Elizabeth Church Manor Nursing Home
863 Front Street, Binghamton, NY 13905 · Non profit - Corporation · 120 certified beds · (607) 722-3463 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- 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 $151,625 in federal fines (most recent 2024-08-22)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 | 27.2% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.3% | 19.5% | 6.5% | better than state‡ — see note marked double-dagger 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 | 6.6% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.3% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.8% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 6.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.3% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.3% | 13.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 63.5% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.1% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.6% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.49 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.50 | 1.36 | 1.80 | better |
‡ 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.
53.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 160 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 91 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 0.28 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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
| 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 | 53.8%CMS range 46.4–60.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.9–14.6 | 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 | 67.0% | 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 | 67.0% | 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 | 55.0% | 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 | 99.0% | 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 | 100.0% | 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 | 1.0% | 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 | 2.0% | 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 | 6.7%CMS range 4.0–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 120 beds and averages 113.5 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.36 hrs/resident/day on weekends vs 4.28 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.58 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 fewer than at the previous inspection — improving. 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.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Lcited before2024-09-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespreadEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, during the abbreviated survey (NY00354300) the facility failed to ensure residents remained as free of accident hazards as possible for 7 of 55 residents (Residents #1, #4, #5, #6, #7, #8 and #9) reviewed. Specifically, Resident #1 who had severely impaired cognition, had a contour mattress and right side bed rail (assist rail) and was not assessed for appropriate alternatives to the bed rail, was not assessed for entrapment risk, did not have the risks and benefits of a bed rail reviewed, and there was no informed consent from the resident's representative before installation of the bed rail. Subsequently, the resident was found with their body out of the bed and their head wedged between the bed rail and the mattress and was pronounced deceased . Additionally, Residents #4, #5, #6, #8, and #9 had multiple risk factors identified on their bed rail assessments and were recommended to have bed rails applied; Residents #4, #5, #6, #7, and #8 did not have risks…
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.
- Immediate jeopardy · L2024-09-30 · tag F0700 — widespreadTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during the abbreviated survey (NY00354300), the facility failed to ensure correct installation, use, and maintenance of bed rails to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for 55 of 55 residents (Residents #1-#16 and #18-#56) reviewed. Specifically, Resident #1 had a contour mattress and a right side bed rail. The facility did not inspect and regularly check the mattress and bed rail for areas of possible entrapment. Additionally, the facility did not evaluate alternatives to bed rails, review the risks and benefits of bed rails with the resident or resident representative or obtain informed consent prior to the installation of bed rails for Resident #1 and all 54 residents with bed rails (Refer to F689). Subsequently, on 9/15/2024, Resident #1was found with their body out of their bed with their head wedged between the bed rail and the mattress. The resident had no pulse or respirations and was pronounced deceased . This resulted in Immediate Jeopardy for 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.
- Potential for harm · F2025-08-01 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 7/28/2025-8/1/2025 the facility did not ensure sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 2 of 3 resident units (Units 1 and 3). Specifically, Unit 1's and 3's meal trays were consistently delivered after the posted scheduled mealtimes and concerns were identified with the effectiveness of meal preparation and other food and nutrition services. Deficiencies related to food and nutrition services were identified in F 809 Frequency of Meals/Snacks at Bedtime; F 812 Food Procurement, Store/Prepare/Serve; and F 814 Dispose of Garbage and Refuse Properly.Findings include:The Resident Listing Report, dated 7/28/2025, documented the facility's resident census was 117. The undated facility policy Dietary Staffing, documented the facility should maintain adequate and qualified dietary personnel, including management and support staff, to ensure that all meals and snacks were safely prepared, handled and serviced in a timely…
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 · E2025-08-01 · 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 during the recertification and abbreviated (NY00385403) surveys conducted 7/28/2025-8/1/2025, the facility did not ensure residents had the right to a dignified existence for 2 of 3 units (First and Third Floors) reviewed. Specifically, the First floor meals were served more than 30 minutes late; the Third floor meals were served more than 30 minutes late, and dining table residents were not served together. Additionally, deficiencies were identified in sufficient dietary support personnel to safely and effectively carry out the functions of the food and nutrition service (F802) that led to an undignified dining experience.Findings include:The undated facility policy, Dining Experience Policy, documented meals would be served at consistent, scheduled times, with flexibility for alternate meal schedules. Communal dining was encouraged for socialization. The undated facility policy, Dignity, documented meals would be served in a manner that maintained dignity and avoid treating residents as a task and resident would be encouraged…
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 before2025-08-01 · 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 7/28/2025-8/1/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in one (1) out of one (1) main kitchen. Specifically, the main kitchen was unclean, had damaged freezer storage equipment, improperly stored utensils, and improper storage of food products.Findings include: The undated facility policy Kitchen Cleaning and Sanitation, documented all surfaces in the kitchen and food preparation areas were to be cleaned and sanitized regularly to maintain a safe environment for food storage and preparation, and to ensure the prevention of foodborne illness and cross-contamination. The undated facility policy Refrigerator and Freezer Cleaning and Temperature Monitoring, documented the facility performed routine cleaning of all cold storage equipment and made sure it functioned properly. The food should be stored six inches off the floor.The undated facility policy Food Storage, documented the facility stored all food…
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 · E2025-08-01 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
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 7/28/2025-8/1/2025, the facility did not ensure garbage and refuse was disposed of properly in one (1) of one (1) main kitchen. Specifically, the main kitchen garbage and refuse areas were not maintained to prevent attraction and harborage of pests.Findings include: The undated facility policy Garbage Disposal and Waste Management, documented all garbage, refuse, and waste was collected, stored, and disposed of in a manner that minimized health risk and prevented pest infestation. Kitchen waste was to be emptied multiple times a day. The exterior waste storage should be covered and secured to prevent pest access and kept free of overflowing waste. During an observation on 7/28/2025 at 10:40 AM, there were piles of trash and debris scattered on the ground around the dumpsters outside the main kitchen.During an interview on 7/30/2025 at 12:23 PM, Food Service Manager #13 stated the kitchen garbage was taken down the hall and put out the side door and into the dumpsters at the end of 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 · D2025-08-01 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 7/28/2025-8/1/2025, the facility did not ensure as needed orders for psychotropic drugs were limited to 14 days for one (1) of five (5) residents (Resident #14) reviewed. Specifically, Resident #14 had a physician order for as needed Ativan (anti-anxiety medication) that was not reevaluated for appropriateness or discontinuation after 14 days. Findings include: The undated facility policy PRN [as needed] Medication Administration Policy, documented special precautions were taken with psychotropic [as needed] medications, which required time-limited orders and clinical justification. Psychotropic medications were any drug that affected brain activities related to mental processes and behavior. All [as needed] orders must include the duration of the order (especially for psychotropics). [As needed] orders for psychotropic medications must be limited to 14 days, unless the attending physician documented and justified the need for continuation. The medications could not be renewed automatically and must 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 · D2025-08-01 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 7/28/2025-8/1/2025, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently both during day-to-day operations and emergencies. The facility did not review and update the facility assessment as necessary. Specifically, the facility assessment did not accurately reflect the clinical nutrition staff and department heads.Findings include:The 2024-2025 Facility Assessment documented the incorrect name of the Director of Nursing. The assessment documented the facility resources needed to provide competent support and care for the resident population every day and during emergencies. The assessment listed one Director of Nurses with a New York State license; 1 Director of Food and Nutrition which included Food service Director/ Diet technician/Registered Dietitian, Certified Dietary Manager, 3 cooks, and 6 food service aides. The registered dietitian listed was not full time or a department head, and the facility did…
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 before2025-08-01 · 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 7/28/2025-8/1/2025, 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 one (1) of six (6) residents (Resident #4) reviewed. Specifically, during Resident #4's wound dressing treatment Licensed Practical Nurse #8 did not perform hand hygiene when changing from contaminated to clean gloves. Findings include:The undated facility Wound Care Dressing Change, documented hand hygiene was required before starting the dressing change, after removing soiled dressings, and at the end of the procedure. Resident #4 had diagnoses including Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) left heel pressure ulcer. The 6/16/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment, an unhealed pressure ulcer, infection of the foot, received 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.
- Potential for harm · D2025-08-01 · tag F0882 — isolatedDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews during the recertification survey conducted 7/28/2025 - 8/1/2025, the facility did not ensure one qualified individual, who was not the Director of Nursing, was responsible for the facility's Infection Prevention Control Program. Specifically, the Assistant Director of Nursing was not qualified based on education, training, experience or certification to assume the role of Infection Preventionist and the Director of Nursing assumed those duties.Findings include: The undated facility policy Infection Surveillance, documented the Infection Preventionist served as the leader of surveillance activities, maintained documentation of incidents, findings, and any corrective actions regarding infection control. They were responsible to report findings to the Quality Assurance Committee and public health authorities.The undated facility Emergency Phone Numbers form documented Director of Nursing #2 was also the Infection Preventionist. Assistant Director of Nursing #3 was the Director of Nursing in Training and the Assistant Director of Nursing.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 · F2024-09-30 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during abbreviated surveys (NY00354147 and NY00354300), it was determined the facility and governing body failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F 689 Accident Hazards and F 700 Bedrails. Specifically, the facility's governing body did not establish and implement policies regarding the management and operation of the facility. Subsequently, there were outdated and a lack of operational policies and equipment to ensure resident safety. Findings include: The facility policy Quality Assurance Performance Improvement, dated 2/2018 defined governing body as individuals who were legally responsible for establishing and implementing policies regarding the management and operations of the facility. A quality deficiency was anything the facility considered to be in need of further investigation and correction or improvement. Examples included problems such as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-22 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not make prompt efforts to resolve resident grievances for 3 of 8 anonymous residents and for 5 additional grievances (Residents #38 [2 grievances], #47, #79, and #94) reviewed. Specifically, 3 residents from the Resident Council meeting stated their grievances were not always acted upon or resolved and they were not provided with a reason why. Additionally, there were five grievances that did not have documented resolution. Findings include: The facility policy Grievances, reviewed 8/2017, documented the facility would ensure prompt resolution of all grievances regarding the resident's rights. The Grievance Official was responsible for overseeing the grievance process through to its' conclusion and issuing written grievance decisions to the resident. Prompt efforts to resolve included the facility acknowledgement of the grievance and active work toward the resolution of the grievance. 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.
Show the remaining 13 citations
- Potential for harm · E2024-08-22 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 4 of 8 residents (Resident #3, #58, #74, and #93) reviewed. Specifically, Resident #93's comprehensive care plan did not include pain management and hospice services; Resident #47's comprehensive care plan did not include the use of antipsychotic medications; Resident #74's comprehensive care plan did not include self-medication administration or diabetes; and Resident #3's comprehensive care plan did not include ordered interventions for edema (swelling). Findings include: The undated facility policy, Resident-Centered Standards of Care and Exceptional Care Planning, documented the facility utilized standards of care and developed exceptional resident-centered care plans that were culturally competent and consistent with the resident's specific conditions,…
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 · E2024-08-22 · 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 observation and interview during the recertification and abbreviated (NY0032236) surveys conducted 8/19/2024-8/22/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 or 2 meal test tray (the 8/20/2024 and 8/21/2024 lunch meals) reviewed; for 8 of 8 anonymous residents present at the Resident Council meeting, and for 6 additional residents (Residents #3, #35, #36, #44, #63, and #74) interviewed during initial screening. Specifically, the 8/20/2024 and 8/21/2024 lunch meals were not served at palatable and appetizing temperatures and were not flavorful. Additionally, 8 anonymous residents at the Resident Council meeting and Residents #3, #35, #36, #44, #63, and #74 stated the food was cold and unappetizing. Findings include: The undated facility policy, Campus Policy & Procedure: Temperatures, documented the service temperatures for a hot entrée was 135-170 degrees Fahrenheit, cold beverages were 40-50 degrees Fahrenheit, and vegetables were 135-170 degrees Fahrenheit. During initial…
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 before2024-08-22 · 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 observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen. Specifically, in the main kitchen potentially hazardous foods were not cooled properly, there were several unclean areas, and the food storage areas contained unprotected food products. Findings include: The 3/1/2004 facility policy, Food Preparation and Storage, documented potentially hazardous foods requiring refrigeration must be cooled by an adequate method, so that every part of the product was reduced from 120 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and 45 degrees Fahrenheit or below within 4 additional hours. Foods particularly important to meet the requirements included gravies. Gravies should be stirred while the container was in an ice water bath at a depth of equal to or greater than the food depth. The 6/10/2024 facility policy, Food Service Sanitation, documented the facility would maintain 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 · D2024-08-22 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 8/19/2024-8/22/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #74) reviewed. Specifically, Resident #74 was observed with medications stored in an unlocked drawer of their dresser, and there was no documented evidence the interdisciplinary team had assessed the resident's ability to safely self-administer medication. Findings include: The facility policy, Medication Self-Administration, dated 5/2005 documented a resident who wished to self-administer medications, was to be determined to be capable of safely doing so by the interdisciplinary team, arrange for storage of medications in locked drawer or box in the resident's room, and observe self-administration until compliance was assured. Resident #74 had diagnoses of acute pancreatitis (inflammation of the pancreas), myasthenia gravis (a disease causing weakness in voluntary muscles), and diabetes. The 8/2/2024 Minimum Data Set…
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 · D2024-08-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 8/19/2024-8/22/2024, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #71) reviewed. Specifically, Resident #71's call bell was not in reach as care planned. Findings included: The facility policy, Call System, dated 1/7/2016 documented residents in their rooms, toilet, and bathing areas should have a means of directly contacting caregivers and should be responded to in a timely manner. Upon admission, attempt to orient the resident to the purpose for and use of the call system. Ensure that the resident could use the call system device, making adaptations for limited hand dexterity or other physical limitations to the extent reasonable. Ensure the call system device was in reach of the resident if the resident was capable of using it. Resident # 71 had diagnoses including Alzheimer's disease and dysphagia (difficulty swallowing). The 7/14/2024 Minimum Data Set assessment (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.
- Potential for harm · D2024-08-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00322036) surveys conducted 8/19/2024-8/22/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 2 of 3 residents (Residents #6 and #71) reviewed. Specifically, Residents #6 and #71 were not assisted with toileting as planned. Findings include: The facility policy, Activities of Daily Living- Functional Impairment, dated 5/2019 documented residents would maintain dignity and self-esteem related to activities of daily living self-performance. Nursing provided the resident activity of daily living support at the level required, as specified in the electronic health record plan of care. 1) Resident #6 had diagnoses including dementia and history of urinary tract infections. The 6/12/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had severe cognitive impairment,…
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 · D2024-08-22 · 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 interview during the recertification survey conducted 8/19/2024-8/22/2024, 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' choice for 1 of 1 resident (Resident #3) reviewed. Specifically, Resident #3 did not have their elastic compression bandage (ACE wrap) applied as ordered. Findings include: The facility policy, Assistance with Compression Stockings, Wraps, and Other Compression Devices, dated 3/29/2016 documented aid with donning and doffing (applying and removing) compression stockings, wraps, and other compression devices would be provided to those residents who were unable to complete the activity independently. Compression wraps were specialized wraps used to improve blood flow in the legs by applying gentle pressure. Resident #3 had diagnoses including lymphedema (tissue swelling due to ineffective drainage by the lymphatic system), and localized edema (extra fluid in the tissues). The 7/13/2024…
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 · D2024-08-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 8/19/2024-8/22/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 2 residents (Resident #31 and #58) reviewed. Specifically, Resident #31 did not have a pillow between their left arm and body for pressure relief as care planned, and Resident #58 did not have pressure relief for their heels as planned. Findings include: The undated facility policy, Pressure Ulcer Prevention, documented the interdisciplinary team was to plan appropriate interventions to remove or modify risk factors that were modifiable and to monitor the impact of interventions and modify as appropriate. Staff was to use appropriate devices to offload pressure from heels that are at high risk. If a resident refused recommended care and treatment, the interdisciplinary team was to evaluate the reason for the refusal, identify…
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 before2024-08-22 · 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 observation, interview, and record review during the recertification survey conducted 8/19/2024-8/22/2024, 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 infection for 1 of 2 residents (Resident #31) reviewed. Specifically, Resident #31's wound care was completed without appropriate hand hygiene, clean supplies, and precautions to prevent contamination of the wound. Additionally, three infection control policies were not reviewed annually as required. Findings included: The facility policy, Skin and Wound Infection Prevention, dated 3/1/2004, documented the facility would reduce the incident of skin and wound infections by utilizing accepted professional standards of care. The clean technique were strategies that were used to reduce the overall number of microorganisms or to prevent the risk of transmission of microorganisms from one place to another. The clean technique involved meticulous handwashing,…
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 before2024-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the abbreviated survey (NY00329178), the facility did not ensure adequate supervision was provided to prevent accidents for 1 of 7 residents reviewed (Resident #5). Specifically, Resident #5 experienced increased anxiety and aggressive behaviors towards Residents #4, 6, 7, 8, 9, and 10 and the facility did not ensure adequate supervision was provided to prevent behaviors directed towards others. Findings include: The 5/2019 Behavioral Symptom Management Policy documented all residents who display symptoms including wandering, physical abuse, pacing, restlessness, socially inappropriate, or disruptive behaviors will not sustain harm to themself or others. Interventions included to ensure the resident's physical and comforts needs were met, move to a less stimulated area when overstimulated, and provide diversional activities. The 11/2003 Incident/Accident Investigation and Evaluation policy documented adequate supervision refers to an intervention 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 · D2024-04-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review during the abbreviated survey (NY00329178), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated or reported to the New York State Department of Health timely when required for 3 of 10 residents (Resident #6, 9 and 10) reviewed. Specifically, Residents #5 and 6 had physical altercations that were not thoroughly investigated and altercations involving Residents #5, 6, and 9 were not reported to the New York State Department of Health as required. Findings include: The facility's Abuse policy dated 6/14/2023 documented all residents would be free from abuse and all reports of resident abuse or neglect were to be promptly and thoroughly investigated. The facility's Incident/Accident Investigation and Evaluation Policy documented it was the policy of the facility to accurately investigate and evaluate incidents and accidents, and to document the occurrence, findings, actions taken, and outcomes in the medical record and on the Incident/Accident Quality Assurance form. Documentation…
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 · D2022-09-01 · 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 interview and record review during the recertification survey conducted 8/29/22-9/1/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 3 residents (Residents #54 and 76) reviewed. Specifically, Resident #54 received an altered consistency diet, had a significant weight loss, did not receive assistance at meals as care planned, and was not reassessed by clinical nutrition staff to address weight loss. Resident #76 had a significant weight loss, was not reassessed by clinical nutrition staff, and had further significant weight loss. Findings include: The facility policy Clinical Nutrition Assessment revised 1/2012 documented a nutritional assessment would be completed based on the individual resident's needs and care plan approaches would be specific to the resident's needs and preferences. The facility policy Weight Measurement and Reweight Measurement revised 11/2013 documented: - All residents would be weighed monthly unless medically ordered; - Residents with a weight loss or gain of 5 pounds (lbs.) or more would 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.
- No harm found · C2022-09-01 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview during the recertification survey conducted 8/29/22-9/1/22, the facility failed to post on a daily basis, at the beginning of each shift, in a prominent place readily accessible to residents and visitors, nurse staffing information including the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. Specifically, the facility did not post nurse staffing information in an accessible place for residents and visitors as required. Findings include: The facility policy Nurse Staffing Information dated 10/2015 documented the facility would post, update, retain, and make available to the public nurse staffing information in accordance with regulatory guidelines. Nurse staffing information that must be posted included facility name, current date, resident census, and total number and actual work hours of all direct care nursing staff per shift. The information must be clear and readable. The information must be posted on a daily basis in a prominent place…
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
$151,625 in federal fines across 1 penalty.
- $151,625 — penalty dated 2024-08-22
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.
Part of a chain
This home belongs to UNITED METHODIST HOMES — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 3 of 5 | 3.5 | -0.5 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 1 home this chain runs (chain average 2.5★, 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 | Since |
|---|---|---|---|
| BERG, SHARON | Individual | CORPORATE DIRECTOR | since 05/29/1996 |
| BETZ, EDWIN | Individual | CORPORATE DIRECTOR | since 05/28/2003 |
| BYRNE COLLING, KATHLEEN | Individual | CORPORATE DIRECTOR | since 08/27/2014 |
| CLARK, DOUGLAS | Individual | CORPORATE DIRECTOR | since 12/16/2020 |
| CROUNSE, JOHN | Individual | CORPORATE DIRECTOR | since 05/28/2008 |
| DIRHAN, COLEMAN | Individual | CORPORATE DIRECTOR | since 05/29/2023 |
| GRILLINI, CATHERINE | Individual | CORPORATE DIRECTOR | since 05/29/2023 |
| HALL, ROBERT | Individual | CORPORATE DIRECTOR | since 05/29/2019 |
| HERTEL, ALAN | Individual | CORPORATE DIRECTOR | since 01/29/2020 |
| HORN, JANICE | Individual | CORPORATE DIRECTOR | since 05/29/2023 |
| JOHNSON, MARYANN | Individual | CORPORATE DIRECTOR | since 05/25/2011 |
| KINSMAN, ALLAN | Individual | CORPORATE DIRECTOR | since 05/23/2002 |
| LAMANTIA, SALVATORE | Individual | CORPORATE DIRECTOR | since 10/03/2017 |
| LEE, LISA | Individual | CORPORATE DIRECTOR | since 05/26/2016 |
| LEWIS, SHARRON | Individual | CORPORATE DIRECTOR | since 08/31/2016 |
| LEWIS, WILLIAM | Individual | CORPORATE DIRECTOR | since 08/28/2013 |
| MULLIGAN, ROSEANNE | Individual | CORPORATE DIRECTOR | since 08/27/2014 |
| OLAVIANY, TANYA | Individual | CORPORATE DIRECTOR | since 05/29/2023 |
| RAY, MARGARET | Individual | CORPORATE DIRECTOR | since 08/29/2018 |
| REID, PHILIP | Individual | CORPORATE DIRECTOR | since 05/26/2016 |
| STARR, WILLIAM | Individual | CORPORATE DIRECTOR | since 05/31/2017 |
| TESTA, KENDRA | Individual | CORPORATE DIRECTOR | since 05/29/2023 |
| THOMAS, CHARLOTTE | Individual | CORPORATE DIRECTOR | since 05/30/2018 |
| PATTI, RONALD | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/19/2015 |
| PICCHINI, BRIAN | Individual | CORPORATE OFFICER | since 01/01/2012 |
| UMH MANAGEMENT SERVICES CORP | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2007 |
| AHMAD, RANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/26/2025 |
| CUNDEY, CHELSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/20/2025 |
CMS files one row per role, so the 31 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 335090. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-01, 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 →
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