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Delaware Oaks Center for Rehabilitation and Nursin

1205 Delaware Avenue, Buffalo, NY 14209 · For profit - Partnership · 95 certified beds · (716) 885-3838 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (21) — 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)
  • its payroll-based staffing rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

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

Location & what’s nearby

Hospital
 
Urgent care / clinic
1083 Delaware Ave · (716) 768-4636 · Call to confirm hours
Pharmacy
Rite Aid0.4 mi
1410 Delaware Ave · (716) 885-9944 · Call to confirm hours
Grocery
783 Elmwood Ave · (716) 887-9777 · Call to confirm hours
Park
2 Gates Cir · Typically dawn to dusk
Place of worship
1243 Delaware Ave · (716) 882-0391

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 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.1%14.1%15.4%better
Long-stay residents who lose too much weight9.0%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.5%0.9%better
Long-stay residents with a urinary tract infection0.3%1.3%2.0%better
Long-stay residents with depressive symptoms8.7%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury1.3%3.1%3.3%better
Long-stay residents whose ability to walk worsened2.4%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.1%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine96.3%95.3%95.3%typical
Long-stay residents with pressure ulcers8.0%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control22.6%19.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.1%13.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine76.0%78.8%79.4%typical
Short-stay residents rehospitalized after admission21.5%20.6%22.6%typical
Short-stay residents with an outpatient ER visit16.4%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.671.701.67typical
Long-stay outpatient ER visits per 1,000 resident days3.491.361.80worse

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

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

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

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

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

41.1% 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 131 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.1%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
78.3%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 78.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 115 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.1%CMS range 33.7–50.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.4–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge78.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge69.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified93.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.9–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.46
RN hours/ resident / day
0.76
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.23
Total nurse hours/ resident / day
0.23
RN hoursweekends
47.4%
Total nursing turnover
52.6%
RN turnover

How full it usually is: this home is certified for 95 beds and averages 92.0 residents a day — about 97% occupied, or roughly 3 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.75 hrs/resident/day on weekends vs 3.43 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.55 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% 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

8
deficiencies at the latest standard inspection (2024-08-09)
5
at the previous standard inspection (2023-03-24)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Dcited before2025-11-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Complaint Investigation (2598732) during the Standard survey completed on 09/19/2025, the facility failed to protect residents from resident-to-resident sexual abuse for one (1) (Resident #12) of three (3) residents reviewed. Specifically, Resident #12 was touched inappropriately by Resident #51 and both residents lacked the ability to consent. The finding is: The policy titled Prevention, Investigation & Reporting Resident Abuse, Mistreatment, Injury of Unknown Source, Neglect & Misappropriation of Resident Property Effective 5/2024 and last reviewed 7/2024 documented that it was the facility's policy to prevent sexual abuse, and documented sexual abuse was defined as non-consensual sexual contact of any type with a resident. Resident #51 had diagnoses which included dementia, depression, and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 08/29/2025 documented Resident #51 was severely cognitively impaired,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during Complaint investigation (2598732) during the Standard Survey completed on 09/19/2025, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse, to the administrator and to other state officials (including to the State Survey Agency) for two (2) (Residents #12 and #51) of three (3) residents reviewed. Specifically, the Administrator was notified of an allegation of resident-to-resident abuse and it was not reported to the State Agency within the required time frame.The finding is:Refer to F 600 Freedom from Abuse and NeglectThe policy titled Prevention, Investigation & Reporting Resident Abuse, Mistreatment, Injury of Unknown Source, Neglect & Misappropriation of Resident Property Effective 5/2024 and last reviewed 7/2024 documented that it was the facility's policy to prevent abuse and any suspected or actual violation required immediate reporting to the Administrator, Director of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review completed during a complaint investigation (#NY000373627), the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. Specifically, Resident #1 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms (MDRO) including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during hands-on care while dressing, changing briefs, changing linens and performing wound care. The finding is: The facility's policy titled Barrier Enhanced Precautions last reviewed 1/2024 documented Enhanced Barrier Precautions expands the use of PPE (personal protective equipment) and designates the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-09 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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, interaview and record review conducted during a Standard survey completed on 8/9/24, it was determined that the facility did not ensure that they maintained an effective pest control program so that the facility is free of pests and rodents. Specifically, two (Units 2 & 3) of two Resident Units and the Main Kitchen had issues with insects including house flies, spiders, and fruit flies. The findings are: The policy and procedure titled Pest Control dated January 2024 documented the facility would maintain an effective pest control program. The policy and procedure documented the facility maintains an ongoing pest control program to ensure the facility is free of insects. A request for exterminator service inspection reports from June 2024 to August 2024 was given to the facility. The facility did not provide exterminator service inspection reports from July 2024 and August 2024. Review of the June 2024 exterminator service inspection reports dated 6/13/24 documented that the drain flies…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during Complaint investigations (#NY00336247 and #NY00319578) during a Standard survey completed on 8/9/24 the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided for one (Unit 3) of two resident units. Specifically, the facility roof was in disrepair and actively leaking resulting in stained and wet ceiling tiles. Additionally, there were walls and floors in disrepair, urine odors, a soiled privacy curtain and a broken window. The findings are: The policy and procedure titled Maintenance Service dated 1/24 documented that maintenance service shall be provided to all areas of the building, grounds, and equipment. a. Observation on the Third Floor on 8/5/24 at 6:40 PM revealed the walls of the shower stall in the [NAME] Shower Room were in disrepair. Further observation revealed the bottom of the plastic shower surround panels were soft and speckled with 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a complaint investigation (Complaint #NY00330109) during the Standard survey completed on 8/9/24, the facility did not ensure the resident's right to be free from abuse for one (Resident #72) of 7 residents reviewed for abuse. Specifically, Resident #72 wandered into Resident #61's room on two separate occasions where a resident-to-resident altercation occurred that resulted in minor injuries to Resident #72. Additionally, care plan interventions (stop signs in doorway) to keep Resident #72 out of the room, were not in place. The finding is: The policy and procedure titled Abuse Prohibition Protocol, Types of Abuse, Response/Reporting dated 1/24 documented every resident has the right to be free from abuse and the facility would do all that is in their control to prevent such occurrences. Physical abuse includes acts of violence like striking (with or without an object), hitting, and shoving. 1. Resident #72 had diagnoses including dementia,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Standard survey completed on 8/9/24, the facility did not ensure that when the use of a restraint was indicated, the facility used the least restrictive alternative for the least amount of time for one (Resident #76) of one resident reviewed. Specifically, the resident's seatbelt restraint was not released every two hours as ordered. The finding is: The policy and procedure titled Use of Restraints dated 1/24 documented a physical restraint was defined as any manual method or mechanical device attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each two hours of restraint use. Resident #76 had diagnoses including cerebral palsy (abnormal brain development that affects ability to control muscles), seizures, and anxiety disorder. The Minimum Data Set (a resident assessment…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Complaint investigation (NY00345819) during a Standard survey completed on 8/9/24, it was determined the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for two (Residents #61 and #63) of nine residents reviewed. Specifically, the residents did not have a stop sign/s across their doorway to deter other residents from entering their room as planned. The finding is: The policy and procedure titled Care Plan, Comprehensive Person-Centered dated 1/24 documented that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #63 was admitted to the facility with diagnoses of schizoaffective disorder and bipolar disorder (mental health conditions.) The Minimum Data Set (MDS - a resident assessment tool)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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, interview, and record review conducted during a Standard survey completed on 8/9/24, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #49) of one resident reviewed. Specifically, the Physician Wound Consultants recommendations for an air mattress were not implemented. The finding is: The facility policy and procedure titled Consultations, last revised 1/24, documented the facility is responsible to provide consultation services for any residents as needed. The facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility, and the timeliness of the services. Nursing will notify physician of consultation and any recommendations if physician is not at facility. Physician will approve any orders he/she agrees with on consult. Physician will document if he/she agrees on consult. The facility policy and procedure titled…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 8/9/24, the facility did not ensure that a resident with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion for one (Resident #5) of one resident reviewed for positioning and mobility. Specifically, Resident #5 had a contracture (loss of joint mobility) and was not provided a device to prevent further contracture. The finding is: The facility policy and procedure titled Contracture Management, last revised on 1/24, documented the facility will engage residents as appropriate in contracture management interventions to improve, maintain and prevent the deterioration of mobility of joints, flexion (bending of a joint) and extension of extremities. A joint contracture is characterized by chronically reduced range of motion secondary to structural changes in non-bony tissues, including muscle, tendons, ligaments, and skin. Prolonged immobilization of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-08-09 · tag F0806 — failed to honor food preferences — isolated
    Ensure 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 observation, interview, and record review conducted during a Complaint investigation (#NY00330919) during the Standard Survey completed on 8/9/24, the facility did not ensure each resident received food that accommodated their allergies, intolerances, and preferences for one (Resident #89) of one resident reviewed. Specifically, Resident #89 received a meal tray with foods that did not accommodate their documented preferences. The findings include: The facility policy and procedure titled Food and Nutrition Services, undated, documented each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Additionally, food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Resident #89 had diagnoses that include protein-calorie malnutrition, dysphagia (difficulty swallowing), and chronic diastolic heart failure. The Minimum Data Set (a resident assessment tool) dated 7/16/24…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during a Standard survey completed 3/24/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: dirty hoods over the ovens/stoves; the light over the stove was out, pipes along the ceiling had a build- up dust; the griddle was soiled with a thick layer of black a greasy dried substance; the wall next to the griddle and behind the ovens/stoves and floor under the ovens/stove were soiled with a black greasy substance; floors throughout the kitchen were soiled with debris black greasy substance; the ice cream freezer had ice build-up; garbage cans were over- flowing with garbage and had no lids. There were multiple crates of outdated milk in the refrigerator; walk-in refrigerator and freezer floors were soiled food drippings/spills. The walk-in refrigerator's condenser had a build of mold and containers of food under the condenser also had spots of mold. There were multiple containers of food that where…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-24 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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, interview, and record review during the Standard survey completed on 3/24/23, the facility did not maintain the resident call bell system in working order. Specifically, call bells in resident rooms, resident bathrooms and shower rooms did not activate the call light above the residents' room doors and did not activate the master station located at the Nurses' Station. This affected one (2nd floor) of two resident units. This involves Residents #35, 59 and 54. The finding is: The policy and procedure titled, Answering the Call Light reviewed 2/2023, documented a general guideline was to report all defective call lights to the nurse supervisor promptly and nursing must notify maintenance department of the defective call light. Review of the Visual Nurse Call System Operating Instructions revealed routine calls are indicated by simultaneous operation of illumination of the associated station selector LED (light-emitting diode) , which indicates origin of call, illumination of call lamp at…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during a complaint investigation (Complaint #NY00298668) during the Standard survey completed on 3/24/23, the facility did not ensure residents had the right to be free from sexual abuse for four (Resident #s 1, 21, 67 and 246) of 11 residents reviewed for abuse. Specifically, the facility did not ensure Resident #246 did not engage in non-consensual sexual contact with Resident #1. Resident #246 was found touching Resident #1's exposed genitals. Additionally, Resident #67 had non- consensual contact with Resident #21 and was found touching Resident #21 on their breast and inner thigh in the dining room. The findings are: The policy and procedure (P&P) titled Abuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting revised on 1/2022, documented sexual abuse was defined as non-consensual sexual contact of any type with a resident, sexual contact with any person incapable of giving sexual consent. This included, but…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a complaint investigation (NY00298668) completed on a Standard survey completed 3/24/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, two (#1 and #246) of eleven residents reviewed for abuse were involved in an allegation of sexual abuse and was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy and procedure titled Abuse Prevention Program/ Abuse and Neglect-Clinical Protocol/ Abuse Investigation and Reporting dated 1/2022 documented all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or designee, to the State licensing/ certification agency responsible 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey, completed on 3/24/23, the facility did not ensure that a resident's drug regimen was free from unnecessary psychotropic medications for one (Resident #70) of five residents reviewed for antipsychotic medications. Specifically, an antipsychotic (AP) medication was restarted without behavioral documentation or psychotic features to support its use and physician progress notes documented the resident was stable with no indication to restart psych meds. Additionally, there was lack of monitoring for side effects after the medication was initiated. The finding is: The facility policy and procedure titled Antipsychotic Medication Use reviewed 1/2022, documented AP medications may be considered for residents but only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Residents will only receive AP medication when…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record conducted during the Standard survey completed on 4/14/21, the facility did not ensure that each resident is treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, one (Resident #340) of one resident reviewed for dignity had issues involving, resident exposure and incontinent care provided by staff in the dayroom in clear view of staff, residents, and visitors. Additionally, meals were served to the resident on a bare mattress that was placed directly on the floor in the dayroom and the resident was not provided with a call light/bell. The findings are: The facility policy and procedure (P&P) titled Quality of Life-Dignity revised 1/2021 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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, interview, and record review conducted during a Standard survey completed on 4/14/21, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for one (Resident #17) of two residents reviewed. Specifically, there was lack of weekly pressure ulcer assessments by a qualified person and the Treatment Administration Records (TAR) were not accurately documented. The findings are: The facility policy and procedure (P&P) titled Pressure Ulcer/ Skin Breakdown - Clinical Protocol dated 3/2021documented; Weekly wound rounding will be conducted with assessing nurse, designated medical services (ex. Wound care physician) and other relevant members of the Interdisciplinary Team (IDT). Weekly documentation will be entered into the resident's chart which include but are not limited to the measurement, wound base, drainage and presence of odor. a. Resident #17 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-14 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during the Standard survey completed on 04/14/21, the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice. Specifically, one (Resident #62) of one resident reviewed for dialysis had an issue involving the lack of ongoing communication and collaboration by the facility staff and the staff of the dialysis center regarding dressing changes to the AVF (arteriovenous fistula) access site (a tube or device surgically implanted to create an artificial connection between an artery and a vein) resulting in the pressure dressing not being removed per physician order. The finding is: The facility policy and procedure (P&P) entitled A/V Shunt Care with the revision date of 1/2021 documented residents returning post dialysis treatment with a pressure dressing in place, check placement of the dressing, observe for bleeding, and review dialysis communication book. Report all changes and/or communication with the MD. Resident #62 was admitted to the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review conducted during the Standard survey completed on 4/14/21, the facility did not ensure that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and PRN (as needed) orders for psychotropic drugs are limited to fourteen days and the Physician believes that it is appropriate for the PRN order to be extended beyond fourteen days should document the rationale in the medical record and indicate the duration of the PRN order. One (Residents #22) of five residents reviewed for unnecessary medications had an issue involving the lack of physician documentation supporting the continued use of the PRN psychotropic medication (Xanax - medication used to treat anxiety) beyond fourteen days. The finding is: Review of the Policy and Procedure (P&P) entitled Medication, Utilization and Prescribing with a revision date of 1/2021 documented the physician and staff will review the rational for existing medications that lack a clear indication or…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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, record review and interview during the Standard survey completed on 4/14/21, the facility did not ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles including expiration date, were stored in locked compartments, and that controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse were stored in separately locked, permanently affixed compartments for 3 of 4 medication storage areas. Specifically, the second floor medication room was left unlocked and contained unsecured/ unattended medications, the second floor Team 1 medication cart contained expired over the counter (OTC) medications and an undated insulin pen for Resident #66. Additionally, discontinued controlled drugs (narcotics) were stored in a cardboard box on the floor of a closet in the Director of Nursing (DON) office. The findings are: The facility policy and procedure (P&P) titled Storage of Medications revision date 1/2021 documented the facility shall store all…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE GRAND HEALTHCARE — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.8+0.2 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 2 of 52.1-0.1 vs chain
Quality measures 3 of 52.1+0.9 vs chain
The other 15 homes this chain runs (chain average 1.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
STRAUSS, ELLIOTIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 11/05/2021
STRAUSS, JEREMYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST95%since 11/05/2021
STERN, SAMUELIndividualCORPORATE OFFICERsince 11/05/2021
BALAN, BELINDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/06/2023

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.

$10.0M
Net patient revenuemost recent cost report
-11.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 81%Medicare 15%Other / private 4%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$350per resident / day
operating cost
$10,633per month
≈ monthly operating cost
$313per day
avg. revenue, all payers

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

What families pay in NY

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335640. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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