Deficiencies (last 5 years)
Deficiencies (over 5 years)
12.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 18
Sep 15, 2025
Visit Reason
Complaint Survey with 7 standard health citations and 11 life safety code citations, mostly Level 2 severity, no actual harm but potential for minor discomfort.
Findings
Complaint Survey with 7 standard health citations and 11 life safety code citations, mostly Level 2 severity, no actual harm but potential for minor discomfort.
Deficiencies (18)
| Description |
|---|
| Covid-19 immunization |
| Food procurement,store/prepare/serve-sanitary |
| Increase/prevent decrease in rom/mobility |
| Infection prevention & control |
| Personal privacy/confidentiality of records |
| Resident rights/exercise of rights |
| Safe/clean/comfortable/homelike environment |
| Building construction type and height |
| Corridor - doors |
| Discharge from exits |
| Electrical systems - maintenance and testing |
| Ep testing requirements |
| Fire alarm system - testing and maintenance |
| Hazardous areas - enclosure |
| Maintenance, inspection & testing - doors |
| Sprinkler system - installation |
| Sprinkler system - maintenance and testing |
| Subsistence needs for staff and patients |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Dec 4, 2023
Visit Reason
Complaint Survey with 4 standard health citations and 11 life safety code citations, mostly Level 2 severity, all corrected by early 2024.
Findings
Complaint Survey with 4 standard health citations and 11 life safety code citations, mostly Level 2 severity, all corrected by early 2024.
Deficiencies (16)
| Description |
|---|
| Activities daily living (adls)/mntn abilities |
| Food procurement,store/prepare/serve-sanitary |
| Resident rights/exercise of rights |
| Safe/clean/comfortable/homelike environment |
| Building construction type and height |
| Corridor - doors |
| Electrical equipment - power cords and extens |
| Exit signage |
| Hvac |
| Illumination of means of egress |
| Maintenance, inspection & testing - doors |
| Physical environment |
| Sprinkler system - installation |
| Sprinkler system - maintenance and testing |
| Subdivision of building spaces - smoke barrie |
| Subsistence needs for staff and patients |
Inspection Report
Annual Inspection
Deficiencies: 4
Dec 4, 2023
Visit Reason
The inspection was conducted as a recertification survey from 11/28/2023 to 12/4/2023 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified existence, maintenance of a safe and homelike environment, ensuring residents maintain mobility, and food service safety. Deficiencies included unauthorized signage in a resident's room, broken bathroom door not repaired for over a year, failure to assist a resident with mobility as ordered, and multiple food safety violations such as soiled fans, improper food handling, expired and unlabeled food items, lack of thermometers for microwaves, and improper sanitation of food thermometers.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Unauthorized sign next to Resident #46's bed stating 'walk me every day' violating resident's right to dignified existence. | Level of Harm - Minimal harm or potential for actual harm |
| Accordion style bathroom door in Resident #40's room was broken and falling off the track for at least a year. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #65 was not assisted to get out of bed as ordered, risking loss of mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Food service safety violations including heavily soiled circulation fans in food areas, kitchen staff using bare hands to retrieve foil from food, peeling food cart surfaces, multiple unlabeled and expired food items in nourishment refrigerators, lack of thermometers and procedures for microwaves on resident units, and improper sanitation of food thermometer probes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Date survey completed: Dec 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Stated signs were to alert staff to walk Resident #46 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated sign was placed to remind staff to ambulate Resident #46 |
| Rehabilitation Director | Stated signs were placed to remind Resident #46 to walk with staff | |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Stated they never noticed the broken bathroom door in Resident #40's room |
| Registered Nurse #1 | Registered Nurse | Knew bathroom door was broken and documented it in maintenance logbook |
| Environmental Services Director | Stated they were unsure why bathroom door was not fixed and provided information on fan cleaning logs | |
| Certified Nurse Aide #2 | Certified Nurse Aide | Stated Resident #65 had not been out of bed this week |
| Director of Nursing | Director of Nursing | Stated Resident #65 should be out of bed daily and no formal system was in place to ensure this |
| Dietary Aide #1 | Dietary Aide | Observed working under dusty fan and stated they did not check fan cleanliness |
| Maintenance Worker #1 | Maintenance Worker | Responsible for cleaning fans monthly but fans were heavily soiled |
| Food Service Director | Acknowledged dusty fans, improper food handling, lack of thermometer use, and improper thermometer sanitation | |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Unaware of ownership of expired food items in nourishment refrigerator |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Stated no thermometer was available for microwaved foods |
Inspection Report
Capacity: 60
Deficiencies: 1
Feb 21, 2023
Visit Reason
Covid-19 Survey with one standard health citation for reporting to national health safety network, Level 2 severity.
Findings
Covid-19 Survey with one standard health citation for reporting to national health safety network, Level 2 severity.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 10
Nov 1, 2022
Visit Reason
Covid-19 Survey with multiple life safety code citations, mostly Level 2 severity, all corrected by December 2022.
Findings
Covid-19 Survey with multiple life safety code citations, mostly Level 2 severity, all corrected by December 2022.
Deficiencies (10)
| Description |
|---|
| Doors with self-closing devices |
| Egress doors |
| Electrical systems - essential electric syste |
| Emergency lighting |
| Ep testing requirements |
| Exit signage |
| Portable fire extinguishers |
| Sprinkler system - installation |
| Subdivision of building spaces - smoke barrie |
| Subsistence needs for staff and patients |
Inspection Report
Annual Inspection
Deficiencies: 1
Oct 13, 2020
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with professional standards for food safety in the storage of food brought in by visitors for residents.
Findings
The facility failed to ensure that foods stored in resident refrigerators on the first and second floors were properly labeled with the resident's name and date, and some food items were kept beyond the allowed 72 hours, posing a risk for foodborne illness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Foods stored in 2 of 3 unit refrigerators were not labeled with the resident's name or the date the item was brought to the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days food kept beyond allowed time: 5
Food discard timeframe: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Observed first-floor refrigerator and stated food must be dated and labeled. | |
| LPN #1 | Unit Manager | Observed second-floor refrigerator and stated nursing is supposed to examine and discard food items after 72 hours. |
| Food Service Director | Interviewed regarding policy for food stored in residents' refrigerators and stated nursing is responsible for labeling and dating foods. |
Inspection Report
Annual Inspection
Deficiencies: 13
Mar 8, 2019
Visit Reason
The inspection was conducted as part of the recertification survey to assess compliance with federal, state, and local regulations and professional standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives and ombudsman in writing of hospital transfers, incomplete care plans addressing pain and depression, failure to include residents in care plan meetings, failure to provide ordered positioning devices, lack of timely optometry services, incomplete nurse staffing postings, administration of unnecessary medications without proper monitoring, storage of expired medications, failure to follow written menus, inadequate food safety and sanitation, lack of carbon monoxide detectors in mechanical rooms, improper infection control practices including hand hygiene, and unsafe mechanical equipment maintenance including roof leaks and inadequate ventilation.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to provide timely written notification to resident representatives and ombudsman of hospital transfers for 3 residents. | Level of Harm - Potential for minimal harm |
| Failure to develop and implement care plans addressing pain and depression for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to include resident in care plan meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide ordered positioning splints to resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide optometry services as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post nurse staffing information daily including resident census. | Level of Harm - Potential for minimal harm |
| Failure to monitor pain level and effectiveness of pain medication for a resident receiving PRN pain medication. | Level of Harm - Minimal harm or potential for actual harm |
| Storage of expired medications in medication storage room. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow written menus and provide adequate fresh fruits as planned. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure refrigerated food safety and maintain food service equipment free of debris. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to install carbon monoxide detectors in mechanical rooms housing fuel-fired equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain infection prevention and control program including hand hygiene and water management plan for Legionella. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain mechanical equipment in safe operating condition including roof leaks and inadequate ventilation in employee dining room. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration dates: 9
Expired medication dates: 3
Dates of nurse staffing postings: 10
Dates missing nurse staffing postings: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding lack of written notification to families and ombudsman of hospital transfers | |
| RN #1 | Registered Nurse | Interviewed regarding notification procedures and hand hygiene during meal observation |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding responsibility for applying splints |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding responsibility for applying splints |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding application of splints and hand hygiene during meal observation |
| Nurse Practitioner | Interviewed regarding pain medication order monitoring and resident pain assessment | |
| Director of Nursing (DON) | Interviewed regarding care plan meetings and nurse staffing postings | |
| Food Service Director (FSD) | Interviewed regarding fresh fruit availability and food safety | |
| Director of Environmental Services | Interviewed regarding carbon monoxide detectors, roof leaks, and ventilation issues | |
| Maintenance Department staff member | Interviewed regarding carbon monoxide detectors, roof leaks, ventilation, and fire alarm system |
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