Dining Services Associate | Hired 10/2/23; nurse aide registry screen dated 10/19/23, after hire date |
| Employee #3 | Member Care Assistant | Hired 11/6/23; nurse aide registry screen dated 12/20/23, after hire date |
| Employee #4 | Laundry Assistant | Hired 12/4/23; nurse aide registry screen dated 12/20/23, after hire date |
| Employee #5 | Unit Secretary | Hired 11/20/23; nurse aide registry screen dated 12/20/23, after hire date |
| Registered Nurse #2 | Nurse Manager | Stated CNAs expected to follow resident's Plan of Care for range of motion |
| Certified Nursing Assistant #2 | Stated Resident #53 had no need for range of motion and referred to Plan of Care | |
| Rehabilitation Director | Stated Resident #53 was totally dependent and needed hand devices and range of motion | |
| Licensed Practical Nurse #3 | Clinical Coordinator | Stated tube feeding documentation was nurse's responsibility and incomplete records were an issue |
| Licensed Practical Nurse #2 | Unable to identify loose pills and debris in medication cart | |
| Registered Nurse #1 | Nurse Manager | Stated nurses responsible for checking medication carts for cleanliness and expired meds |
| Licensed Practical Nurse #1 | Checked medication expiration dates at administration; night shift nurse responsible for cart checks | |
| Assistant Director of Nursing | Infection Preventionist | Designated Infection Preventionist; had not completed specialized infection control training |
| Director of Health Services | Director of Nursing | Stated expectations for Infection Preventionist training and infection control program oversight |
| Dining Services Director | Noted dish machine rinse temperature issues and contacted vendor | |
| Director of Facilities | Reported vendor found no machine issues; boiler temperature fluctuations noted |
Inspection Report — Mar 2, 2022
Complaint Investigation CMS
Date: Mar 2, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and complaint investigation (#NY00270684) to assess compliance with regulations regarding resident transfer/discharge notifications, readmission policies, care planning, and environmental safety.
Complaint Details
The complaint investigation (#NY00270684) revealed issues with transfer/discharge notifications for Residents #146 and #346, failure to permit Resident #346 to return after hospitalization, and deficiencies in care planning and environmental safety.
Findings
The facility failed to provide timely and complete written notifications of transfer or discharge to residents or their representatives for two residents, did not permit a resident to return after hospitalization as required, failed to develop comprehensive care plans for two residents addressing key medical and psychological needs, and did not ensure the environment was free from accident hazards, including unsafe hot liquid temperatures and unprotected heating surfaces.
Citations (4)
Failure to provide timely notification to residents or representatives before transfer or discharge, including appeal rights.
Failure to permit a resident to return to the nursing home after hospitalization or therapeutic leave exceeding bed-hold policy.
Failure to develop and implement a complete care plan that meets all the resident's needs with measurable actions.
Failure to ensure the nursing home area is free from accident hazards, including hot liquids accessible to residents and unprotected heating surfaces.
Report Facts
Residents reviewed for care planning: 26
Residents affected by care planning deficiency: 2
Residents affected by transfer/discharge notification deficiency: 2
Residents affected by readmission deficiency: 1
Residents affected by environmental hazard deficiency: 4
Coffee machine hot water temperatures: 183
Coffee machine hot water temperatures: 169
Coffee machine hot water temperatures: 185
Coffee machine hot water temperatures: 167
Gas fireplace glass panel temperature: 283
Gas fireplace glass panel temperature: 276
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work | Director of Social Work (DSW) | Provided statements regarding transfer/discharge notification policies and specific resident cases. |
| Admissions Coordinator | Admissions Coordinator | Provided information about transfer/discharge notices and bed hold policies. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Described care procedures for suprapubic catheter and observations of resident care. |
| Registered Nurse Manager | Registered Nurse Manager (RNM) | Responsible for developing care plans and provided statements on care plan deficiencies. |
| Staff Educator | Staff Educator and Acting Director of Nursing (ADON) | Discussed expectations for care plan development and revisions. |
| Dining Services Representative | Dining Services Representative | Provided information about coffee machine usage and resident access. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) #1 | Commented on resident wandering and coffee machine usage. |
| Registered Nurse Manager #1 | Registered Nurse Manager (RNM) #1 | Discussed resident wandering and coffee machine control. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) #2 | Stated coffee machines are locked except during meal service. |
| Registered Nurse | Registered Nurse (RN) | Commented on resident wandering and coffee machine usage. |
| Registered Nurse Manager #2 | Registered Nurse Manager (RNM) #2 | Stated no wandering concerns on unit and coffee machine control. |
| Director of Dining Services | Director of Dining Services (DDS) | Discussed coffee machine usage and temperature logging. |
| Maintenance Staff Member | Maintenance Staff | Explained operation of gas fireplace by lobby receptionist. |
| Director of Building Services | Director of Building Services | Stated gas fireplace was used as secondary heat source. |
Inspection Report — Sep 17, 2019
Annual Inspection CMS
Date: Sep 17, 2019
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in developing complete, person-centered care plans for residents, maintaining appropriate range of motion devices, and implementing proper infection prevention and control practices. Deficiencies involved failure to include antidepressant use and non-healing wounds in care plans, lack of palm protectors for a resident with severe hand contracture, and improper hand hygiene during wound care.
Citations (3)
Failure to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and interventions for antidepressant use and non-healing wounds.
Failure to provide appropriate care to maintain or improve range of motion, specifically not providing a palm protector for a resident with severe hand contracture.
Failure to provide and implement an infection prevention and control program, including improper hand hygiene by staff during wound care.
Report Facts
Residents reviewed for unnecessary medications: 7
Residents reviewed for skin conditions: 8
Residents reviewed for positioning: 5
Wound size: 3
Wound size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager #1 | Registered Nurse Manager | Responsible for developing care plans; acknowledged failure to develop care plan for antidepressant use |
| RN Manager #2 | Registered Nurse Manager | Stated non-healing wound should be addressed in care plan |
| Director of Nursing | Director of Nursing | Stated non-healing wound should be addressed in care plan |
| CNA | Certified Nursing Assistant | Reported missing splints and difficulty with resident's hand care |
| Occupational Therapist | Occupational Therapist | Completed resident evaluation and expected use of palm protector |
| Director of Therapy | Director of Therapy | Expected staff to follow care card instructions and notify therapy of missing equipment |
| RN Assistant Manager | Registered Nurse Assistant Manager | Explained therapy orders and documentation process for splints |
| LPN | Licensed Practical Nurse | Unaware of resident's splints or palm protectors |
| LPN | Licensed Practical Nurse | Observed not washing hands or using sanitizer during wound care |
| Infection Control Nurse | Infection Control Nurse | Explained hand hygiene expectations after wound dressing changes |
| RN Manager | Registered Nurse Manager | Stated expectations for glove changes and hand hygiene during wound care |
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