Deficiencies per Year
80
60
40
20
0
Severe
High
Moderate
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Unclassified
Inspection Report
Relicensure
Deficiencies: 45
Jun 11, 2025
Visit Reason
State-compiled facility profile showing 33 inspections from August 1, 2021 through July 31, 2025 with deficiency history and enforcement actions.
Findings
Across 33 inspections, the facility had a total of 86 violations with multiple inspections resulting in no violations. Deficiencies covered a range of regulatory areas including operating certificates, resident services, medication management, environmental standards, and personnel. Enforcement actions include a stipulation and order issued on May 1, 2024.
Complaint Details
Multiple complaint surveys are included, some with violations and some with none; plans or notices of correction were approved or not required as noted per inspection.
Deficiencies (45)
| Description |
|---|
| 485.5 (g) — Operating certificates: No operator shall change or modify a facility, or the services originally approved and stipulated by the operating certificate, without the prior written approval of the department. |
| 487.7 (f) (8) — Resident services: If a resident refuses to take medications or appears unable to independently administer medications, the operator shall notify the prescribing physician and, if different, the primary physician. |
| 487.8 (e) (1) — Food service: The operator shall comply with regulations relating to food service for sanitation, safety and health, as set forth by the New York State Sanitary Code and other applicable codes. |
| 487.8 (e) (12-13) — Food service: Tableware appropriate for the meal being served shall be used; disposable plates and utensils shall not be regularly used for service. |
| 487.9 (a) (1) — Personnel: The operator shall provide staff sufficient in number and qualified by training and experience to render mandated services. |
| 487.9 (a) (6) — Personnel: The operator shall develop and maintain current written staffing schedules and retain past schedules for 12 months. |
| 487.11 (f) (8) — Environmental standards: Required smoke barriers, including smoke-stop doors, shall be smoketight, equipped with self-closing devices, maintained closed unless connected to smoke detection, and open in direction of exit. |
| 487.11 (f) (12) — Environmental standards: Each required exit door shall meet height, opening direction, panic hardware, self-closing device, and accessibility requirements. |
| 487.11 (f) (17) — Environmental standards: Fire extinguishers meeting NFPA standards shall be placed accessibly, wall-hung, properly charged and checked. |
| 487.11 (f) (19) — Environmental standards: Fire hazards including smoking outside designated areas, portable electric heaters, nonmetal containers for ashes, combustible material accumulation, improper storage of flammable liquids, cooking appliances in resident rooms, and overloaded circuits are prohibited. |
| 487.11 (i) (1) — Environmental standards: Operator shall provide furnishings and equipment that do not endanger resident health and support daily activities. |
| 487.11 (k) (1-3) — Environmental standards: Operator shall ensure continued maintenance of facility, grounds, equipment, and furnishings in clean, orderly condition and good repair. |
| 487.11 (k) (13) — Environmental standards: Sprinkler systems shall be maintained in good repair and working order. |
| 487.11 (k) (14) — Environmental standards: Smoke and fire protection equipment, including fire extinguishers, shall be maintained per manufacturer's specifications. |
| 487.11 (k) (15) — Environmental standards: Systems and equipment including smoke detection, fire alarm, sprinkler, extinguishers, heating, elevators, and water supply must be inspected or tested at least annually or as required. |
| 487.11 (k) (16) — Environmental standards: All inspection certificates required by authorities shall be available for review. |
| 487.12 (a-b) — Disaster and emergency planning: Operator shall have a written, approved plan detailing procedures for protection of residents and staff during emergencies, including evacuation, drills, relocation, coordination with community resources, and maintenance of service during personnel reductions. |
| 1001.7 (k) (5) — Admission and retention standards: Individualized Service Plan shall be reviewed and revised every six months or as ordered by physician to reflect changing care needs. |
| 1001.10 (i) (1) — Resident services: Identify and evaluate resident needs and facility capability prior to admission and at least annually. |
| 1001.10 (i) (5-8) — Resident services: Provide ongoing information and referral, coordinate with service providers, develop mechanisms to identify changes in resident behavior or appearance, and maintain complete personal records. |
| 1001.10 (l)(1) — Medication management: Medication acquisition, storage, disposal, and assistance with self-administration shall conform to standards dictated by facility certification and operative guidance. |
| 1001.10 (l) (4-7) — Medication management: PRN medication orders must be reviewed with physician; use limited for persons with dementia; assistance requires observation or consultation with licensed staff; records must include observed behavior or symptoms. |
| 487.7 (f) (11) (iii) — Resident services: Operator retaining controlled substance prescriptions must obtain a class 3a controlled substance license and comply with storage and recording standards. |
| 487.7 (d) (1) (i) — Resident services: Supervision services include maintaining knowledge of general whereabouts of each resident. |
| 487.7 (d) (11) — Resident services: Operator must prepare incident reports for various resident incidents including unknown whereabouts, assaults, suicide attempts, abuse complaints, deaths, behavior impairing safety, accidents requiring medical care, or suspected felony crimes. |
| 487.4 (a) — Admission standards: Operator shall admit and retain only individuals not requiring services beyond those permitted by law and regulation. |
| 487.4(f)-(g) — Admission standards: Determination of facility program support based on medical evaluation, resident interview, and mental health evaluation if indicated. |
| 487.7 (d) (6) (i) — Resident services: In emergencies, operator shall protect resident safety and comfort, secure emergency medical assistance, and arrange transfer if necessary. |
| 487.7 (f) (5) — Resident services: Operator shall establish system for staff to provide proper medication dosage and observe and record resident medication intake. |
| 487.7 (f) (11) (i-v) — Resident services: Medications must be kept in secure storage areas; drugs for external use stored separately; refrigerators for pharmaceuticals not used for food unless locked compartment provided. |
| 487.7 (f) (12) (iii) — Resident services: Recording for medications must include resident name, medication, assisting staff, date and time, and be done by observer. |
| 487.8 (c) — Food service: Information on resident dietary regimen and allergies must be available and used in meal planning and service. |
| 487.11 (i) (7) — Environmental standards: Each resident shall be supplied with two sheets, pillowcase, at least one blanket, bedspread, towels, washcloths, soap, and toilet tissue. |
| 487.7 (d) (10) (i-iii) — Resident services: Operator must report suspected felony crimes by or against residents to department, law enforcement, and Justice Center within specified timeframes. |
| 1001.11 (c) (2) (i-iv) — Personnel: Operator shall provide sufficient qualified staff including resident aides who receive initial and ongoing training, maintain training records, and undergo annual performance assessments. |
| 487.3 (g) (1-2) — General provisions: Operator may request waivers of nonstatutory requirements with written approval and documentation ensuring resident health and safety. |
| 494.4 (k) — Admission and retention standards: Operator must make persistent efforts to secure alternative placement for residents who cannot be retained, including application filing, follow-up, and notification to department. |
| 485.5 (f) — Operating certificates: No operator shall change or modify a facility or services without prior written approval of the department. |
| 487.11 (a) — Environmental standards: Operator shall maintain facility in good repair and sanitation conforming to applicable laws and ordinances. |
| 487.9 (a) (3) — Personnel: Operator shall conduct initial orientation and in-service training covering resident needs, rights, duties, emergency procedures, reporting responsibilities, and code of conduct. |
| 1001.7 (k) (1) — Admission and retention standards: Written Individualized Service Plan shall be developed for each resident upon admission. |
| 1001.10 (l) (2) — Medication management: Operator shall develop medication management policies and procedures compliant with applicable regulations. |
| 1001.10 (l) (3) — Medication management: Medication assistance record shall include diagnoses, medications, indications, labels, special directions, allergies, and resident identification. |
| 487.10 (e) (2) — Records and reports: Operator shall submit quarterly statistical information reports to the department. |
| 485.11 (b) — Records and reports: Operators shall supply and provide access to information and records as determined by the department. |
Report Facts
Inspections on page: 33
Total violations: 86
No-violation inspections: 11
Enforcement actions: 1
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