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The Commons On St Anthony, A S N F & Short T R C

3 St Anthony Street, Auburn, NY 13021 · Non profit - Corporation · 297 certified beds · (315) 253-0351 Medicare & Medicaid certified

Call the home — (315) 253-0351 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2024Resident-funds citations (F0568, F0570)1 actual-harm citation$8,512 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
  • it has citations for mishandling residents’ money or property (F0568, F0570)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,512 in federal fines (most recent 2024-03-06)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing 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) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 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 — 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
161 Genesee St · (315) 255-0947 · Call to confirm hours
Pharmacy
Walgreens0.4 mi
301 Genesee St · (315) 258-9702 · Call to confirm hours
Grocery
352 Genesee St · (315) 252-7995 · Call to confirm hours
Park
8 Bostwick Ave · Typically dawn to dusk
Place of worship

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 4 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 improved from 2 to 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 increased11.7%14.1%15.4%better
Long-stay residents who lose too much weight7.5%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection0.8%1.3%2.0%better
Long-stay residents with depressive symptoms8.0%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 injury2.3%3.1%3.3%better
Long-stay residents whose ability to walk worsened9.6%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.2%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine99.3%95.3%95.3%typical
Long-stay residents with pressure ulcers5.8%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control30.2%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.3%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.1%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine79.7%78.8%79.4%typical
Short-stay residents rehospitalized after admission20.2%20.6%22.6%better
Short-stay residents with an outpatient ER visit9.8%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days0.911.701.67better
Long-stay outpatient ER visits per 1,000 resident days0.841.361.80better

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.

44.0% 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 557 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.0%U.S. median 51.5%
Got home and stayed home
12.6%U.S. median 10.7%
Went back to hospital
75.2%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 75.2% 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 218 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF44.0%CMS range 39.8–47.051.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.6%CMS range 10.4–14.610.7%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 discharge75.2%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 discharge71.1%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 discharge63.8%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 identified100.0%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 stay1.0%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 worsened1.0%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 hospitalization6.4%CMS range 4.5–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 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

0.32
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.17
RN hoursweekends
40.4%
Total nursing turnover
37.9%
RN turnover

How full it usually is: this home is certified for 297 beds and averages 291.2 residents a day — about 98% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.83 hrs/resident/day on weekends vs 3.16 on weekdays — 11% thinner on weekends. RN hours go from 0.38 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as 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

13
deficiencies at the latest standard inspection (2024-11-01)
4
at the previous standard inspection (2022-12-20)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2024-03-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    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

    Based on record review and interview during the abbreviated survey (NY00333847), the facility failed to ensure residents were free from neglect for 1 of 5 residents reviewed (Resident #1). Specifically, Resident #1 was care planned for transfers with a mechanical lift and certified nurse aides #1 and #2 did not utilize a mechanical lift when transferring the resident out of bed; certified nurse aides #14 and 15 did not use a mechanical lift when transferring the resident back into bed, and the resident was not assessed timely after complaints of extreme pain. Subsequently, Resident #1 was found with a fractured arm. This result in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The 6/7/2019 Transferring Residents with Assistive Devices facility policy documented a mechanical lift was used for residents who were unable to, or inconsistently bear weight on one or both legs and participated less than 50% during the transfers; all total lifts (mechanical lifts) were to utilize 2 staff. Transferring a resident that required maximal assistance without 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-07-02 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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, the facility failed to ensure the services arranged or provided by the facility meet professional standards of quality for one of six residents reviewed. Specifically, Resident #2 had increased confusion, urinary frequency and a strong urine odor, a physician order was obtained for a urinalysis, culture and sensitivity and Resident #2's urine sample was not collected to rule out a urinary tract infection. Findings include:The 04/01/2024 facility policy, Change in a Resident's Condition or Status documented a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions.The undated facility policy, Laboratory Specimens Collection of Routine Urine Specimen documented explain procedure to resident, bring equipment to the bedside and provide privacy. Require resident to urinate, place urine in specimen cup 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2024-11-01 · tag F0550 — failed to protect resident dignity and rights — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 1 of 2 residents (Resident #196) and for 3 of 8 resident units (Units 3, 5, and 6) reviewed. Specifically, Resident #196's room had personal care information posted in an area visible to other residents and visitors; and Units 3, 5, and 6 had signs on the elevators documenting they were out of order to keep cognitively impaired residents from using the elevators. Findings include: The facility policy, Quality of Life-Dignity, dated 1/10/2023, documented residents were to be treated with dignity and respect at all times. Each resident should be cared for in a manner that promotes and enhances their sense of wellbeing, level of satisfaction with life, and feeling of self-worth and self-esteem. Signs indicating the resident's…

    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 · D2024-11-01 · tag F0563 — failed to protect the right to visitors — isolated
    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during recertification and abbreviated (NY00318491) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure residents had the right to receive visitors of their choosing at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident for 1 of 1 residents (Resident #243) reviewed. Specifically, the facility restricted Resident #243's family member's visitation based on the resident's healthcare proxy's wishes. Findings include: The facility policy, Visitation Policy, dated 5/23/2023, documented unless visitation was suspended to comply with applicable laws or regulations, the residents were permitted to receive visitors 24/7 subject to the resident's wishes and the protection of the rights of other residents in the facility. The facility recognized the resident's needed to maintain contact with the community they lived and/or were familiar with and they could have visitors as they wished. The facility provided 24-hour access to all…

    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 · D2024-11-01 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the individual financial record was available to the resident through quarterly statements and upon request for 2 of 2 residents (Residents #93 and #198) reviewed. Specifically, Residents #93 and #198 were not provided with personal fund statements within 30 days after the end of the quarter, and upon request. Finding include: The facility policy, Resident Fund Policy and Procedures, dated 10/1/2015, documented the Resident Banker was on duty Monday- Friday from 9:00 AM-12:00 PM and from 1:00-3:00 PM; resident fund statements were delivered to the resident and/or authorized representative quarterly and showed the prior quarter's transactions; and the resident and/or authorized representative could request balance and/or printed statements during banking hours. Resident #93 was admitted with diagnoses including Parkinson's Disease (a progressive neurological disorder). The 10/23/2024 Minimum Data Set assessment documented the resident had 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0656 — failed to write and follow a full care plan — isolated
    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

    Based on observation, record review, and interview during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident to meet medical and nursing needs identified in the comprehensive assessment for 1 of 3 residents (Residents #20) reviewed. Specifically, Resident #20 did not have footrests and lateral supports while in their scoot chair (a specialty chair used to improve positioning and mobility) as planned. Findings include: The facility policy, Turning and Repositioning, dated 3/27/2024, documented the resident would receive the required assistance for repositioning based on their assessment from the interdisciplinary team. Repositioning would be provided to prevent the development of secondary conditions that could infringe on the resident's ability to function at the highest practical level attainable. The certified nurse aide would provide turning and repositioning per the care plan and document in the electronic medical record plan of care. Nursing…

    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 · D2024-11-01 · 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 observations, record review, and interviews during the recertification and abbreviated (NY00356778) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure residents received treatment and care in accordance with professional standard of practice for 1 of 2 residents (Residents #1 and #232) reviewed. Specifically, Resident #232 had bilateral (both sides) above the knee amputations and the facility did not follow up on a prosthetics (artificial limb) referral timely and Resident #1 experienced an emotionally distressing event that was not addressed timely. Findings include: The facility policy, Request for Consultation and Follow Up, dated 1/22/2024, documented upon return from an appointment, the nursing staff conveyed the results of the consultation to the attending provider and the recommendations for additional interventions or follow-up. The consult form was dated and initialed and indicated it had been reviewed by nursing. The facility policy, Resident Rights and Notice of Resident Rights and Responsibilities. dated 4/30/2024, documented the resident had 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 · D2024-11-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 during the recertification and abbreviated (NY00347746) surveys conducted 10/28/2024-11/1/2024, the facility failed to ensure a resident with an indwelling catheter (a tube inserted into the bladder to drain urine) received the appropriate care and services to prevent urinary tract infections for 1 of 1 resident (Resident #238) reviewed. Specifically, Resident #238's urinary drainage collection bag was not positioned below the level of the bladder to promote free urine flow (allows urine to back flow into urinary tract). Findings include: The facility policy, Catheter Care Indwelling Urinary Catheter, revised 12/2023, documented the urinary drainage device drainage bag was positioned below the level of the bladder at all times and tubing was positioned to prevent urine reflux toward the bladder. The facility policy, Urinary Tract Infection Prevention and Catheter Use and Care, dated 12/12/2023, documented leg bags (a small urine collection bag attached to 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 · D2024-11-01 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 conducted 10/28/2024-11/1/2024, the facility did not ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for 1 of 2 residents (Resident #152) reviewed. Specifically, Resident #152 received hemodialysis treatments at a community-based dialysis center and: - did not have ongoing assessments of their condition and monitoring for complications before and after dialysis treatments; - there was inconsistent communication and collaboration between the dialysis center and the facility; - the resident did not receive a bagged lunch prior to attending dialysis as planned; - the resident frequently did not complete treatments due to discomfort from the mechanical lift pad left under them in their wheelchair, and medical was not notified; - staff documented the resident's permacath (central catheter used for long-term venous access) dressing was dry and intact and the resident did not…

    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 · D2024-11-01 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not post on a daily basis the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for 5 of 5 days. Specifically, the current daily resident census and nurse staffing schedules were located on the nursing supervisor/staffing office door that was down a hallway off the main lobby and not readily accessible to visitors or residents. Findings include: There was no documented facility policy on nurse staffing posting requirements. The daily nurse staffing information was observed posted on the nursing Supervisor/Staffing office door located down a hallway off the main lobby that was not readily accessible to visitors and residents: - on 10/28/2024 at 4:09 PM. - on 10/29/2024 at 8:15 AM. - on 10/30/2024 at 8:50 AM. - on 10/31/2024 at 7:56 AM. - on 11/1/2024 at 7:39 AM and did not include 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 the recertification and abbreviated (NY00356778) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure routine and emergency drugs and biologicals were provided to 1 of 1 resident (Resident #1) reviewed. Specifically, Resident #1 was not administered the respiratory syncytial virus vaccine (helps protect against a common respiratory virus, RSV) timely after the vaccine was ordered in 2023 and 2024. Findings include: The facility policy, Resident Immunizations, dated 3/27/2024, documented upon admission resident's immunization records were reviewed. If the resident had not received the respiratory syncytial virus vaccine and was [AGE] years of age or older, the vaccine would be offered, and an order was obtained. Prior to administration, the vaccine information sheet was reviewed with the resident or designated health care proxy and consent was obtained. Resident #1 had diagnoses including heart disease, hypertension (high blood pressure),…

    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
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-11-01 · 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

    Based on record review and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 1 resident (Resident #152) reviewed. Specifically, Resident #152 did not receive 24 of 26 doses of physician ordered levetiracetam (brand name Keppra, used to treat seizures). Findings include: The facility policy, Medication Administration Pour-Pass-Sign, dated 8/2021, documented registered nurses and licensed practical nurses appropriately and safely administered and documented medications administered to residents. Refusals were documented in the electronic medical record and included a refusal reason and progress note. The policy did not include details of required documentation if a resident was out of the building during the scheduled medication administration time. Resident #152 had diagnoses including epilepsy (seizure disorder), end stage renal (kidney) disease, and dependence on renal dialysis (removal of waste products from the body when the kidneys don't work properly). 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 · D2024-11-01 · 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, record review, and interview during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure they 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 for 2 of 3 residents (Residents #238 and #52) and for 1 of 1 staff (Cycle Cleaner #1) reviewed. Specifically, Cycle Cleaner #1 did not practice appropriate use of personal protective equipment or hand hygiene during the cleaning of Resident #644's room who was on precautions for COVID-19; Resident #238's urinary drainage collection bag was not stored in a manner to prevent contamination; and Resident #52's urinary collection bag was observed lying directly on the floor. Findings include: The facility policy, Guideline for Type and Duration for Selected Infections and Condition, dated 5/30/2023, documented in addition to standard precautions, special droplet contact precautions would be put in place for…

    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 · D2024-03-06 · 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

    Based on observation, record review, and interview during the abbreviated (NY00330077) survey, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #4) reviewed. Specifically, Resident #4 exhibited exit seeking behaviors and had a wanderguard (device to detect wandering) and eloped from the facility (left the facility undetected) during a fire drill when staff did not monitor the exit doors per facility policy. Findings include: The facility's Elopement Evaluation (Wandering/Elopement Risk) policy revised 1/16/2024, documented an elopement was defined as the ability of a resident to leave the facility unsupervised or unnoticed by staff and enter into harm's way. The facility provided a safe environment for residents by evaluating, identifying, and responding to residents who presented a risk based on wandering or elopement behaviors. New admissions would be assessed by licensed nursing staff to determine elopement or wandering risk. A reassessment would be conducted quarterly, annually, and with changes in 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 · D2024-03-06 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    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 abbreviated survey (NY00334306), the facility did not comply with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 1 of 5 residents reviewed (Resident #5). Specifically, Resident #5 was found deceased on the floor in another resident's room. The resident had a laceration to their head with bleeding. The facility called the County Coroner (referred to as the Medical Examiner by the facility), who instructed them to notify the police. The facility did not comply with the directives to immediately notify the police, moved the resident's body, and performed post-mortem care prior to the coroner's and police department's arrival. Findings include: The [DATE] Deaths Reportable to the Medical Examiner policy documented New York State County Law mandates the Medical Examiner make an inquiry regarding all unnatural deaths within…

    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 · D2022-12-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 7 residents (Residents #44, 82, and 209) reviewed. Specifically, Residents #44, 82, and 209 were observed with unclean wheelchairs. Findings include: The facility did not have a wheelchair cleaning policy in place prior to 12/14/22. The 7/2022-11/2022 facility Wheelchair Cleaning Schedule by day and teams documented unit and rooms (team) scheduled for wheelchair cleaning on a specific day of each month. The schedule documented the following; - Resident #44's wheelchair was last scheduled for cleaning on 12/1/22; - Resident #82's wheelchair was last scheduled for cleaning on 12/9/22; and - Resident #209's wheelchair was last scheduled for cleaning on 11/25/22. The schedule did not document if the cleanings were completed. The following observations were made of Resident #82's wheelchair: - on 12/12/22 at 11:50 AM the resident was sitting in a scoot chair (an adjustable height…

    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 · D2022-12-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 9 (Resident #204) reviewed. Specifically, Resident #204 was observed unshaven and with soiled clothing. The facility policy Activities of Daily Living - ADLs dated 1/21/2020 documented the resident who was unable to carry out activities of daily living would receive all the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Resident #204 had diagnoses including chronic obstructive pulmonary disease (COPD, lung disease), tremor, and need for assistance with personal care. The 9/9/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required limited to extensive assistance with personal hygiene and dressing. 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 before2022-12-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, and the comprehensive person centered care plan for 1 of 4 residents (Resident #214) reviewed. Specifically, Resident #214 did not have a physician order for oxygen (O2) and was observed on multiple days receiving O2 via a nasal cannula (NC, a tube delivering oxygen through the nose). Findings included: The facility policy titled Oxygen Therapy dated 10/10/19 documented a nurse may administer oxygen with a physician order. The standing physician order for oxygen therapy was used under the following conditions: Shortness of breath, cyanosis (skin, lips or nails turn blue due to a lack of oxygen in the blood), respiratory distress, and/or oxygen saturation less than 90%. Resident #214 had diagnoses including pneumonia, pulmonary hypertension, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-20 · 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

    Based on observation, record review and interview during the recertification and abbreviated (NY00303532) surveys conducted 12/12/22-12/20/22, the facility failed to ensure residents were free of significant medication errors for 1 of 8 residents (Resident #1) reviewed. Specifically, Resident #1 did not receive their phenobarbital (anti-seizure medications) and diazepam (antianxiety/sedative) as ordered. Findings include: The facility policy, Medications, Ordering Process, dated 1/11/22 documented the night nurse on each unit will review the narcotic supply for each resident every night. The night nurse will write the need for a new script on the medical doctor's clip board with enough time in advance to be sure the supply is adequate to last through holidays and long weekends. If needed, the medical doctor can call in a 5-day supply of Narcotics. The facility policy, Medication Errors, dated 1/11/22 documented medication errors are defined as a circumstance or event that includes the omission of a medication that reached the patient to require monitoring to confirm that 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 · E2020-03-05 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 assessment of residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 6 of 7 residents (Residents #1, 2, 3, 5, 6 and 7) reviewed for resident assessments. Specifically, Residents #1, 2, 3, 5, 6 and 7's Minimum Data Set (MDS) assessments were completed later than 14 days following the Assessment Reference Date (ARD). Findings include: The facility policy Resident Assessment documented the facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment for each resident's functional capacity. The Minimum Data Set (MDS) assessment will be conducted per the guidelines set in the Resident Assessment Instrument (RAI) Manual. The first comprehensive assessment must be within 14 calendar days after admission, thereafter a quarterly assessment must be within 92 days from the assessment reference date of the previous…

    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 · D2020-03-05 · 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 record review and interview during the recertification survey the facility did not ensure residents received the necessary care and services to ensure that a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 1 resident (Resident #55) reviewed for rehabilitation and restorative services. Specifically, there was no documentation Resident #55 was ambulated by staff as care planned; in addition staff reported the resident had a decline in ambulation and it was not re-assessed timely. Findings include: The 1/2019 Ambulation Program: Walk Around the Clock policy documents the facility is to ensure that all residents with functional ability to ambulate maintain that ability. Ambulation goals could be achieved by walking the resident from the bed to the bathroom and back, from the resident's room to the unit lounge, from the lounge to the dining room and so on. The CNA (certified nurse aide) would document all ambulation in the ADL section. Resident #55 was admitted with diagnoses including osteoarthritis. The 2/14/20 Minimum Data Set (MDS)…

    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 · D2020-03-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview during the recertification survey the facility did not ensure residents with limited range of motion received the appropriate treatment and services to increase or prevent decrease in range of motion (ROM) for 2 of 6 residents (Residents #96 and 282) reviewed for range of motion. Specifically, Resident #96 was provided a palm guard (a device used for hand contractures) with no parameters for use. Resident #282 did not have interventions in place to prevent further decline in a neck contracture. Findings include: The facility policy Range of Motion, dated 1/21/20, documents the facility will provide the services, care and equipment to ensure: - A resident maintains or improves to their highest level of range of motion (ROM) and mobility, unless a reduction is clinically unavoidable. - A resident with limited range of motion and mobility maintains or improves function unless reduced ROM/ mobility is unavoidable based on the resident's clinical condition. - The therapy department will perform an assessment and recommend any ROM and/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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-03-05 · 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 observation, interview, and record review during the recertification survey, the facility did not ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #155) reviewed for respiratory care. Specifically, Resident #155 had orders for a Continuous Positive Airway Pressure machine (CPAP, a machine used to deliver constant and steady air pressure to people with sleep apnea) and scheduled care and cleaning of the equipment was not provided. Findings include: The 2/2020 BiPAP/CPAP/Trilogy Non-Invasive Policy documented the purpose is to provide non-invasive ventilatory support in patients with compromised airway or chronic pulmonary/cardiac disease. The policy documented the C-PAP must have: - A physician order which includes settings. - An infection control process which includes cleaning and maintenance of the machine, mask and tubing. - The headgear/mask be stored in a dated, ventilated bag when not in use. Resident #155 was admitted to the facility with diagnoses including chronic…

    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
  • No harm found · C2024-11-01 · tag F0570 — widespread
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the recertification survey conducted 10/28/2024 -11/1/2024, the facility did not ensure that a surety bond (an agreement between the facility, the insurance company, and the resident wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds the facility holds, safeguards, manages, and accounts for) was purchased in the amount equal to or greater than the total resident funds to assure the security of all personal funds of residents deposited with the facility for 239 of 296 residents with personal funds accounts. Specifically, the facility's surety bond was for an amount less than the total of all resident personal fund accounts being held by the facility. Findings include: The facility policy, Resident Fund Policy and Procedures, dated 10/1/2015, documented the facility shall hold, safeguard, manage and account for resident personal funds placed in its care. The facility would ensure compliance with Federal, State, and County resident fund requirements. There was no documented…

    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
  • No harm found · C2024-11-01 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the rights of citizenship, including the right to receive mail, were maintained for 296 of 296 residents residing in the facility. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Additionally, 3 of 6 anonymous residents present at the resident group meeting stated their mail was opened prior to it being delivered to them. Findings include: The facility policy, Resident Mail, dated 2/27/2024, documented residents received their mail promptly and unopened unless requested in writing by the resident or designated representative. Any front desk deliveries were delivered to the resident promptly. On Saturdays, the nursing supervisor delivered mail to the units during rounds. Staff then distributed the mail to residents on the same day. The facility policy, Resident Rights & Notice of Resident Rights and Responsibilities, dated 4/30/2024, documented residents had…

    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

$8,512 in federal fines across 1 penalty.

  • $8,512 — penalty dated 2024-03-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
LORETTO MANAGEMENT CORPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2014
MURRAY, JOHNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 04/01/2014
TOWNSEND, KIMBERLYIndividualCORPORATE OFFICERsince 04/01/2014

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$31.3M
Net patient revenuemost recent cost report
-5.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 71%Medicare 10%Other / private 19%

About 71% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$351per resident / day
operating cost
$10,667per month
≈ monthly operating cost
$331per 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 335382. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-01, 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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