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Highpointe On Michigan Health Care Facility

1031 Michigan Ave, Buffalo, NY 14203 · Non profit - Corporation · 300 certified beds · (716) 748-3101 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)1 immediate-jeopardy citation$129,149 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $129,149 in federal fines (most recent 2024-09-16)
  • 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)
  • 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 1 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
100 High St · (716) 859-1400 · Call to confirm hours
Pharmacy
1091 Main St · (716) 954-8877 · Call to confirm hours
Grocery
883 Jefferson Ave · (716) 710-0955 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 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 increased15.1%14.1%15.4%typical
Long-stay residents who lose too much weight4.2%5.8%5.4%better
Long-stay residents with a catheter left in their bladder1.4%0.5%0.9%worse
Long-stay residents with a urinary tract infection2.8%1.3%2.0%worse
Long-stay residents with depressive symptoms0.8%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 worsened14.0%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.4%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine97.3%95.3%95.3%typical
Long-stay residents with pressure ulcers8.6%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control25.7%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table5.9%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine78.8%78.8%79.4%typical
Short-stay residents rehospitalized after admission11.9%20.6%22.6%better
Short-stay residents with an outpatient ER visit8.3%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days0.891.701.67better
Long-stay outpatient ER visits per 1,000 resident days1.741.361.80typical

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.

45.1% 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 148 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.1%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
52.0%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 52.0% 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 77 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.1%CMS range 37.3–51.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.8–14.310.7%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 discharge52.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.3%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 discharge55.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.3%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 worsened7.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.8–9.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

1.16
RN hours/ resident / day
1.11
LPN hours/ resident / day
3.13
Aide hours/ resident / day
5.41
Total nurse hours/ resident / day
0.75
RN hoursweekends
31.6%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 300 beds and averages 258.2 residents a day — about 86% occupied, or roughly 42 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 5.41 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.16 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.13 is at or above 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 4.62 hrs/resident/day on weekends vs 5.73 on weekdays — 19% thinner on weekends. RN hours go from 1.33 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

11
deficiencies at the latest standard inspection (2024-09-16)
7
at the previous standard inspection (2022-08-30)

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.

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Lcited before2024-09-16 · tag F0600 — failed to protect residents from abuse and neglect — widespread
    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 observations, interviews and record reviews conducted during a complaint investigation (#NY00330798 and #NY00325133) during an extended standard re-certification survey from 9/3/2024 to 9/16/2024, the facility failed to protect the residents' right to be free from sexual abuse by a resident for three (Residents #33, #50, #208) of ten residents reviewed. Specifically, the facility failed to implement safeguards that resulted in repeated instances of sexual abuse with residents that had impaired cognitive status and lacked the ability to consent. This resulted in and had the likelihood for psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #33, #50, #208 with the likelihood to affect all residents (census 265) in the facility. The findings are: The policy and procedure titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident revised on 9/12/2024 documented any resident abuse will not be tolerated.…

    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
  • Actual harm · Gcited before2024-09-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review completed during complaint investigations (Complaint #NY00345300 and #NY00324827) during an extended recertification survey, the facility failed to ensure that each resident received adequate supervision to prevent accidents and elopement for two (Resident #20 and #228) of ten residents reviewed. Specifically, Resident #228 required 1:1 (one to one) supervision for safety and had an unwitnessed fall, sustaining a right hip fracture. In addition, on 9/24/2023 at 1:25 PM Resident #189 eloped through the front door of the facility. This resulted in actual harm to Resident #228 that was not Immediate Jeopardy. The findings are: 1. During an interview on 9/11/2024 at 12:39 PM both the Director of Nursing and the Administrator stated there was no policy for 1:1 supervision. Review of the Role of the Sitter and Sitter Safety in the Acute Healthcare Setting education revealed the definition of 1:1 is constant observation, meaning a situation in which a staff member is…

    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 · Ecited before2026-03-05 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 survey the facility did not ensure the resident's right to be free from neglect for twenty two (22) (Residents #1, 2, 3, 7, 8 ,9 ,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) of twenty two (22) residents reviewed. Specifically, on 08/18/2025, 08/27/2025, 08/28/2025, and 12/04/2025 staff did not provide incontinent rounds and/or care every two (2) to three (3) hours per the residents' plan of care and safety checks.The findings are but not limited to: The policy titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d revised 10/22/2024 documented that resident abuse and neglect, will not be tolerated. Any staff member or volunteer shall not physically, mentally, sexually or emotionally abuse, mistreat or neglect a resident. Neglect is defined as the failure of the facility, it's employees or service providers to…

    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 before2026-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review conducted during a survey, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for two (2) (Residents #4 and #5) of three (3) resident reviewed for accidents. Specifically, the facility did not ensure that Resident #4, who was severely cognitively impaired and at risk for elopement, was adequately supervised to prevent them from exiting through a stairwell door and they were found in the stairwell; the facility did not ensure Resident #5 was reassessed for elopement risk or had interventions in place to prevent/address exit seeking behavior when they had improvement in their functional levels and the resident was found on the sidewalk next to the building by staff. The findings are:The policy titled Elopement Long Term Care/ Missing Person, last revised 12/08/2025, documented it was required and desired for the facility to provide a safe environment for all residents. The facility would properly…

    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 before2025-04-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review conducted during the Abbreviated Survey (Complaint #NY00376929) the facility did not ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) (Resident #1) of three (3) reviewed. Specifically, a BiPAP machine (Bilevel Positive Airway Pressure machine used as a non-invasive respiratory support) was not provided until five days after admission to the facility. The finding is: The policy and procedure titled Resident Assessment Process revised 12/2022 documented the external data collection of medical documents begins at the time of admission from transferring institutions. These documents will assist the interdisciplinary team in the development of the comprehensive assessment. Data will be collected from various sources, not limited to hospitals. The internal collection process was conducted simultaneously 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
  • Potential for harm · Fcited before2024-09-16 · tag F0610 — failed to investigate and act on abuse reports — widespread
    Respond appropriately to all alleged violations.
    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 (#NY00330798 and #NY00325133) during an extended standard survey on 9/16/24, the facility did not ensure that all alleged violations of abuse were thoroughly investigated for four (Resident #33, Resident #50, Resident #208, Resident #226) of ten residents reviewed. Specifically, facility investigations lacked interviews with potential witnesses and other potential victims (Resident #50, Resident #208, and Resident #226). Also, there was lack of an investigation when Resident #226 exposed their genitals in front of Resident #33 and Resident #50 in a common area. The findings are: The policy and procedure titled Identification and Reporting of Abuse, Neglect, Exploitations, of Mistreatment of a Skilled Nursing Facility Resident revised on 9/12/24, it documented that the facility begins an investigation immediately upon discovery of an incident, gather statements from the resident who is the suspected victim of abuse, gather statements…

    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 · F2024-09-16 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 an extended standard survey completed from 9/3/2024 to 9/16/2024, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure policies and procedures were…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-16 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    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 an extended survey completed on 9/16/24, the facility did not ensure a quality assurance and performance improvement (QAPI) program did not ensure the committee developed and implemented appropriate plans of action to correct quality deficiencies and regularly reviewed, analyzed and acted on available data to make improvements. Specifically, the facility quality assurance and improvement program did not identify, develop, and implement an appropriate plan to prevent and protect all residents from sexual abuse when repeated patterns of sexually inappropriate behaviors occurred. Additionally, when there was a change in the facilities processes for addressing hospital transfer/discharge notifications and bed hold policy notices; the facility quality assurance and performance improvement program did not identify they were not being completed as required. Refer to: F 600 - Free from Abuse and Neglect F 610 - Investigate/Prevent/Correct Alleged Violation F 623 -…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review conducted during an Extended survey completed on 9/16/24, the facility did not ensure the resident's representative was notified immediately of a change of condition for one (Resident #267) of two residents reviewed for notification of change. Specifically, Resident #267's representative was not notified of the resident's tracheostomy (opening into the trachea) tube being removed. The finding is: Resident #267 had diagnoses that included traumatic subdural hemorrhage (bleeding in the brain), acute kidney failure, and depression. The Minimum Data Set (a resident assessment tool) dated 8/11/24 documented Resident #267 was moderately cognitively impaired, usually understood and sometimes understands. The comprehensive care plan dated 5/11/24 documented Resident #267 had a tracheostomy related to impaired breathing mechanics. The comprehensive care plan documented the resident had a knowledge deficit related to their medical condition and/or plan of care. Review of Resident #267's admission Record, with a printout date of 9/9/24,…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a complaint investigation (#NY00324941) during an Extended survey completed on 9/16/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Residents #20) of two residents reviewed. Specifically, Resident #20 had greasy, disheveled hair, with matting and knots to the back of their head. The finding is: Resident #20 had diagnoses that included multiple sclerosis (disease central nervous system), age-related physical debility, and epilepsy (seizure disorder). The Minimum Data Set (a resident assessment tool) dated 7/7/24 documented the resident was understood, understands, and had severe cognitive impairment. The Minimum Data Set documented Resident #20 did not exhibit rejection of care behaviors and they required substantial/maximal assistance for personal hygiene. Review of the facility Orientation Checklist 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · tag F0700 — isolated
    Try 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during an extended standard survey completed on 9/16/24, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtained informed consent prior to the installation of bed rails for one (Resident # 20) of one resident reviewed for bed rails. Specifically, Resident #20 was not assessed for risk of entrapment from bed rails, there was no documented evidence the risks and benefits of bed rails were reviewed and that consents were obtained prior to bed rail use. Additionally, there was lack of maintaining the bed rails in proper working order. The finding is: The policy and procedure titled Transfer/Bed Mobility Bar revised 10/25/22 documented the goal is always to maintain the highest practical functional status for our residents. The use of a transfer/bed mobility bar facilitates this commitment and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during a Complaint investigation (#NY00336618) during an Extended survey completed on 9/16/24, the facility did not ensure that residents are free of significant medication errors for one (Resident #250) of three residents reviewed. Specifically, on 3/20/24 Registered Nurse #3 erroneously administered Resident #247's morning medications to Resident #250 which resulted in a significant medication error. The finding is: The policy and procedure titled Medication Ordering, Interpretation and Administration Guidelines revised 10/3/22 documented prior to all medication administration, scanning both the patient's wristband and the medication barcode are required. The facility's Medication Administration Competency Assessment Tool revised 5/11/23 documented medications were administered using the right resident, right medication, right dose, resident route, right time, right reason/indication for medication, right documentation, and right response. Resident #250 had diagnoses including chronic respiratory failure, tracheostomy status (an…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-05-22 · 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 an Abbreviated survey (Complaint #NY00342510) completed on 5/22/24, the facility did not ensure that all alleged violations including abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation is made. If the events that caused the allegation do not involve abuse or result in seriously bodily injury not later than 24 hours to the facility's Administrator and to other officials (including to the State Survey Agency) for one (Resident #1) of three residents reviewed. Specifically, facility staff did not report an allegation of resident neglect to the Director of Nursing or the Administrator which resulted not reporting to the State Survey Agency as required. The finding is: The policy and procedure titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d dated 8/30/99 documented any nursing home employee who becomes aware of abuse, mistreatment, neglect shall…

    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 before2022-08-30 · 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 observation, interview and record review conducted during a Standard survey (Complaints NY00295560 and NY00289847) completed 8/23/22 through 8/30/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for three of four residents reviewed. Specifically, the facility did not report an injury of unknown origin (Resident #137) and allegations of verbal abuse and neglect (Residents #46 and #106) within the two-hour time frame. The findings are: 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #29) of six residents reviewed for quality of care during activities of daily living. Specifically, Resident #29 was observed to have a bilateral axillary (underarm) rash on 8/26/22 and a treatment was not ordered until 8/29/22. Additionally, a nurse applied a medicated powder to Resident #29's bilateral axillary rash without a physician's order on 8/26/22. The finding is: The facility policy and procedure (P&P) titled Physician Orders-Long Term Care effective 7/21/14 documented telephone and verbal orders shall be accepted only by a licensed nurse, pharmacist or such other licensed practitioner as permitted by regulation or law. All verbal and/or telephone orders shall be transcribed in a medical record entry which shall include the date, title, name, title/status…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-30 · 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, record review, and interview conducted during the Standard survey started 8/23/22 and completed on 8/30/22, the facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and equipment to prevent further decrease in range of motion for two (Resident #100 and #138) of four residents reviewed for range of motion (ROM) services. Specifically, Resident #100 was not provided ROM according to therapy recommendations and plan of care and Resident #138 was not provided a palm posey (assistive device that positions the fingers away from the palm) to their right and left hand as planned by Occupational Therapy (OT). The findings are: Review of the facility policy and procedure (P&P) titled Physical/Occupational Therapy-SNF (skilled nursing facility)-Range of Motion (preventative routine) dated 7/23/19, documented ROM programs are implemented to prevent and manage contractures (loss of joint mobility), maintain joint mobility, and for stretching of upper…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey started 8/23/22 and completed on 8/30/22, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #56) of four residents reviewed for respiratory care. Specifically, there was not an order for oxygen (O2) or humidification since 12/10/21. The finding is: The facility policy and procedure (P&P) titled Oxygen Therapy, O2 revised 11/10 documented a written physician order was necessary to initiate oxygen therapy, with exception for emergency short term use only. All oxygen therapy orders must include parameters, flow rate or percent FIO2 (fraction of inspired oxygen). Oxygen therapy is defined as the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia (low oxygen level). Oxygen is listed as a medication by the U.S.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and Director of Nursing (DON), and that these reports were acted upon for one (Resident #159) of five residents reviewed for Drug Regimen Reviews. Specifically, the Consultant Pharmacist's did not identify the continued use of a PRN (as needed) Ativan (psychotropic antianxiety medication) in use for six months, and the physician did not act upon the recommendations in a timely manner. Additionally, there was lack of identifying and reporting that the medication was not administered per the physician's order. The finding is: The facility policy and procedure (P&P) titled Guidelines for the Use of Psychoactive Medications revised 11/9/15, documented a psychoactive medication is defined as any medication whose primary function is to treat disorders of thought process, mood, behavior, or sleep. Pharmacy responsibility included to initiate…

    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 · D2022-08-30 · 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 interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that PRN (as needed) orders for psychotropic drugs were limited to fourteen days and if the attending physician believes that it was appropriate for the PRN order to be extended beyond fourteen days, they should document the rationale in the medical record and indicate the duration of the PRN order for one (Resident #159) of five residents reviewed for unnecessary medications. Specifically, there was lack of physician documentation indicating the duration of use for a PRN psychotropic medication (Ativan - medication used to treat anxiety) used beyond fourteen days. The finding is: The facility policy and procedure (P&P) titled Guidelines for the Use of Psychoactive Medications revised 11/9/15 documented a psychoactive medication is defined as any medication whose primary function is to treat disorders of thought process, mood, behavior, or sleep. Pharmacy responsibility included to initiate psychotropic Drug Review and collaborate with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-30 · tag F0886 — failed to test for COVID-19 as required — isolated
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review during a Standard survey beginning on 8/23/22 and ending on 8/30/22, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility had no documented evidence that three (Certified Nursing Assistant (CNA) #1, #2, and Dietary Service Worker #4) out of four staff reviewed for COVID-19 testing, who were not up to date with their COVID-19 vaccination, were tested for COVID-19 as required. The findings are: The Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH revised 3/10/22 documented that staff who are not up to date with their COVID-19 vaccinations needed to be tested at minimum twice a week when the COVID-19 community transmission level is at high (red). The QSO documented up to date meant a person had received all recommended COVID-19 vaccines, including any booster doses when eligible. The facility policy and procedure (P&P) titled Staff and Resident COVID-19 testing revised 12/23/21…

    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 · E2020-01-22 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 (Complaint # NY00241999) completed on 1/22/20 the facility did not meet the nutritional needs of residents in accordance with established national guidelines and follow the prepared menus. Four (Unit 1, Unit 2, Unit 3, and Unit 4) of four-unit serveries did not serve proper portion sizes. Specifically, Unit 1 and Unit 3 at lunch on 1/15/20 and Unit 2 and Unit 4 at lunch on 1/17/20. In addition, on 1/15/20 menu read garlic toast and puree consistencies did not receive garlic toast or any type of similar substitution. The findings are: Review of the policy and procedure titled Portion Control dated 1/2015 revealed purpose to standardize portions for nutritional balance of diet. Standard portion sizes are determined for all food items, served in the cafeteria, tray lines, and catering functions. The proper type and size serving utensils are used as per production chart. Portions are documented in writing on the production…

    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 · D2020-01-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during a Standard survey completed on 1/22/20, it was determined the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (Units Kensington Heights, Elmwood Village and Cold Springs) of nine units observed for the environment. Specifically, the shower gurney mats were soiled and in disrepair. Underneath the mats, extending the full length of the shower gurney, the mesh beds were heavily soiled with garbage and unknown substances. The findings are: Review of the Policy and Procedure (P&P) entitled Medical Equipment Management System with a revision date of 9/6/19 documented department managers have overall responsibility for ensuring all subordinated are properly trained and informed of all equipment instructions and safety related issues as they pertain to the specific equipment, location, job and task. The P&P further documented equipment users are responsible for daily equipment support such as setup, cleaning and replacement 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited beforedisputed · IDR2020-01-22 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 1/22/20, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for one (Resident #29) of three residents reviewed for abuse. Specifically, there was a lack of a thorough investigation into verbal abuse allegations from 11/22/19. The finding is: Review of the policy and procedure titled Identification and Reporting of Abuse, Neglect or Mistreatment of a Skilled Nursing Facility Resident with review date of 7/17 documented the facility begins an investigation immediately upon discovery of an incident. The investigation is the process used to try to determine what happened. When an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of the appropriate personnel. The investigation will include who was involved; Residents statements; resident roommate statements; involved staff and witness statements of events; resident specific information including: 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 1/22/20, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for two (Resident #16 and # 243) of five residents observed for ADL's. Specifically, residents who were dependent on staff for ADL's, had long, jagged fingernails (#16 and #243) with brown debris under multiple fingernails (#16). In addition, the lack of proper incontinent care ( #243). The findings are: 1. Resident #16 had diagnoses that included dementia with behavioral disturbance, mild cognitive impairment and congestive heart failure. The Minimum Data Set (MDS - a resident assessment tool) dated 12/28/19 documented the resident is understood and understands and moderately cognitively impaired. Section G: Functional Status for ADL (activities of daily living) for Personal hygiene: limited assist. During an observation on 1/15/20…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-22 · 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, record review, and interview completed during the Standard survey completed 1/22/20, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion. Specifically, one (Resident #243) of four residents reviewed for range of motion (ROM) services was not provided with a palm posey (assistive device that positions the fingers away from the palm) to their right hand as planned by Occupational Therapy (OT). The finding is: Review of the facility policy and procedure (P&P) titled Physical/Occupational Therapy-SNF (skilled nursing facility)-Range of Motion (preventative routine) dated 7/23/19, documented ROM programs are implemented to prevent and manage contractures, maintain joint mobility, and for stretching of upper extremities and lower extremities muscles for functional benefits. Review of the facility P&P titled Upper Extremity Splint dated 7/23/19 documented splints are used to prevent and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 1/22/20 the facility did not ensure that residents who had an indwelling Foley catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #511) of two residents reviewed for catheter care. Specifically, the lack of maintaining infection control practices, improper Foley care. Additionally, the lack of care plan development to address a history of urinary tract infections (UTI). The finding is: Review of the undated document titled Urinary Catheter: Indwelling (Foley) Catheter Care -CE Quick Sheet documented instructions for catheter care for males: Retract the skin if the patient is not circumcised. Hold the genitalia at the shaft just below the glans. Assess the urethral meatus (external opening of the urinary tract) and surrounding tissues for inflammation, encrustations, swelling, or discharge. Provide routine perineal care with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-22 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure 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, record review, and interview conducted during a Complaint investigation (Complaint #NY00241999) during the Standard survey completed on 1/22/20, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Cold Springs Village, Kensington) of three resident units reviewed for food temperatures during meals had issues involving food items that were not at safe and appetizing temperatures. Residents #A, B, family representative C, D, E, and F were involved. The findings are: Review of the undated Patient Tray Assessment provided by the General Manager/ Food Service Director on 1/17/20 revealed As Served Standards: Soup/ Hot Beverage: > (greater than) 150°F (degrees Farenehight) Hot Entrees, Starch, Vegetables: >135°F Salad, Dessert, Fruit: < (less than) 50°F Milk, Cold Beverage, Potentially Hazardous Cold Food: < 45°F Review of Dining Committee minutes dated 12/17/19 revealed the residents stated the food can be warmer and there are dislikes for the coffee. During an interview on 1/15/20…

    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 · D2020-01-22 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Standard Survey (Complaint # NY00241999) completed on 1/22/20, the facility did not store and distribute food in accordance with professional standards for food service safety. Specifically, one of one main kitchen and five (Cold Springs B POD, Elmwood A Pod, [NAME] B Pod, Kensington A and B Pods) of fifteen-unit nourishment pods had issues with unclean equipment, wet and dirty stacked pots and pans and outdated and undated food. The finding is: Review of a policy and procedure (P&P) titled Cleanliness & Sanitation dated 1/2015 revealed purpose to achieve a clean, sanitary environment. Procedure: follow the guidelines given to define the standard of clean for kitchen equipment, food preparation, storage, dining, and ware washing areas. Pots and pans: free of grease and air dried. Hoods/ Hood Filters: hoods should be smooth to the touch and free of grease, dust, and dirt. Slicer machine: blade, blade guard, carriage, machine surface 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-09-16 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 record review and interview conducted during an extended standard survey completed on 9/16/24, the facility did not ensure that the resident or resident representative was notified in writing, of the transfer and the reason for hospitalization for three (Resident #91, #222 and #250) of three residents reviewed. Specifically, Resident #91 was sent to the hospital on 8/30/24 and Resident #222 had multiple hospitalizations (4/14/24, 5/16/24, 5/23/24 and 8/13/24) with no written notification to the resident or their representative of the Notice of Transfer or Discharge. Resident #250 was transferred to the hospital on 3/20/24 with no written notification to the resident or their representative of the Notice of Transfer or Discharge and facility did not send a copy of the Transfer or Discharge notice to the Office of the State Long Term Care Ombudsman. The findings are: The facility policy titled Transfer, Resident Discharge revised 8/2023 documented, it was the policy of this facility that each resident has…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-09-16 · tag F0625 — widespread
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during an extended standard survey completed on 9/16/24, the facility did not ensure that the resident or resident representative was notified in writing of the bed hold policy for three (Resident #91, #222 and #250) of three residents reviewed for hospitalization. Specifically, Resident #91 was sent to the hospital on 8/30/24, Resident #222 had multiple hospitalizations (4/14/24, 5/16/24, 5/23/24 and 8/13/24) and Resident #250 was transferred to the hospital on 3/20/24 with no written notification to the resident or their representative of the facility's bed hold policy. The findings are: Review of facility Resident Handbook undated documented; Bed Reservation Policy as follows: Residents hospitalized paying with private funds - Residents privately paying for basic services with private funds may reserve their room at the facility by continuing to pay the basic daily service rate while they are in the hospital. The resident / representative will be contacted with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$129,149 in federal fines across 1 penalty.

  • $129,149 — penalty dated 2024-09-16

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

Who owns this facility

Owner / managerTypeRoleShareSince
KALEIDA HEALTHOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/03/2011
PRUDENTIAL HUNTOON PAIGE ASSOCIATES, LLC.Organization5% OR GREATER MORTGAGE INTERESTsince 04/01/1998
BARKOWSKI, RAKHIIndividualCONTRACTED MANAGING EMPLOYEEsince 04/01/2024
CHISHOLM, HUGHIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 04/01/2024
DRAKE, MATTHEWIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/05/2021
DUNN, JENNIFERIndividualW-2 MANAGING EMPLOYEEsince 04/01/2024
HARDY, STEPHENIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 03/11/2019
HART, JONATHANIndividualW-2 MANAGING EMPLOYEEsince 04/01/2024
MCCROREY, ANGELAIndividualW-2 MANAGING EMPLOYEEsince 06/01/2019
O'CONNELL, KATIEIndividualW-2 MANAGING EMPLOYEEsince 06/01/2018
ORMOND, JO ANNIndividualW-2 MANAGING EMPLOYEEsince 08/19/2019
SILVESTRINI, CORINIndividualW-2 MANAGING EMPLOYEEsince 04/01/2024
AQUINO, NICHOLASIndividualCORPORATE DIRECTORsince 05/01/2015
BEAUFORD, THOMASIndividualCORPORATE DIRECTORsince 04/01/2022
BOYD, DONALDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/01/2009
CHEVLI, KIndividualCORPORATE DIRECTORsince 04/01/2022
CLEMO, LORRIEIndividualCORPORATE DIRECTORsince 05/01/2017
CROSBY, GARYIndividualCORPORATE DIRECTORsince 05/01/2017
EDDIB, ABEERIndividualCORPORATE DIRECTORsince 06/01/2019
JAVED, MUHAMMEDIndividualCORPORATE DIRECTORsince 05/01/2019
MAGGIO, WILLIAMIndividualCORPORATE DIRECTORsince 05/01/2015
MATTHEWS, GEORGEIndividualCORPORATE DIRECTORsince 05/01/2008
MCEVOY, TIMOTHYIndividualCORPORATE DIRECTORsince 06/01/2019
O'LEARY, PAULIndividualCORPORATE DIRECTORsince 04/01/2018
PERSONS, JOHNIndividualCORPORATE DIRECTORsince 04/01/2022
ROSS, CHRISTOPHERIndividualCORPORATE DIRECTORsince 05/01/2015
RUSIN, MARY LOUIndividualCORPORATE DIRECTORsince 05/01/2015
BARRETT, IANIndividualCORPORATE OFFICERsince 10/01/2022
BRYANT, SHANNONIndividualCORPORATE OFFICERsince 12/01/2020
HUGHES, MICHAELIndividualCORPORATE OFFICERsince 09/01/2004
MINEO, MICHAELIndividualCORPORATE OFFICERsince 07/01/2022
NADLER, JAMIEIndividualCORPORATE OFFICERsince 04/01/2022
QUINT-BOUZID, MARJORIEIndividualCORPORATE OFFICERsince 04/01/2024
SNYDER, KENNETHIndividualCORPORATE OFFICERsince 04/01/2022
SPAULDING, ALYSONIndividualCORPORATE OFFICERsince 08/01/2014

CMS files one row per role, so the 39 rows in the source record cover these 35 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$35.0M
Net patient revenuemost recent cost report
-32.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 84%Medicare 4%Other / private 12%

About 84% 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

$495per resident / day
operating cost
$15,063per month
≈ monthly operating cost
$374per 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 335834. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-16, 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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