Chautauqua Health and Rehabilitation

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Met the expected recovery: 33.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 145 beds and averages 122.7 residents a day — about 85% occupied, or roughly 22 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.67 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.36 hrs/resident/day on weekends vs 3.68 on weekdays — 9% thinner on weekends. RN hours go from 0.54 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 14 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · K2021-08-27 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews and facility policy review, it was determined that the facility failed to protect residents from physical, sexual, and verbal abuse for five (5) (Residents #35, #8, #58, #54, and #87) of five (5) sampled residents reviewed for abuse by Resident #85 and Resident #6. Specifically, Resident #85 knocked down Resident #35 down on 08/21/2021, and knocked Resident #8 down on 08/22/2021, resulting in a femur fracture. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed himself/herself, sexually during an activity, to Resident #58 and Resident #87. Staff reported that when Resident #6 came into the common area, other residents left due to the resident's behaviors. Staff indicated they were fearful Resident #6 would hurt another resident. The Director of Nursing (DON) indicated Resident's #6's behaviors created a stressful environment for the other residents. It was determined the facility's non-compliance with one or more…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2021-08-27 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, it was determined the facility failed to report abuse allegations and injuries of unknown origin to the State Survey Agency for six (6) (Residents #35, #8, #58, #54, #83, and #87) out of six (6) residents reviewed for abuse. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not reported. Resident #85 had physical or verbal altercations with other residents and the incidents were not reported. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a hip fracture. Resident #83 had injuries of unknown origin, including bruising and a hip fracture, that were not reported to the State Survey Agency. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2021-08-27 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to investigate abuse allegations for six (6) (Residents #35, #8, #58, #54, #87 and #83) out of six (6) residents reviewed for abuse by Resident #85 and Resident #6. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not investigated. Resident #85 had physical or verbal altercations with other residents and the incidents were not investigated. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a hip fracture. Resident #83 had injuries of unknown origin, including bruising and a hip fracture, that were not thoroughly investigated. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2021-08-27 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews and reviews of the facility's policies, it was determined the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This deficient practice affected one (1) (Resident #6) of six (6) sampled residents reviewed for behaviors. Specifically, Resident #6 displayed behaviors directed toward other residents, and no new interventions were implemented to address behaviors. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed self sexually during an activity. Staff reported that when Resident #6 came into the common area, other residents left due to the resident's behaviors. Staff indicated they were fearful Resident #6 would hurt another resident. The Director of Nursing (DON) indicated Resident's #6's behaviors created a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-05-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety which had the potential to affect all residents who consumed meals from the kitchen. The findings include:1). Review of the facility's policy titled, Food Storage, dated 10/2019, revealed the Dietary Manager was to ensure all food items were stored properly in covered containers. Further review revealed the containers were to be labeled, dated, and arranged in a manner to prevent cross-contamination.Observation of the kitchen, on 05/05/2026 at 11:05 AM, revealed a dessert cart with 20 cups of chocolate trifle stored uncovered and undated in the freezer. Observation of the dry pantry storage revealed one large 6.61-pound canned peaches, two large 6.61-pound canned mandarin oranges, and three large 6.38-pound stewed tomatoes were dented but stored in active rotation to serve to residents. Chicken soup base was stored in the 1.25-pound original container with the lid lying on top, unsealed, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-08 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility document and policy review, the facility failed to report all alleged violations of abuse to the State Agencies (including the State Survey Agency (SSA) for 1 of 1 residents sampled for sexual abuse out of the total sample of 25 residents, (Resident (R)61).The findings include:Review of the facility policy titled, Abuse, Neglect and Exploitation, last reviewed 04/2026, revealed, under section II Employee Training, new employees were to be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation and existing staff to receive annual education through planned in-services and as needed. Continued review under section VII Reporting/Response, the facility was to have written procedures that included reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. Further review revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-08 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of facility policy, the facility failed to follow standard precautions to prevent the spread of infection. Appropriate infection prevention and control practices were not implemented during medication administration. Hand hygiene was not performed while administering medications to 2 of 5 residents, sampled for medication observation out of the total sampled 25 sampled residents, (Resident (R)46 and R75). The findings include: Review of the facility policy titled, Infection Prevention and Control Program, last revised 01/2025, revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Additionally, all staff were to assume all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility policy titled, Medication Administration, last reviewed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of facility policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Observation on 04/02/2025 at 8:45 AM, on the Dementia unit, revealed medication cups containing medications that had been pre-pulled for 3 residents. The cups were marked with the residents' names in black sharpie. The findings include: Review of the facility's policy titled, Medication Administration, revised 02/20/2024, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. Review of the facility's policy titled, Residents Rights, dated 01/20/2020 and revised on 01/2025, revealed the facility will ensure all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Observation of Medication Tech (MT)3 on the Dementia unit, on 04/02/2025 at 8:45 AM, revealed she was at the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-04 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 26 sampled residents, Resident (R)1 and R97. 1. During observation of incontinence care for R97, provided by Certified Nursing Assistant (CNA)8 and CNA10, on 04/03/2025 at 10:14 AM, the CNAs removed the urine soaked sheets from the air mattress, used them to wipe the mattress and then threw the sheets on the floor while wearing gloves. The CNAs then failed to perform hand hygiene and don new gloves, but wore the same soiled gloves to provide incontinence care for the resident. Further, the CNAs failed to clean/disinfect the air mattress after providing incontinence care. 2. Furthermore, observation on 04/01/2025 at 9:10 AM, and 04/03/2025 at 9:05 AM, revealed the infusion stand which held R1's enteral feeding bag was soiled with an unidentified…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2021-08-27 · tag F0801 — widespread
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure there was a qualified food and nutrition director with appropriate competencies and skill sets to carry out food and nutrition services for all one hundred eleven (111) residents in the facility. The facility failed to ensure the Director for Food and Nutrition Services was a Certified Dietary Manager (CDM), a Certified Food Service Manager, had a national certification for food service management or had an Associates or higher degree in food service management. The findings included: Review of the facility's policy titled, Professional Staffing revised 10/2019, revealed a qualified Food Services Director was one who: was a Certified Dietary Manager; or was a Certified Food Service Manager; or had similar national certification for food service management and safety from a national certifying body; or had an Associate's or higher degree in food service management or in hospitality, if the course of study included food service or restaurant management from an accredited…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2021-08-27 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure the menus and recipes were followed in one (1) of one (1) facility kitchen with the potential to affect one hundred and eleven (111) residents. The findings include: Review of the facility's polic,y titled Menus revised 10/2019, revealed menu cycles would include standardized recipes. Continued review revealed the Menus were served as written, unless changed in response to preference, unavailability of an item, or a special meal. Review of the menus provided by the Registered Dietitian (RD), on 08/25/2021 at 12:15 PM, revealed the following menu: 08/24/2021 Tuesday lunch: Southern fried chicken, orange twist, macaroni and cheese, buttered chopped spinach, dinner roll, and cookie, 08/25/2021 Wednesday lunch: Salisbury steak, beef gravy, chopped parsley rice pilaf, buttered kernel corn, dinner roll, and orange sherbet. Observations of the lunch preparation in the kitchen, on 08/25/2021 at 9:51 AM, revealed the Dietary Aide (DA) was preparing a pureed dessert.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2021-08-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record reviews, and review of the facility's policies, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (1) of one (1) kitchen and one (1) of two (2) nourishment refrigerators with the potential to affect all one hundred and eleven (111) residents. Staff failed to ensure cold foods were covered, expired foods were disposed of, the kitchen and equipment were cleaned, food was stored at the proper temperature, and food was prepared and held at the proper temperatures prior to meal service. The findings include: Review of the facility's policy titled, Food Preparation revised 10/2019, revealed time/temperature control for safety (TCS) hot food items would be heated according to the following guidelines: mechanically altered foods: reheated to one hundred and sixty-five (165) degrees Fahrenheit (F) for fifteen (15) seconds; reheated foods: one hundred and sixty-five (165) degrees Fahrenheit for 15 seconds and then discarded after two (2) hours.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2021-08-27 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record reviews, and facility policy review, it was determined the facility failed to ensure an effective Quality Assurance (QA) program was in place. The facility's census was 111 residents. Staff failed to ensure the QA program put plans in place to correct past deficiencies, identify its' own deficiencies, and resolve those deficiencies. The findings included: A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, dated 07/2016, revealed the primary goals of the QAPI Committee are to .help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systemic problems; help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care. 1. Review of the facility's repeat deficiencies from the 07/25/2019 survey included: -F686- failure to provide care and services related to pressure ulcers. -F690-…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2021-08-27 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and the review of a facility policy, it was determined that the facility failed to keep the indwelling catheter drainage bag off the floor for one (1) of four (4) sampled residents (Resident #67); and, failed to maintain social distancing in the main hallway and wear the face mask properly in three (3) locations within the building. The deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents. The findings included: Review of the facility's policy, titled Catheter Care, Urinary, revised 09/2014, indicated under the section Infection Control that the catheter tubing and bag were to be kept off the floor. 1. Record review revealed the facility admitted Resident #67 on 01/18/2021 and re-admitted him/her on 02/14/2021 with diagnoses that included disruption of a surgical wound and obstructive uropathy. Review of Resident #67's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KY