Bridgewater Center For Rehab & Nursing L L C
159 163 Front Street, Binghamton, NY 13902 · For profit - Limited Liability company · 356 certified beds · (607) 722-7225 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 3 to 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.7% | 14.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.4% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.3% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 19.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 8.6% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.1% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.2% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.0% | 13.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.3% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.2% | 20.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.3% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.81 | 1.36 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
42.3% 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 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 28.1% 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 96 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 0.25 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.3%CMS range 35.2–48.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.9–13.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 28.1% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 28.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.4% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 98.2% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 5.3–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 356 beds and averages 348.3 residents a day — about 98% occupied, or roughly 8 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 2.79 hrs/resident/day on weekends vs 3.72 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.49 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Ecited before2026-06-12 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 (IQIES intake 2647397), the facility failed to 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 three of three residents (Residents #19, #41, and #72) reviewed and for 10 of 12 anonymous residents present at a resident group meeting. Specifically, Resident #19's wheelchair was unclean and in disrepair; Resident #41's ceiling dripped liquid over their bed; Resident #72's clothing was improperly labeled and was worn by another resident; and 10 anonymous residents reported their clothing was not labeled properly, was not returned to them after laundering and was distributed to other residents. Findings include: The facility policy Wheelchair Cleaning, revised 12/2025, documented all resident wheelchairs were cleaned and disinfected at least weekly and as needed to maintain a clean and sanitary condition to reduce the risk of infection transmission, promote resident comfort, and maintain a safe environment. The facility policy…
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.
- Potential for harm · Ecited before2026-06-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, (IQIES intake 2991234), the facility did not ensure a safe, clean, comfortable, and homelike environment for four of seven resident units (Units 2A, 3A, 4A and 5A) reviewed. Specifically, Units 2A, 3A, 4A and 5A were unclean and in disrepair. Findings include: The facility policy Homelike Environment, revised 12/2025, documented residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Unit 2A During an observation on 06/10/2026 at 10:57 AM, the floors were very sticky throughout the unit and staff shoes were heard squeaking. Unit 3B During an observations on 06/08/2026 at 4:54 PM and 06/09/2026 at 1:37 PM, room [ROOM NUMBER]'s wallpaper was peeling off the wall and the toilet paper holder was broken. The visitor in the room stated it was like that for a long time and they reported it to the facility months ago. Nothing was done to repair the wall or the toilet…
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.
- Potential for harm · Ecited before2026-06-12 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews (IQIES intakes 2991229 and 3008641) the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two of two test trays (06/08/2026 lunch tray and 06/09/2026 breakfast tray) sampled, and for 10 of 12 anonymous residents present at the Resident Council meeting. Specifically, the 06/08/2026 breakfast tray and the 06/09/2026 lunch tray had hot foods served below 130 degrees Fahrenheit, cold foods served above 49 degrees Fahrenheit and were not palatable; and 10 anonymous residents stated the hot food was cold and flavorless, milk was often served spoiled, lettuce was often brown, and the facility often ran out of food and cups.Findings include: The facility policy Food Temperature at Point of Service, revised 01/2026, documented hot food would be held and served at 135 degrees Fahrenheit or higher and cold food would be held and served at 41 degrees Fahrenheit or lower to prevent foodborne illness. During an observation on 6/8/2026 at 10:31 AM, the 2-door mobile refrigerator…
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.
- Potential for harm · Ecited before2026-06-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews (iQIES intake #2997455 and 3008641), the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of eight residents (Resident #13 and Resident #376) reviewed and two of two staff (Housekeeper #64 and Certified Nurse Aide #61) observed. Specifically, Resident #13 was on contact precautions for clostridioides difficile (a highly infectious bacteria that causes diarrhea) and Certified Nurse Aide #61 walked into the resident's room to retrieve a meal tray without wearing a gown or gloves or washing their hands with soap and water; Resident #376 did not have a contact precaution sign on their door with clostridioides difficile results pending; and Housekeeper #64 cleaned the floors of all rooms, including contact precaution for clostridioides difficile, with a quaternary sanitizer (broad spectrum sanitizer ineffective against clostridioides…
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.
- Potential for harm · D2026-06-12 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews (IQIES intake 482787), the facility failed to ensure accommodation of resident food preferences for one of one resident (Resident #9) reviewed. Specifically, Resident #9's meal trays were missing preferred food items and included foods they requested not to receive.Findings include: The facility policy Food Service Tray Accuracy, revised 9/2025, documented the Dietary Department will ensure that each resident receives the correct meal, diet, portion size, and nourishments as ordered by the physician and care team to promote safety, satisfaction, and compliance with physician ordered diets while ensuring quality meal service. Special diets, allergies, food preferences, and texture modifications shall be prepared and served as ordered. Meal trays would be checked for accuracy prior to leaving the kitchen and when errors were identified it should be corrected immediately.Resident #9 had diagnoses including anxiety and diabetes. The 3/24/2026 Minimum Data Set assessment documented the resident had intact cognition, required set up…
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.
- Potential for harm · Ecited before2025-02-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification and abbreviated (NY00355972, NY00357410, NY00358321, and NY00367882) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 8 resident units (Units 2 A, 3 A, and 4 A) reviewed. Specifically, Unit 2 A had a strong smell of urine, unclean bedrooms floors, a bathroom with brown splatter on the toilet, and an over bed table with food debris; Unit 3 A's dining room floor was unclean and sticky, there was debris on the base of the food carts, and brown material on a raised toilet seat in a resident room; and Unit 4 A had a continuously running sink in a resident room, unclean floors in multiple resident rooms, and food splatter on the floors and walls. Findings include: The facility policy, Resident Room Cleaning, revised 3/2020, documented resident rooms were cleaned daily to ensure optimal levels of cleanliness and sanitation, prohibit the spread of infection 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.
- Potential for harm · Ecited before2025-02-25 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure that each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals (2/21/2025 and 2/24/2025 lunch meals) reviewed. Specifically, the 2/21/2025 and 2/24/2025 lunch meals were not served at palatable and appetizing temperatures and the 2/24/2025 lunch meal was not palatable or attractive. Additionally, 7 of 7 anonymous residents at the Resident Council meeting stated the food was not appetizing and not served at appropriate temperatures; and Residents #46, #47, and #210 stated the food was not served at appetizing temperatures. Finding included: The facility policy, Food Temperatures and Test Tray Audits, revised 4/5/2024, documented the minimum temperatures at the time of service for: - milk and milk products were less than 45 degrees Fahrenheit. - hot entrees was greater than 135 degrees Fahrenheit. - hot…
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.
- Potential for harm · E2025-02-25 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and on1 unit (Unit 2A). Specifically, the main kitchen had multiple unclean surfaces, there were stored food items past their expiration dates, and staff did not wear hair nets. Unit 2A had a steam table with dried food, discolored water, and debris: and there was debris and 3 mouse traps behind the unit ice machine. Findings include: The facility policy, Dining and Meal Service, revised 4/5/2024, documented the dining room would be cleaned promptly after every meal. The facility policy, Dining Services Department Traffic, revised 4/5/2024, documented anyone coming into the kitchen must have a hair net on. All employees were educated to comply with the procedure and reasoning for implementation (i.e. cross contamination). Hair nets would be placed in an area within entrance to the department. The facility policy, Food Storage-…
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.
- Potential for harm · D2025-02-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observations, record review, and interviews during the recertification and abbreviated (NY00358321 and NY00368342) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 11 residents (Residents #46 and #99) reviewed. Specifically, Residents #46 and #99 were not assisted with showering as planned. Findings include: The facility policy Activities of Daily Living revised 10/2022 documented the facility would assist and encourage all residents to their highest practicable level of independence and to provide the necessary support in all activities of daily living functioning. Activities of daily living included bathing- inclusive of showers, tub bath, and bed bath. Activities of daily living would be completed on a daily basis for the resident with the assistance of the facility resident care staff as needed. The facility policy, Bathing or Showering a Resident, revised 11/2022 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.
- Potential for harm · Dcited before2025-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 (NY00370596, NY00368342, and NY00355972) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 2 residents (Resident #99 and #236) reviewed. Specifically, for Resident #236 Licensed Practical Nurses #14 and #17 administered medications outside of acceptable time parameters, a tube feeding was not given and documented as administered, medications were signed as given prior to administration, signed as given on time when they were given late, and treatments were signed completed when they were not; Resident #99 had an order for a medicated shampoo weekly with showers, the medicated shampoo was left at the resident's bedside, and certified nurse aides administered the medicated shampoo instead of licensed staff. Additionally, the provider was not notified of late and missing medications and treatments.…
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.
Show the remaining 16 citations
- Potential for harm · D2025-02-25 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure each resident who required colostomy (a surgical opening in the abdomen that allows waste to pass out of the body) services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #745) reviewed. Specifically, Resident #745 had a colostomy and there were no orders for ongoing monitoring, there was no order for the wafer of the 2 piece system, there was no care plan for the colostomy, no care instructions for the drainage pouch, and staff were unaware the resident had a colostomy. Additionally, the drainage bag was observed not in place and was not emptied timely when it was in place. Findings include: The facility policy, Colostomy/ Ileostomy Care, revised 3/2022, documented exposure of the resident's fecal matter to their skin should be…
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.
- Potential for harm · D2025-02-25 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 record review and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure residents who required dialysis (a process that filters the blood during kidney failure) received such services consistent with professional standards of practice for 1 of 1 resident (Resident #257) reviewed. Specifically, the facility did not consistently assess Resident #257 vital signs (blood pressure, heart rate, respirations, temperature) prior to dialysis, review the dialysis communication book sheets upon return from dialysis, or notify the provider of incomplete and refused dialysis procedures. Findings include: The facility policy, Dialysis, revised 2/2023, documented residents received dialysis on an outpatient basis at a prearranged center and received quality nursing care. Nursing staff were to check the physician's orders, check the bruit and thrill (to ensure adequate blood flow) for residents with fistulas (a connection between an artery and a vein used for dialysis), send the resident with their communication binder to dialysis, observe…
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.
- Potential for harm · D2025-02-25 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 2/19/2025-2/25/2025, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #153) reviewed. Specifically, Resident #153 had an extensive mental health history, did not have person-centered mental health interventions, and Preadmission Screening and Resident Review Level II recommendations were not implemented into the resident's plan of care. Additionally, Resident #153 hid butter knives under their mattress and there were no documented social services follow ups with the resident following their behavioral symptoms. Findings include: The facility policy, Care Planning/Care Conference, initiated 11/2022, documented a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. Care plans included person-specific, measurable…
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.
- Potential for harm · Dcited before2025-02-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 2/19/2025-2/25/2025, the facility did not ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #744) reviewed Specifically, Resident #744 did not receive Abilify (an antipsychotic medication) for 4 consecutive days (10 doses). Findings include: The facility policy, Medication Administration, revised 11/2022, documented medications were administered in a way that ensured the resident's safety. If the medication was not available on the nursing unit and not in the Pyxis machine (a machine that dispenses certain medications), the Registered Nurse Supervisor was notified, and they notified the pharmacy and physician as necessary. The physician or nurse practitioner were notified of any missed doses and a registered nurse completed an assessment of the resident as needed for missed dose of medications. If the registered nurse had any problems with obtaining medication the Director of Nursing or designee was notified and ensured prompt delivery of medications.…
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.
- Potential for harm · Dcited before2025-02-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 6 medication carts (2B East cart) reviewed. Specifically, the 2B East medication cart contained 4 opened undated insulin vials, 7 opened undated insulin pens, and one expired insulin vial. Additionally, 2 vials of vaccines (Prevnar, pneumococcal vaccine and Abrysvo, respiratory syncytial virus vaccine) were observed sitting on top of the medication cart unsecured and unattended. The facility policy, Insulin Orders, revised 11/2016, documented the pharmacy assigned a 28-day expiration date on all insulin pen delivery devices once removed from the refrigerator. The facility policy, Storage of Medications, revised 9/2019, documented medications and biologicals would be stored safely, securely, and properly; the medication supply would be accessible only to licensed 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.
- Potential for harm · Dcited before2025-02-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 2/19/2025-2/25/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #49 and #226) reviewed. Specifically, Resident #226 was on transmission-based precautions (enhanced barrier precautions) and Licensed practical nurse #1 performed gastrostomy tube (feeding tube) care without wearing required personal protective equipment. Resident #49 was on isolation precautions (contact precautions) and X-Ray Technician #10 obtained an abdominal X-ray without wearing required personal protective equipment and Certified Nurse Aide #9 provided Resident #49 their meal tray wearing gloves and did not perform hand hygiene after removing their gloves. Findings included: The facility's Enhanced Barrier Precautions policy dated 2/1/2023 documented Enhanced Barrier Precautions were…
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.
- Potential for harm · Ecited before2023-03-28 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview during the recertification and abbreviated (NY00308658, NY00311004, and NY00298919) surveys conducted 3/12/23-3/16/23, the facility failed to provide a safe, clean, comfortable, and homelike environment for 15 resident rooms (resident rooms 520, 505, 504, 448, 432, 430, 425, 406, 405, 403, 361, 359, 346, 260, and 248); 10 resident common areas (fifth floor north hall shower room, fifth floor hall near the 5A emergency exit stairwell, fifth floor north hall bathroom, fourth floor north shower room, fourth floor north dining room, third floor south shower room, third floor south dining room, second floor hall near resident room [ROOM NUMBER], and second floor south training bathroom); and 1 resident device (resident chair in fifth floor hall). Specifically, resident rooms 520, 505, 504, 448, 432, 430, 425, 406, 405, 403, 361, 359, 346, 260, and 248; fifth floor north hall shower room, fifth floor hall near the 5A emergency exit stairwell, fifth floor north hall…
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.
- Potential for harm · Ecited before2023-03-28 · tag F0880 — failed to prevent and control infections — patternProvide 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 and abbreviated (NY00304704) surveys conducted 3/21/23-3/28/23, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 staff members (certified nurse aide {CNA} #32, licensed practical nurse {LPN} #33, unit helper #34, and dietary supervisor #38 observed and for 1 of 7 residents (Resident #197) reviewed. Specifically, CNA #32 was not wearing a N95 mask as required, and LPN #33, unit helper #34, and dietary supervisor #38 were not wearing N95 masks correctly on a unit with COVID-19 positive residents; and infection control standards during wound care for Resident #197 were not maintained. Findings include: The facility policy Donning and Duffing of Personal Protective Equipment-COVID-19 reviewed/revised 11/2022 documented prior to working with COVID-19 residents, all employees must have received 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.
- Potential for harm · Dcited before2023-03-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observation, interview, and record review during the recertification and abbreviated (NY00302292) surveys conducted 3/21/23-3/28/23, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance and enhancement of quality of life for 2 of 7 (Residents # 24 and 165) reviewed. Specifically, Resident #24 was not provided their bathing preference of a shower; and Resident #165's urinary catheter collection bag was uncovered with the contents visible. Findings include: The facility policy Quality of Life-Dignity revised 2/2022 documented each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction of life, feeling of self-worth, and self-esteem. The facility culture was one that supported and encouraged humanization and individualization of residents, and honored resident choices, preferences, values, and beliefs. Respect for choices and values included personal grooming in which residents were groomed as they wished to be…
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.
- Potential for harm · Dcited before2023-03-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 survey conducted 3/21/23-3/28/23, the facility failed to ensure residents were free of any significant medication errors for 1 of 1 resident (Resident # 250) reviewed. Specifically, Resident #250 had physician orders to receive nothing by mouth (NPO) and had six medications ordered with a route of administration by mouth (PO). Findings include: The facility policy Medication Administration revised 11/2022 documented a registered nurse (RN) or a licensed practical nurse (LPN) must check all residents' orders carefully prior to administering medications. The basic rules of safe administration should be kept in mind and included the right drug, the right resident, the right time, the right dose, and the right route. If there was any doubt about a medication, the nurse should not administer it and should contact the nurse practitioner or physician for clarification and instruction. The facility policy Medication Therapy revised 5/2022 documented medication use should be consistent with an individual'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.
- Potential for harm · Dcited before2023-03-28 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 conducted 3/21/23-3/28/23, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 2 of 6 medication carts (Units 4-A and 4-B) and 2 of 4 medication storage rooms (Units 2-A and 4-A) observed. Specifically, Units 2-A, 4-A, and 4-B had expired resident specific medications, stock medications and biologicals in the medication carts, medication room and/or the medication room refrigerators. The facility policy Insulin Administration via a Pen reviewed/revised 4/2019 documented pharmacy assigned a 28 day expiration date on all insulin pen delivery devices once removed from the refrigerator. Insulin pens were for single resident use only. The facility policy Storage of Medications reviewed/revised 9/2019 documented outdated medications were to be immediately removed from inventory and disposed of. The facility policy Vials and Ampules of Injectable Medications revised 8/2020…
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.
- Potential for harm · Dcited before2020-10-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, interview, and record review during the recertification survey, the facility did not ensure residents had the right to a safe, clean, comfortable and homelike environment for 1 of 5 residents reviewed. Specifically, Resident #34's room contained a clock that was not functioning, and 2 outdated calendars were hung on the wall for 4 days of survey. Findings include: The facility's Quality of Life/Homelike Environment policy updated 1/2/20 documents: - Residents are provided with a safe, clean, homelike environment and encouraged to use their personal belongings to the extent possible. - Staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Resident #34 had diagnoses including alcohol dependence with alcohol induced persisting dementia, abnormal gait and mobility, and need for assistance with personal care. The 6/24/20 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, no behavioral symptoms, required extensive assistance of one person 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.
- Potential for harm · D2020-10-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 record review and interview during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan that includes services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 of 3 (Resident #127) residents reviewed. Specifically, Resident #127 was care planned to have an Ethics Committee review related to treatment options and the committee did not meet to review the resident. Findings include: The facility Ethics Committee Policy and Procedure revised 1/2020, stated it is the policy of the facility to have an established interdisciplinary body that provides guidance and assistance, on a consultant basis, to residents, families and healthcare providers in making decisions related to life threatening medical decisions. Resident #127 had diagnoses including multiple myeloma not having achieved remission, traumatic subdural hemorrhage (brain bleed) and vascular dementia. The 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.
- Potential for harm · Dcited before2020-10-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview during the recertification survey, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 (Resident # 212) reviewed. Specifically, Resident #212 had an order for sliding scale insulin before meals (amount of insulin given depends on blood glucose level), the resident was observed not eating a meal after insulin was administered and there was no documented evidence the nurse was aware of the resident's intake to observe for signs and symptoms of hypoglycemia (low blood glucose). Findings include: The facility policy Mealtime Guidelines revised 2/2020 documented all residents will be encouraged to feed themselves. If they are unable to do so, assistance will be provided as needed. Staff will make frequent rounds on the unit to monitor residents eating in their rooms. Meal consumption will be documented on the Hydration/Nutrition Output Log. Any change in appetite, refusing to eat or poor…
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.
- Potential for harm · D2020-10-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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, interview and record review during the recertification survey, the facility did not ensure a resident with limited range of motion (ROM) receives appropriate treatment and services to prevent further decrease in range of motion for 1 of 3 (Resident #179) residents reviewed. Specifically, Resident #179 had contractures of both hands and was observed without bilateral palm grips as care planned. Findings include: The facility policy Splint: Use, Care and Cleaning revised 2/2020 documented fabricated splints will be fabricated and monitored by the Therapy Department for application schedules and continued use. Nursing staff will ensure appropriate use and care of the splints under the direction of the therapy department. Application and removal of splints will be the responsibility of nursing staff. Special instruction for splint application and wearing times will be included on the resident care plan, and use will be documented accordingly on the resident treatment record. Splint use will be reflected on the profile care card and on the TAR (treatment…
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.
- Potential for harm · D2020-10-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 maintained acceptable parameters of nutritional status for 1 of 4 (Resident #212) residents reviewed. Specifically, Resident #212 was not provided with needed meal assistance and had a significant weight loss. Findings include: The facility policy Weight Protocol revised 4/2019 documented any weight gain or loss of 5 pounds or more since the previous weight will trigger a reweighing within 72 hours for confirmation and will be communicated to the dietitian/diet tech. The facility policy Mealtime Guidelines revised 2/2020 documented all residents will be encouraged to feed themselves. If they are unable to do so, assistance will be provided as needed. Staff will make frequent rounds on the unit to monitor residents eating in their rooms. Meal consumption will be documented on the Hydration/Nutrition Output Log. Any change in appetite, refusing to eat or poor intake will be reported to the nurse for follow up. Resident #212 had diagnoses including Type 2 diabetes…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to UPSTATE SERVICES GROUP — 17 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 3 of 5 | 2.6 | +0.4 vs chain |
| Quality measures | 3 of 5 | 2.8 | +0.2 vs chain |
The other 16 homes this chain runs (chain average 2.0★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KOENIG, URI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 55% | since 12/22/2010 |
| STEIF, EFRAIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 45% | since 01/28/2005 |
| EBELING, JADE | Individual | W-2 MANAGING EMPLOYEE | — | since 11/01/2021 |
| WUERTZER, AMY | Individual | CORPORATE OFFICER | — | since 09/14/2017 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $5.5M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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
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
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.
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 335228. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-25, 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 →
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