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Teresian House Nursing Home Co INC

200 Washington Ave Ext, Albany, NY 12203 · Non profit - Corporation · 302 certified beds · (518) 456-2000 Medicare & Medicaid certified

Call the home — (518) 456-2000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609) — most recent Nov 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1971 Western Ave #239 350 · (888) 963-9963 · Call to confirm hours
Pharmacy
12 Interstate Ave · (518) 452-7795 · Call to confirm hours
Grocery
48 Railroad Ave · (518) 226-8700 · Call to confirm hours
Park
136 Fuller Rd · (518) 434-5300 · Typically dawn to dusk
Place of worship
1400 Washington Ave · (518) 442-5591

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

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.2%14.1%15.4%better
Long-stay residents who lose too much weight4.5%5.8%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.5%0.9%better
Long-stay residents with a urinary tract infection0.0%1.3%2.0%better
Long-stay residents with depressive symptoms3.7%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury6.1%3.1%3.3%worse
Long-stay residents whose ability to walk worsened9.3%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.8%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers2.0%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control12.9%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table13.9%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%78.8%79.4%better
Short-stay residents rehospitalized after admission11.5%20.6%22.6%better
Short-stay residents with an outpatient ER visit2.9%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.011.701.67better
Long-stay outpatient ER visits per 1,000 resident days0.471.361.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

41.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 121 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.0%U.S. median 51.5%
Got home and stayed home
8.7%U.S. median 10.7%
Went back to hospital
60.0%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 60.0% 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 60 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.0%CMS range 31.3–46.651.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.7%CMS range 5.9–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified70.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.2–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.41
RN hours/ resident / day
1.06
LPN hours/ resident / day
2.42
Aide hours/ resident / day
3.88
Total nurse hours/ resident / day
0.22
RN hoursweekends
33.5%
Total nursing turnover
30.4%
RN turnover

How full it usually is: this home is certified for 302 beds and averages 285.7 residents a day — about 95% occupied, or roughly 16 beds typically open. It runs fairly full. 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 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 is below 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 3.58 hrs/resident/day on weekends vs 4.01 on weekdays — 11% thinner on weekends. RN hours go from 0.48 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

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

9
deficiencies at the latest standard inspection (2024-11-08)
5
at the previous standard inspection (2021-12-23)

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.

ABCDEFGHIJKL

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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2021-12-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 observation, medical and facility record review, video footage, and staff interview during a recertification and abbreviated survey (Case # NY00287505) the facility failed to provide adequate supervision for one (Resident #216) of 8 residents reviewed for accidents. Specifically, on 12/3/21 at 11:30 AM the facility failed to provide Resident #216, who was severely cognitively impaired, with supervision. Subsequently, Resident #216 was able to exit the building through a coded/locked door off the unit and 2 sets of alarmed doors exiting the facility for over two hours. Both alarmed doors were disabled by facility staff. Facility video footage revealed resident exited the facility at 11:30AM and facility staff did not discover the resident missing until lunch time at 12:15PM. In addition, facility staff did not follow their process for elopement when the facility staff member that exited through the coded/locked door did not observe and ensure the door closed and locked behind them; did not perform 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 · Past Non-Compliance
  • Potential for harm · E2024-11-08 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 1 (Resident #77) of 4 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 24%. This is evidenced by: The facility's Policy and Procedure titled Administering Medications, last reviewed 3/16/2023 and Last Revision: 11/5/2024, documented medications were administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation #2: medications may be administered within (1) hour before or after prescribed times. Scheduled medications designated as time-critical (medications that may cause harm or sub-therapeutic effect if administered before or after the scheduled time were administered at the scheduled time (for example, rapid-acting insulin) or within 30 minutes of the scheduled time. #8: The individual administering the medication checks the label THREE (3) times to verify: a. right resident, b. right medication, c.…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-08 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents were free of any significant medication errors for 2 (Resident #s 88 and 144) of 2 resident reviewed. Specifically, (a.) on 6/27/2024 Resident #88 received medications that were prescribed for another resident; (b.) on 11/02/2024 and 11/03/2024 Resident #144 did not receive a medication as prescribed. Additionally, there was no documented evidence that physician was notified, and that Resident #144 was monitored for side effects. This is evidenced by: The facility's Policy and Procedure titled Administering Medications, last reviewed 3/16/2023 and last Revision: 11/05/2024, documented medications were administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation #15: If a drug was withheld or refused, the nurse administering the medication should initial and code the space provided for that drug and dose. If resident refused medication after 3 attempts document in Electronic Medication Administration Record…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-08 · 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 interviews and record review during the recertification survey and an abbreviated survey (Case #NY00346710), the facility did not ensure that (a.) all alleged violations of resident abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or resulted in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protective services where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures; and (b.) reported the results of all investigations to the administrator or their designated representative, and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 (Resident #s88 and 144) of 5 residents reviewed for reporting of…

    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 · D2024-11-08 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure a Significant Change Minimum Data Set assessment was completed for a 1 (Resident #141) of 42 residents reviewed for significant changes in health status. Specifically, Resident #141 sustained a fractured wrist on 8/18/2024, and a fracture of the other wrist on 9/27/2024 after a fall on 9/04/2024. There was no documented evidence that a significant change assessment was done. This is evidenced by: The policy Change in a Resident's Condition or Status, revised 3/3/2023, documented that if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the Minimum Data Set Resident Assessment Instrument instruction manual. Resident #141 was admitted to the facility with the diagnoses of adjustment disorder with mixed disturbance of emotions and conduct (difficulty adjusting to new situations…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs for 2 (Residents #83 and #261) of 62 residents reviewed. Specifically, for Resident #s 83 and 261, the facility did not ensure an interdisciplinary care plan meeting reviewed the comprehensive care plan to include weight monitoring. This is evidenced by: The Policy and Procedure titled Change in a Resident's Condition or Status dated 04/22/2024, documented it was the facilities policy to promptly identify changes in condition, notify his or her attending physician, and the resident/representative of changes in the resident's medical/mental condition and/or status. The Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set assessment. The assessments of residents were ongoing and care plans were revised as…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their language and communication for 1 t (Resident #268) of 1 resident reviewed for Activities of Daily Living. Specifically, Resident #268 was not provided with an adequate, structured approach and tools to communicate effectively in accordance with professional standards of care. This is evidenced by: The facility's Policy on Communication with Residents with Speech Impairments reviewed on 1/24/2024, documented its purpose was to provide staff with a structured approach to communicate effectively and compassionately with residents affected by speech impediments due to stroke, ensuring clear, respectful, and supportive interactions. Procedures include use of communication aids; non-verbal cues; environment adjustments, documentation, and staff training. The New York State Department of Health Code, Rules and Regulation, Volume C (Title 10) Section 415.3 Effective…

    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 · D2024-11-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (Resident #83) of 9 residents reviewed for Activities of Daily Living. Specifically, Resident #83 was not provided assistance with personal hygiene during care leaving facial hair to grow on the upper lip. This is evidenced by: Resident #83 was admitted to the facility with the diagnoses of anxiety, Alzheimer's, and mood disorder. The Minimum Data Set (an assessment tool) dated 01/19/2024 documented the resident could rarely understand and rarely be understood by others; resident was cognitively impaired. The facility policy Activities of Daily Living Support effective 03/16/2023 documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Comprehensive Care Plan dated 9/22/2023 documented the resident…

    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 · D2024-11-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice for 1 (Resident #'s 148) of 4 residents reviewed for oxygen administration. Specifically, Resident #148's portable oxygen tank ran out of oxygen. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Administration, last revised on 5/09/2024, documented that oxygen would be administered by licensed nurses with a physician's order. Oxygen could be delivered via an E size oxygen tank for short-term use and when the resident was not on their concentrator. Resident #148 was admitted to the facility with diagnoses including malignant neoplasm of the right upper bronchus or lung (a cancerous tumor located in the upper lobe of the right lung, specifically within the bronchus, the airway leading to the lung lobe), acute respiratory failure with hypoxia (breathing disorder when there is not enough oxygen…

    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 before2024-11-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 2 of 14 resident unit kitchenettes. Specifically, refrigerators and freezers were not operating appropriately. This is evidenced by: A review of facility policy for the environment last revised 3/04/2024 documents that the facility was to maintain a clean and safe environment. The policy documents the facility would maintain the building and all department equipment to comply with all current Federal, State, and Local regulations and guidelines. The facility should maintain a regularly scheduled maintenance on all department equipment and repair as needed. During observations on the Carmel Garden [NAME] Unit on 11/06/2024 at 10:34 AM, the resident kitchenette refrigerator flashed an E-1 error code. During observations on the second-floor west unit on 11/06/2024 at 10:46 AM, the resident kitchenette freezer had a temperature reading of 33 degrees Fahrenheit. An…

    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 before2024-01-03 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 record review and interviews during an abbreviated survey (Case # NY00279837), the facility did not ensure residents were free from significant medication errors for 2 (Resident #s 1 and 2) of 3 residents reviewed. Specifically, the facility (1) did not ensure Residents #1 and #2 received their own medication as ordered when Resident #2 received Resident #1's antibiotic for 5 days from [DATE] through [DATE] for a total of 5 doses, and (2) did not ensure the electronic medical record was accurate for Resident #s 1 and 2 for those 5 days. This is evidenced by: The Policy and Procedure titled Physician's Order Entry last revised [DATE] documented physician orders would be entered by a licensed nurse in a timely manner. It documented all new orders entered in the electronic medical record order portal by a licensed nurse must be confirmed by a second nurse. It documented the nurse would document in the progress notes and on the 24-hour report that the new order was received and entered. If the order was…

    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.

    Pharmacy Service Deficiencies · Past Non-Compliance
Show the remaining 15 citations
  • Potential for harm · Ecited before2021-12-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The sanitizing chemical in the final rinse of low temperature automatic dishwashing machines are to be within a specific range, and food preparation and serving areas are to be kept clean. Specifically, the automatic dishwashing machine chemical sanitizing final rinse was too concentrated, and the unit kitchens required cleaning. This is evidenced as follows. When checked on 12/19/2021 at 9:14 AM, the concentration of sanitizing chemical in the final rinse of the automatic dishwashing machine final rinse was 200 parts per million of available chlorine (ppm). The directions on the bottle of sanitizing chemical concentrate state the concentration is to be between 50 and 100 ppm. The Director of Dining Services stated in an interview on 12/19/2021 at 11:16 AM that the vendor will be contacted to adjust the concentration of available chlorine to be compliant. In 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-12-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews during a recertification survey, the facility did not maintain the residents' right to personal privacy and confidentiality on 2 (1st floor and 6th Floor) of 6 units (the 4th floor was closed). Specifically, for the 1st Floor and 6th Floor, the facility did not ensure the residents' right to privacy and confidentiality were maintained when finger sticks (blood sugar monitoring for diabetes) and blood pressures were obtained, and the results were read out loud, with other residents were present in the dining rooms and common areas. This was evidenced by: The Policy and Procedure titled Resident Dignity dated 10/31/2019, documented the policy of the facility was to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in a full recognition of their individuality, and this included maintaining resident privacy. A review of Resident Council Minutes dated 12/2/2021, documented the dining room was sometimes used as a laboratory. Vital signs were taken in there, as well…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-12-23 · 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 record review and interviews during a recertification, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment were immediately reported to the Administrator of the facility for 1 (Resident #167) of 4 residents reviewed for abuse. Specifically, the facility did not ensure an allegation of abuse involving Resident #167 was immediately reported to the Administrator. This is evidenced by: Resident #167: Resident #167 was admitted with diagnoses of non-ST elevation myocardial infarction, muscle weakness generalized and acute respiratory failure. The Minimum Data Set (MDS - an assessment tool) dated 12/2/2021 documented the resident was cognitively intact, was understood and could understand others. The facility's policy and procedure (P&P) titled Abuse Prevention Protocol last revised on 5/26/2021, documented abuse allegations were reported per Federal and State Law. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or…

    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 · D2021-12-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #195) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #195, the facility did not ensure a PRN Trazodone (antidepressant medication) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #195: Resident #195 was admitted to the facility with the diagnoses of major depressive disorder, anxiety disorder, and dementia with behavioral disturbance. The Minimum Data Set (MDS - an assessment tool) dated 11/19/2021 documented the resident had moderately impaired cognition, could understand others and could make self understood. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-10-10 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 observation, record review, and interview conducted during the recertification survey, the facility did not ensure development of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for five (Residents #'s 24, 120, 134, 152, and #221) of thirty-two residents reviewed for comprehensive care plans (CCP). Specifically; for Resident #152, the facility did not ensure a CCP for the diagnosis of urinary retention requiring the need for monitoring and treatment was developed and implemented with specific person-centered interventions; for Resident #221, the facility did not ensure a CCP was developed for the resident's diagnosis of pulmonary embolism, and deep vein thrombosis with anticoagulant therapy; for Resident #24, the facility did not ensure a CCP was developed for the use of Meclizine (a medication for dizziness), and for Resident #120,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-10-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and food and non-food contact surfaces are to be kept clean. Specifically, automatic dish washing machines were not rinsing at the specified water pressure, and floors and equipment were not clean. Also, safe food handling was not practiced to prevent the outbreak of foodborne illnesses. This is evidenced as follows: Finding #1: The main kitchen and unit kitchenettes were inspected on 10/03/2019 at 9:00 AM. The slicer and the floor under cooking equipment and next to walls in the main kitchen were soiled with food particles. The cabinets and cabinet doors, window sills, and floor next to walls were soiled with food particles. Finding #2: The automatic dish washing machine (machine) on the 4-B unit was rinsing at 0 pounds per square inch (psi). The machine on the Mount Carmel East unit was…

    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 · D2019-10-10 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of potential financial liability for rehabilitative services during a non-covered stay. Specifically, residents who remained in the facility and after receiving covered rehabilitative services were not provided with the SNF ABN, Form CMS-10055. This was evident for two (2) (Resident #'s 214 and 234 out of three (3) sampled residents reviewed for Beneficiary Protection Notification. This is evidenced by: The findings are: 1) Review of the medical records for Resident #214 of 10/07/2019 revealed that though the resident remained in the facility after receiving rehabilitative services, the resident was not provided the SNF ABN, Form CMS-10055 to inform the resident of their potential financial liability if receiving non-covered rehabilitative services. 2) Review of the medical records for Resident #234 of 10/07/2019 revealed that though the resident remained in the facility after receiving…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-10 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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, record review, and interviews during a recertification survey the facility did not ensure that a resident was free from physical restraints, for one (Resident #126, of three reviewed for physical restraints. Specifically, the facility did not ensure that the least restrictive restraint for the least amount of time was used for the resident and that the Merry [NAME] (an enclosed walker, that the resident could not exit alone), was care planned as a restraint. This is evidenced by: Resident #126: The resident was admitted to the nursing home on 9/8/16, with diagnoses of Alzheimer's disease, hypertension, and glaucoma. The Minimum Data Set (MDS-an assessment tool) dated 5/24/19, assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. The Comprehensive Care Plan (CCP) for High Risk for Falls, dated 3/15/18, documented that the Merry [NAME] was to maximize ambulating…

    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 · D2019-10-10 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 record review and interview, the facility did not refer residents with newly evident mental illness for a level II resident review for two (Resident #'s 31 and 280) of two residents reviewed for PASRR (Pre-admission Screening and Resident Review). Specifically, the facility did not ensure Resident #'s 31 and 280, both newly diagnosed with a mental illness, received a level 1 screen to determine if a level II screen needed to be done. This is evidenced by: Resident #31: The resident was admitted on [DATE] with diagnoses of schizoaffective disorder-bipolar type, major depressive disorder and obsessive-compulsive disorder. The Minimum Data Set (MDS) of 7/05/19, documented the resident had moderate impairment for cognition, was able to understand others, and was able to be understood by others. The resident was also diagnosed with bipolar disorder on 11/04/15 and anxiety disorder, unspecified on 9/29/17. The Screen Form dated 4/12/12, Level 1 Review for Possible Mental Illness (question #23) documented 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-10 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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, record review, and interviews during a recertification survey the facility did not ensure it had an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one (Resident #109) of one resident reviewed for activities. Specifically, the facility did not ensure that the resident was provided activities based on the resident's mental and physical abilities, and for 3 of 6 units the facility did not ensure that television (TV's) stations in the common areas were set on stations appropriate for residents' who were in the those areas. This is evidenced by: Resident #89: The resident was admitted to the nursing home on 2/15/16, with diagnoses of dementia, Coranary Artery Disease, and Alzheimer's Disease with late onset. The Minimum Data Set (MDS - an assessment tool) dated 8/3/19,…

    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 before2019-10-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 record review and interview during a recertification survey and an abbreviated survey (Case #NY00241822), the facility did not ensure the resident environment remained as free of accident hazards as possible, and did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #383) of 4 residents reviewed for accidents and supervision. Specifically, for Resident #383, the facility did not ensure the resident, with a roam alert, was adequately supervised after the resident was escorted to the chapel by a staff member. Additionally, the front door did not alarm when the resident exited the building and returned a short time later through the same front door. This is evidenced by: Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey. Resident #383: The resident was admitted to the facility on [DATE], with…

    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 · D2019-10-10 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process. Specifically, the facility did not ensure there were time frames established for the steps in the MRR process concerning actions the pharmacist and facility needed to take when an irregularity was identified. This is evidenced by: Pharmacy Consultation Reports with a review date of 2/12/18 documented: - The pharmacy will compile any recommendations and send them to the facility to the attention of the Director of Nursing. A detailed summary is emailed to the Medical Director and copy to the DON/designee. - The Director of Nursing/designee will send the original to the specific units for the MD to address and sign. - The attending physician will acknowledge by making a comment and signing the consultation. During an interview on 10/08/19 at 08:15 AM, the Director of Nursing stated all pharmacy recommendations arrive by fax and are divided up by unit…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-10 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview during the recertification survey, the facility did not ensure the policy regarding foods brought in to residents is in accordance with adopted regulations. Specifically, the facility policy does not include the provision to provide information to families and other visitors on the safe and sanitary storage, handling and consumption of food and does not include a procedure to ensure facility staff assist dependent residents in accessing and consuming the food. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 10/03/2019. The policy did not include a process to ensure family and other visitors are provided information on safe food handling practices and did not include a method by which staff assists residents in accessing and consuming the food, if the resident is not able to do so on his or her own. The Director of Nursing stated in an interview on 10/03/2019 at 1:51 PM, that the she is not aware of any information on food safety that is provided to families or visitors,…

    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 · D2019-10-10 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 record review and interview during the recertification surveys the facility did not conduct an ongoing review that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for Resident #238, the facility did not ensure that their antibiotic stewardship program was implemented to improve antibiotic use when an antibiotic was prescribed without appropriate indications and monitoring. This was evidenced by: The facility's policy and procedure titled Antibiotic Stewardship - Staff and Clinical Training Roles last updated on 3/19 documented that the facility will educate and train staff and practitioners about the Facility Antibiotic Stewardship Program, including appropriate prescribing, monitoring and surveillance of antibiotic use and outcomes to ensure staff have a complete understanding of the goals of the program and their roles for ensuring good outcomes for the residents. For the role of the Director of Nursing and the Infection Preventist it documented that…

    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
  • No harm found · C2019-10-10 · tag F0550 — failed to protect resident dignity and rights — widespread
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it treated each resident with respect and dignity and cared for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one of fourteen dining rooms observed. Specifically, the facility did not ensure staff were talking with the residents rather than each other while assisting with meals, and that three (Resident #'s 119, 122 and #175) of three residents in Broda chairs (chair that the seat can be moved closer to the ground to prevent falls) were not eating their meals while sitting at nose level to the table. This is evidenced by: Finding #1: During dining observations on 10/07/19 at 11:56 AM - 12:35 PM, Resident #'s 119, 122, and #175 were sitting in Broda chairs in the low seat position at nose level to their tables. Resident #119 picked her plate up from the table and held it in her hand near her lap so she could eat her food. A staff member approached…

    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.

    Resident Rights 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARMELITE SISTERS FOR THE AGED & INFIRM — 9 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 →

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 4 of 53.8+0.2 vs chain
Quality measures 5 of 53.9+1.1 vs chain
The other 8 homes this chain runs (chain average 2.8★, per CMS)

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

Owner / managerTypeRoleSince
ANTENUCCI, ANGIOLAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
BOWKS, HARVEYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
CONSIGLIO, JACKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2021
DIMARIA, LILLIANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
DUQUETTE, JOANNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
GREGORY, JOSEPHIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
HARTIGAN, JOANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
JENNINGS, GERALDIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2015
KASPER, ROSEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2001
LONGOBUCCO, ROBERTIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
MCNAUGHTON, LISSAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
MONTGOMERY, PAULIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2022
MORRELL, JAMESIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2019
REILLY, JOEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2001
DELBROCCO, MICHAELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/29/1994
YEBOAH, FRANKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/12/2020
BONADIO & CO LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2025
PREFERRED THERAPY SOLUTIONS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2025
SPECTRUM PARENT, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2025
UNIDINE CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2025
ALVAREZ, KELSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/30/2021
ARCURI, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2025
AUSTIN, COLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/22/2021
BAUMES, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/14/1996
BERTAZZO, HELENEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/2020
COELHO, LUIZIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2019
DELVECCHIO, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/10/1984
FLYNN, KATHLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/26/2012
FOWLER, TIMOTHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
FREEMANTLE, PAULIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/05/2022
HANS, CATHLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/07/1999
HASANI, ABIGAILIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/09/2024
HAWVER, KATHRYNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/09/1996
LEBOEUF, SANDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/09/2014
MARCHI, EDMONDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/21/2024
NOEL, TAMMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/20/2023
SCOTT, JODIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/27/1993
SHELDON, HEATHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2023
WRIGHT, LEAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/11/2023

CMS files one row per role, so the 108 rows in the source record cover these 39 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.

4 organizational owners 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.

$33.0M
Net patient revenuemost recent cost report
-1.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 75%Medicare 3%Other / private 22%

About 75% 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.

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

$340per resident / day
operating cost
$10,345per month
≈ monthly operating cost
$335per day
avg. revenue, all payers

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 NY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335627. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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