Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 23, 2025
Visit Reason
The abbreviated survey was conducted to evaluate compliance with care planning and treatment protocols for residents, specifically focusing on the adequacy of person-centered care plans and adherence to physician and specialist orders.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, lacking measurable objectives and timely interventions. Additionally, the facility did not promptly act on oncologist recommendations for Resident #1, resulting in delayed medication orders and communication failures.
Deficiencies (2)
F 0656: The facility did not develop and implement a comprehensive person-centered care plan with measurable objectives and time frames for Resident #1, who required interventions for constipation prevention.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences by not timely implementing oncologist recommendations for Resident #1, including delayed medication administration and inadequate communication.
Report Facts
Residents sampled for care plan review: 6
Residents affected: 1
Medication dosages: 17
Medication dosages: 8.6
Medication dosages: 10
Medication dosages: 5
Medication dosages: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Named in care plan deficiency and communication failures regarding Resident #1 |
| Director of Nursing | Director of Nursing | Named in responsibility for care plan completion for Resident #1 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in failure to notify Medical Doctor of oncologist recommendations |
| Medical Doctor #1 | Medical Doctor | Named in delayed receipt and review of oncologist recommendations for Resident #1 |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The visit was an abbreviated survey triggered by a complaint (Complaint 2588679) to investigate alleged violations involving abuse, neglect, and injuries of unknown source at the facility.
Complaint Details
The complaint investigation (Complaint 2588679) was substantiated. The facility failed to report an unwitnessed fall and subsequent injury of Resident #2 within the required timeframes to the New York State Department of Health.
Findings
The facility failed to timely report an unwitnessed fall and subsequent acute humeral neck fracture of Resident #2 to the New York State Department of Health as required by policy and regulation. The fall occurred on 07/16/2025, but the fracture was identified two days later and was not reported because staff correlated the injury with the fall.
Deficiencies (1)
F 0609: The facility did not timely report suspected abuse, neglect, or theft and failed to report the results of the investigation to proper authorities. Resident #2's fall and resulting acute fracture were not reported to the New York State Department of Health within required timeframes.
Report Facts
Residents reviewed for accidents: 6
Resident #2 fall date: Jul 16, 2025
Resident #2 fracture identification delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and stated responsibility for reporting allegations to the New York State Department of Health | |
| Administrator | Interviewed and stated responsibility for reporting incidents to the New York State Department of Health |
Inspection Report
Annual Inspection
Census: 611
Deficiencies: 9
Date: Apr 2, 2024
Visit Reason
The inspection was a Recertification survey conducted from 3/26/2024 to 4/2/2024 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to post survey results prominently, inadequate notice of Medicare non-coverage, insufficient assistance with activities of daily living, improper use of psychotropic medications, inadequate staffing levels, unsafe food storage practices, and lapses in infection control procedures.
Deficiencies (9)
F 0577: The facility did not ensure notice of survey results availability was posted in prominent areas accessible to the public.
F 0582: The facility failed to provide timely Notice of Medicare Non-Coverage to Medicare beneficiaries' representatives upon discharge from skilled services.
F 0677: Residents unable to perform activities of daily living did not consistently receive necessary assistance with grooming, showering, and transfers.
F 0688: Resident with limited range of motion was not provided appropriate treatment and services to prevent further decline, including failure to apply ordered carrot splint.
F 0689: The facility did not ensure a resident remained free from accident hazards, resulting in bilateral thigh burns from unsupervised microwave use.
F 0725: The facility did not provide sufficient nursing staff to meet residents' needs, resulting in short staffing on multiple shifts and delayed care.
F 0758: Psychotropic medications were administered without documented necessity, nonpharmacological interventions, or medical assessments for two residents.
F 0812: Food was not stored in accordance with professional standards; expired, undated, and unlabeled food was found in kitchen and unit pantries; dietary staff did not wear required head coverings.
F 0880: Infection prevention and control program was deficient; blood pressure cuff was not sanitized between residents and hand hygiene was not performed during medication administration; infection control policies were not reviewed annually.
Report Facts
Census: 611
Staffing shortfalls: 11
Staffing shortfalls: 19
Staffing shortfalls: 27
Residents reviewed: 38
Residents affected: 10
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #13 | Named in relation to failure to provide scheduled showers to Resident #175. | |
| Registered Nurse #4 | Interviewed regarding shower assistance and staffing shortages. | |
| Certified Nursing Assistant #18 | Interviewed regarding Resident #210 not being transferred out of bed. | |
| Director of Nursing | Interviewed regarding staffing, care provision, and infection control policies. | |
| Psychiatrist | Interviewed regarding psychotropic medication use for Residents #190 and #141. | |
| Medical Doctor #1 | Interviewed regarding psychotropic medication use for Resident #190 and #141. | |
| Food Service Director #1 | Interviewed regarding expired food and food labeling practices. | |
| Licensed Practical Nurse #4 | Observed and interviewed regarding failure to sanitize blood pressure cuff and hand hygiene. |
Inspection Report
Annual Inspection
Census: 611
Deficiencies: 3
Date: Apr 2, 2024
Visit Reason
The inspection was conducted as a Recertification and Complaint survey to assess compliance with regulatory requirements related to resident care, staffing, and safety.
Complaint Details
The survey included complaint investigations (NY00315735, NY00330475, NY00327086) related to inadequate assistance with activities of daily living, insufficient staffing, and resident safety hazards. Complaints were substantiated as deficiencies were found.
Findings
The facility was found deficient in providing adequate assistance for activities of daily living, ensuring resident safety from accident hazards, and maintaining sufficient nursing staff to meet resident needs. Staffing shortages led to residents not receiving scheduled showers and assistance with transfers, and a resident sustained burns due to lack of supervision.
Deficiencies (3)
F 0677: The facility failed to provide care and assistance for activities of daily living to residents unable to perform them, evidenced by residents not receiving scheduled showers or assistance to transfer out of bed.
F 0689: The facility did not ensure a resident remained free from accident hazards, resulting in a resident sustaining bilateral upper thigh burns from unsupervised use of a microwave.
F 0725: The facility failed to provide sufficient nursing staff daily to meet resident needs, causing delays in care, missed showers, and inadequate response to call bells.
Report Facts
Facility census: 611
Certified Nursing Assistants needed daily: 68
Certified Nursing Assistants needed daily: 66
Certified Nursing Assistants needed daily: 44
Staffing shortfalls: 11
Staffing shortfalls: 11.5
Staffing shortfalls: 7
Staffing shortfalls: 14
Staffing shortfalls: 19
Staffing shortfalls: 9
Staffing shortfalls: 27
Staffing shortfalls: 7
Residents on unit: 45
Residents attending Resident Council meeting: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #13 | Interviewed about staffing shortages and shower assistance | |
| Registered Nurse #4 | Interviewed about shower schedules and staffing challenges | |
| Certified Nursing Assistant #18 | Interviewed about resident transfers and staffing levels | |
| Certified Nursing Assistant #19 | Interviewed about resident transfers and staffing shortages | |
| Registered Nurse #11 | Interviewed about staffing levels and call outs | |
| Registered Nurse #12 | Interviewed about resident care and staffing challenges | |
| Licensed Practical Nurse #5 | Interviewed about staffing shortages and care responsibilities | |
| Certified Nursing Assistant #8 | Interviewed about staffing shortages and workload | |
| Certified Nursing Assistant #9 | Interviewed about staffing shortages and workload | |
| Certified Nursing Assistant #10 | Interviewed about staffing and prioritization of care | |
| Certified Nursing Assistant #4 | Interviewed about staffing reductions and care challenges | |
| Staffing Coordinator | Interviewed about staffing plans and challenges | |
| Director of Nursing | Interviewed about staffing initiatives and resident care oversight | |
| Administrator | Interviewed about staffing efforts and recruitment |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 28, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate the facility's compliance with timely reporting of suspected abuse allegations to the New York State Department of Health (NYSDOH).
Findings
The facility failed to report two alleged abuse incidents involving residents within the required two-hour timeframe. The incidents involved physical and sexual abuse allegations that were reported late to NYSDOH.
Deficiencies (1)
F 0609: The facility did not ensure that alleged abuse violations were reported to NYSDOH within two hours as required. Two residents' abuse allegations were reported late, violating the facility's abuse reporting policy.
Report Facts
Residents sampled for abuse: 8
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Received abuse report from Resident #2. | |
| Registered Nurse Supervisor (RNS) #1 | Received abuse report from Resident #3 and documented nursing note. | |
| Director of Nursing (DON) | Interviewed regarding late reporting of abuse allegations. | |
| Administrator | Interviewed regarding oversight of abuse reporting. |
Inspection Report
Annual Inspection
Capacity: 705
Deficiencies: 9
Date: Dec 16, 2022
Visit Reason
The inspection was a recertification survey conducted from 12/11/2022 to 12/16/2022 to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including inadequate surety bond coverage for residents' personal funds, failure to maintain a clean and homelike environment, late and inaccurate Minimum Data Set (MDS) submissions, incomplete and outdated comprehensive care plans (CCPs), insufficient provision of assistive devices for residents with limited mobility, inadequate staffing levels to meet resident needs, and failure to provide appropriate dementia care interventions.
Deficiencies (9)
F 0570: The facility did not ensure a surety bond was purchased to cover the total value of residents' personal funds, with 367 residents' funds exceeding the bond amount of $100,000.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment, evidenced by urine odors and stains in resident bathrooms and dirty medication carts, linen carts, wheelchairs, and Hoyer lifts on multiple units.
F 0640: The facility did not ensure MDS assessments were electronically transmitted to CMS within 14 days of completion for 22 of 26 residents reviewed.
F 0641: The facility did not ensure MDS assessments accurately reflected a resident's status, as Resident #600's MDS did not document wanderguard use.
F 0656: The facility did not develop and implement person-centered comprehensive care plans for 6 residents, including care plans related to contractures, antipsychotic medication, vision impairment, wandering, and anticoagulant therapy.
F 0657: The facility did not review and revise comprehensive care plans after each assessment or as needed for 2 residents, including seizure disorder and COVID-19 related care plans.
F 0688: The facility did not provide appropriate equipment to maintain or improve range of motion for 2 residents with limited mobility, as ordered devices were not applied consistently.
F 0725: The facility did not ensure sufficient nursing staff to meet resident needs, with documented shortages of CNAs on multiple units and shifts, including inadequate staff for residents requiring 1:1 supervision and behavioral support.
F 0744: The facility did not provide appropriate treatment and services to a resident with dementia, failing to develop and implement a person-centered care plan addressing dementia-related behaviors and refusal of care.
Report Facts
Residents with personal funds exceeding surety bond: 367
Total residents with personal funds: 632
Total personal funds balance: 935493.32
Residents reviewed for MDS transmission: 26
Residents with late MDS transmission: 22
Residents reviewed for comprehensive care plans: 38
Residents with incomplete CCPs: 6
Residents with unreviewed CCPs: 2
Facility total licensed capacity: 705
Residents on Unit H-7: 34
Residents on Unit SNF-4: 44
Residents on Unit NF-6: 41
Agency staff expenditure: 12000000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Interviewed regarding Resident #376 behavior and staffing on Unit SNF-4. |
| CNA #8 | Certified Nursing Assistant | Interviewed about Resident #376 supervision needs. |
| Director of Nursing | Director of Nursing | Interviewed about staffing, care plans, and facility operations. |
| MDS Director | MDS Director | Interviewed about late MDS submissions and accuracy. |
| Administrator | Administrator | Interviewed about facility issues including bathroom cleanliness and staffing. |
| President of Human Resources | President of Human Resources | Interviewed about staffing agencies and recruitment efforts. |
| RN #8 | Registered Nurse | Interviewed about care for Resident #298 and care plan updates. |
| CNA #7 | Certified Nursing Assistant | Interviewed about care refusals and behavior of Resident #298. |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Nov 19, 2020
Visit Reason
The survey was a re-certification inspection to assess compliance with regulatory requirements related to resident dignity, medication management, and infection control.
Findings
The facility was found deficient in ensuring residents were treated with dignity, specifically failing to have staff knock before entering a legally blind resident's room. The facility also failed to notify the physician of elevated blood glucose levels in a resident on sliding scale insulin and did not ensure proper infection control practices, as staff entered a contact isolation room without donning PPE.
Deficiencies (3)
F 0550: The facility failed to ensure staff knocked before entering a legally blind resident's room, violating the resident's right to dignity and respect.
F 0757: The facility did not notify the physician when a resident on sliding scale insulin had blood glucose levels above 300 mg/dL, failing to ensure adequate monitoring of the drug regimen.
F 0880: The facility failed to ensure staff donned Personal Protective Equipment when entering a resident's room on contact isolation for MRSA, risking transmission of infection.
Report Facts
Residents reviewed for dignity: 37
Residents reviewed for unnecessary medications: 5
Residents investigated for UTI: 37
Elevated blood glucose events above 300 mg/dL: 4
Dates of survey completion: Nov 19, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed entering resident room without knocking; interviewed about protocol |
| RN Manager #3 | Registered Nurse Manager | Interviewed regarding staff expectations for knocking and monitoring |
| Director of Nursing | Director of Nursing | Interviewed about staff training on customer service and infection control |
| RN #5 | Registered Nurse | Interviewed about insulin administration and physician notification |
| LPN #1 | Licensed Practical Nurse | Interviewed about blood sugar testing and insulin administration |
| LPN #2 | Licensed Practical Nurse | Interviewed about blood sugar testing and physician notification |
| RN #6 | Registered Nurse | Covering Head Nurse interviewed about notification procedures |
| RN #7 | Nurse Manager | Interviewed about physician notification and nurse in-service |
| RN #1 | Registered Nurse | Observed entering isolation room without PPE and interviewed |
| RN Manager #2 | RN Manager | Interviewed about contact isolation procedures and staff briefing |
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