Inspection Report Summary
The most recent inspection on May 16, 2025, identified a deficiency related to expired medications stored in the Unit C medication cabinet. Earlier inspections showed a mix of deficiencies involving medication management, quality of care issues such as resident accommodations and reporting, and life safety code violations including fire safety and electrical systems. Complaint investigations included a substantiated case in February 2022 concerning timely resident assessments and medication management, while most other complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with medication storage and quality of care, with some life safety issues addressed over time but no clear pattern of consistent improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Renewal
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The inspection was conducted as a Recertification Survey from 05/12/2025 to 05/16/2025 to assess compliance with medication storage and labeling regulations.
Findings
The facility failed to ensure that all drugs and biologicals were stored according to accepted professional principles, specifically noting expired medications stored in the Unit C medication cabinet.
Deficiencies (1)
Expired medications were stored in Unit C medication cabinet, including Zinc Sulfate, Iron tablets, and Vitamin C with expiration dates past the current date.
Report Facts
Number of bottles of Zinc Sulfate: 2
Number of tablets in Iron bottle: 200
Volume of Vitamin C bottle: 473
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Interviewed and stated it is the nurse's responsibility to check expiration dates but did not check on the day of observation | |
| Assistant Director of Nursing | Interviewed and stated responsibility of night shift Licensed Practical Nurse and Central Supply Room person to check and replace expired medications |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: May 16, 2025
Visit Reason
Inspection identified 1 standard health citation and 14 life safety code citations, mostly level 2 severity, with some corrected during follow-up.
Findings
Inspection identified 1 standard health citation and 14 life safety code citations, mostly level 2 severity, with some corrected during follow-up.
Deficiencies (15)
Label/store drugs and biologicals — quality of care
Egress doors — life safety code
Electrical equipment - testing and maintenanc — life safety code
Electrical systems - essential electric syste — life safety code
Electrical systems - other — life safety code
Electrical systems - receptacles — life safety code
Exit signage — life safety code
Fire alarm system - testing and maintenance — life safety code
Hazardous areas - enclosure — life safety code
Hvac — life safety code
Means of egress - general — life safety code
Physical environment — life safety code
Sprinkler system - installation — life safety code
Sprinkler system - maintenance and testing — life safety code
Vertical openings - enclosure — life safety code
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 23, 2024
Visit Reason
The inspection was conducted as a recertification survey from 01/16/2024 to 01/23/2024 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 accommodate a resident's right to use their bathroom due to a locked door and non-functional toilet, failure to maintain a safe and clean environment with dirty equipment and stained furnishings, failure to timely report a resident's fall resulting in spinal fracture to the state, failure to meet professional standards in managing a diabetic resident's high blood sugar readings, and failure of the physician to adequately review and address the resident's care related to diabetes management.
Deficiencies (5)
Resident #15 was prevented from using their room's bathroom due to the door being locked and the toilet being clogged and non-functional.
Resident rooms and common areas had loose wires, dusty and dirty equipment, stained wheelchairs, and dirty window shades.
Resident #30's fall resulting in spinal fracture was not reported to the New York State Department of Health within the required timeframe.
Nurse did not inform Physician #1 of Resident #16's high fingerstick blood sugar readings as ordered.
Physician #1 did not address Resident #16's consistently high blood glucose levels during care reviews.
Report Facts
Residents sampled: 21
Units observed: 3
Residents sampled: 18
Fingerstick blood sugar readings above 350: 5
Hemoglobin A1c: 12.8
Hemoglobin A1c: 12.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Interviewed regarding Resident #15's bathroom use and maintenance reporting | |
| Licensed Practical Nurse #1 | Interviewed regarding awareness of Resident #15's bathroom access and toilet functionality | |
| Director of Environmental Services | Interviewed regarding maintenance and cleaning responsibilities and awareness of toilet clogging behavior | |
| Director of Social Services | Interviewed regarding awareness of Resident #15's bathroom access | |
| Director of Nursing | Interviewed regarding staff rounds and bathroom access for Resident #15 | |
| Licensed Practical Nurse #2 | Interviewed regarding management of Resident #16's high blood sugar readings | |
| Physician #1 | Interviewed regarding management of Resident #16's diabetes and blood glucose levels | |
| Acting Director of Nursing | Interviewed regarding failure to report Resident #30's fall and fracture |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jan 23, 2024
Visit Reason
Inspection identified 6 standard health citations and 1 life safety code citation, mostly level 2 severity, all corrected by March 18, 2024.
Findings
Inspection identified 6 standard health citations and 1 life safety code citation, mostly level 2 severity, all corrected by March 18, 2024.
Deficiencies (7)
Physician visits - review care/notes/order — quality of care
Reasonable accommodations needs/preferences — quality of care
Reporting of alleged violations — quality of care
Requirements before submitting a request for — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Services provided meet professional standards — quality of care
Sprinkler system - installation — life safety code
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 25, 2022
Visit Reason
Covid-19 Survey identified 1 standard health citation related to reporting to the national health safety network, level 2 severity, widespread scope.
Findings
Covid-19 Survey identified 1 standard health citation related to reporting to the national health safety network, level 2 severity, widespread scope.
Deficiencies (1)
Reporting - national health safety network — quality of care
Inspection Report
Recertification/complaint Investigation
Deficiencies: 4
Date: Feb 16, 2022
Visit Reason
The survey was conducted as a Recertification and Complaint Survey to assess compliance with regulatory requirements, including review of Minimum Data Set (MDS) assessments, medication management, and resident care.
Complaint Details
The survey included complaint investigation elements related to failure to complete timely Significant Change MDS assessments and medication management issues. The complaint was substantiated with findings of deficiencies.
Findings
The facility failed to complete a Significant Change MDS assessment within 14 days for a resident with decline in multiple ADLs, delayed submission of a resident's Discharge MDS assessment beyond the required timeframe, administered unnecessary drugs without appropriate response to elevated drug levels, and improperly stored refrigerated medications.
Deficiencies (4)
Failure to complete a Significant Change MDS assessment within 14 days after a resident's decline in more than two ADLs.
Delayed submission and transmission of a resident's Discharge MDS assessment beyond 14 calendar days after completion.
Failure to ensure resident's drug regimen was free from unnecessary drugs despite elevated Dilantin blood levels and lack of timely physician response.
Failure to store refrigerated medications properly; unopened eye drop requiring refrigeration was found unrefrigerated in medication cart drawer.
Report Facts
Residents reviewed for ADL decline: 23
Residents reviewed for Resident Assessment: 23
Residents reviewed for medication regimen: 16
Dilantin blood level: 37.8
Dilantin blood level: 40
Medication dispensing date: Jan 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor | LPN Supervisor | Interviewed regarding resident feeding and transfer status changes |
| Rehab Director | Rehab Director | Interviewed regarding resident assessments and MDS Coordinator responsibilities |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment completion and submission delays |
| Director of Nursing | Director of Nursing | Interviewed regarding requirements for Significant Change MDS assessments |
| Administrator | Administrator | Interviewed regarding MDS Coordinator responsibilities and awareness of deficiencies |
| Primary Medical Doctor | Primary Medical Doctor | Interviewed regarding elevated Dilantin blood levels and treatment plan |
| Registered Nursing Supervisor | Registered Nursing Supervisor | Interviewed regarding lab result handling and communication with physician |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding communication of lab results to physician |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage and nurse responsibilities |
| Licensed Practical Nurse | LPN | Interviewed regarding medication distribution and storage |
| Registered Nurse | RN | Interviewed regarding medication receipt and storage practices |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Feb 16, 2022
Visit Reason
Inspection identified 4 standard health citations and 2 life safety code citations, mostly level 2 severity, all corrected by April 2022.
Findings
Inspection identified 4 standard health citations and 2 life safety code citations, mostly level 2 severity, all corrected by April 2022.
Deficiencies (6)
Comprehensive assessment after signifcant chg — quality of care
Drug regimen is free from unnecessary drugs — quality of care
Encoding/transmitting resident assessments — quality of care
Label/store drugs and biologicals — quality of care
Means of egress - general — life safety code
Standards of construction for new existing nh — life safety code
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