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Seton Health At Schuyler Ridge Residential H C

1 Abele Drive, Clifton Park, NY 12065 · Non profit - Other · 120 certified beds · (518) 371-1400 Medicare & Medicaid certified

Call the home — (518) 371-1400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 20251 Medicare payment denial
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 (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
  • 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
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
9 Old Plank Rd · (518) 371-0777 · Call to confirm hours
Pharmacy
Walgreens0.3 mi
121 Old Route 146 · (518) 371-5842 · Call to confirm hours
Grocery
15 Park Avenue
Park
Stever Hill Rd · 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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 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 rating1★
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 increased9.4%14.1%15.4%better
Long-stay residents who lose too much weight4.7%5.8%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.5%0.9%better
Long-stay residents with a urinary tract infection0.7%1.3%2.0%better
Long-stay residents with depressive symptoms4.1%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 injury4.9%3.1%3.3%worse
Long-stay residents whose ability to walk worsened9.0%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.5%13.2%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers4.1%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control18.3%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.5%13.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.3%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine93.6%78.8%79.4%better
Short-stay residents rehospitalized after admission33.4%20.6%22.6%worse
Short-stay residents with an outpatient ER visit8.0%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.711.701.67typical
Long-stay outpatient ER visits per 1,000 resident days1.911.361.80typical

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.

48.9% 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 172 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.9%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
46.8%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 46.8% 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 94 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% 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 SNF48.9%CMS range 42.9–55.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.4–14.210.7%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 discharge46.8%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 discharge37.2%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 discharge44.7%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 setting98.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%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 hospitalization9.2%CMS range 5.5–13.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 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

0.64
RN hours/ resident / day
1.00
LPN hours/ resident / day
2.27
Aide hours/ resident / day
3.92
Total nurse hours/ resident / day
0.31
RN hoursweekends
48.7%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 116.5 residents a day — about 97% occupied, or roughly 4 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 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.44 hrs/resident/day on weekends vs 4.11 on weekdays — 16% thinner on weekends. RN hours go from 0.78 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

14
deficiencies at the latest standard inspection (2025-03-04)
0
at the previous standard inspection (2022-07-07)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Ecited before2025-03-04 · 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 record review and interview during the recertification and abbreviated survey (Case #s, NY00319900 and NY00344983), the facility did not ensure each resident's right to be free from neglect for 2 (Resident #s 53 and 112) of 7 residents reviewed for abuse/neglect. Specifically, (a.) for Resident #53, the resident had a fall out of bed with injuries and staff did not follow the care plan by placing the fall mats next to the resident's bed. Specifically, (b.) Resident #112 had a fall on 5/31/2024 and complained of back pain post fall and X-ray was ordered . Assistant Director of Nursing #2 reviewed the radiology report, which verified the resident had a thoracic (back) #12 vertebrae fracture (bone break), but documented that there was no fracture. This delayed care necessary to avoid the resident's pain. This is evidenced by: Resident #53 Resident #53 was admitted to the facility with orthostatic hypotension (low blood pressure might cause dizziness, lightheadedness or fainting when rising from sitting 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-04 · tag F0656 — failed to write and follow a full care plan — pattern
    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, record review, and interviews conducted during a recertification and abbreviated survey (case #'s NY00319900, NY00349063, and NY00372837), the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 8 (Residents #s 20, 22, 46, 57, 101, 109, 113, and,114) of 24 residents reviewed for Care Plans. Specifically, (a.) for Resident #20, oxygen administration was not implemented according to the resident's care plan; (b.) for Resident #22, the right blue [NAME] posey splint was not consistently applied as indicated in the Resident's Comprehensive Care Plan; (c.) for Resident #46 did not have a care plan in place that addressed their incontinence concerns; (d.) for Resident #57, a Comprehensive Care Plan for hospice was not implemented 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-04 · tag F0676 — failed to keep up residents' daily-living abilities — pattern
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during the recertification survey, the facility did not ensure dependent residents was provided with appropriate treatment and services to maintain or improve their language and communication for 2 (Resident #s 13 and 74) of 5 residents reviewed. Specifically, (a.) for Resident #13, nursing staff did not ensure there was consistent access to their communication dry/erase board so staff could use it to write down what they wanted to express as Resident #13 had hearing loss, and for (b.) Resident #74, who was nonverbal, communication board was not used to allow resident to express their wants and needs. This is evidenced by: Facility's Policy titled Effective Communication with Residents with Hearing, Vision and Verbal Impairments effective 2023 documented the purpose of the policy was to ensure all residents including those with vision, hearing, and verbal impairments receive respectful and appropriate communication that supports their well-being and dignity.…

    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 · E2025-03-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were following professional standards of practice, for 3 (Resident #s 20, 60, and 75) of 3 residents reviewed for oxygen administration. Specifically, (a) supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b) supplemental oxygen was not provided as ordered by the physician. This is evidenced by: A review of the facility policy titled Oxygen Administration dated 1/2019 documented the facility was to provide oxygen by oxygen mask/cannula to residents with deficiencies or abnormalities of pulmonary function, to prevent or reverse hypoxia, and improve tissue oxygenation. The procedure documented that the tubing was to be attached, labeled, and dated, as well as following the orders for oxygen in the electronic record system to guide staff. Resident #20 Resident #20 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 · E2025-03-04 · tag F0761 — failed to label and store drugs safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 3 ([NAME] Unit Cart A, [NAME] Hills Unit Carts A and B) of 3 medication carts, and 1 ([NAME] Hills Side B) of 3 medication rooms reviewed. Specifically, (a.) 2 open bottles of ear drops had no open dates and or expiration dates (b.) 1 bottle of ear drops had expired; (C.) 3 bottles of open eye drops had expired; (d.) 4 inhalers had no expiration dates; (e.) 2 vials of insulin had no open date and or expiration dates and; (f.) 1 bottle of purified protein derivative (PPD) had no open and or expiration date. This is evidenced by: The facility's Policy and Procedure titled Storage and Expiration Dating of Medications and Biologicals, reviwed 8/01/2024, documented facility should ensure medications and biologicals that:(1) have an expired date on the label; (2) have been retained longer than…

    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 · E2025-03-04 · tag F0807 — failed to offer suitable drinks — pattern
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey, the facility failed to ensure each resident received drinks, including water and other liquids, consistent with resident needs and preferences and sufficient to maintain resident hydration. Specifically, Residents on Saratoga Hills unit were not offered beverages of their preference during a lunch meal observation. This is evidenced by: The facility policy Hydration effective date 10/15/2021 documented it is the policy to provide residents with sufficient fluids to maintain adequate hydration and health, including fluids served at mealtimes and between meals, offered consistent with care plan, preferences, and choice. The facility policy Resident Food Services date issued 05/1995, revised 01/2025 documented residents will be offered menu choices for all meals, beverages and snacks based on their prescribed diet, food preferences, allergies, intolerances, preferences and consistent with their plan of care. During the lunch meal observation on 02/26/2025 at 12:23 PM on Saratoga Hills unit, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 and interview during the recertification survey, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for 3 of 5 resident unit kitchenettes and the main kitchen. Specifically, walls were not in good repair and microwave ovens, refrigerators, and tables were not clean. This is evidenced by: During observations on 2/25/2025 at 10:21 AM: • 10 wall coving tiles were broken in the dishwashing machine area. • Seven wall coving tiles were broken in the main kitchen. • The microwave ovens, the refrigerators including door gasket, and the underside of dining tables were soiled with food particles on the [NAME] kitchenette, [NAME] A kitchenette, and [NAME] B kitchenette. During an interview on 2/25/2025 at 11:38 AM, Executive Chef #1 stated that they would contact housekeeping to clean the tables and would remind the maintenance department of the work order they submitted to repair the coving tiles. Executive…

    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 · E2025-03-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during a recertification survey, the facility did not ensure an infection control prevention and control program was implemented to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #s 57 and #77) of 5 residents. Specifically, (a.) for Resident #57, staff did not perform proper doffing and donning of personal protective equipment between care of residents; and (b.) for Resident #77, the staff did not perform proper infection control procedures while conducting wound care. This is evidenced by: A review of the 2025 Infection Prevention and Control Plan documented that the plan's purpose is to provide an effective system-wide program for the surveillance, prevention, and control of infection and infectious diseases. The goals of the Infection Prevention and Control Program were to assist in maintaining a safe environment and improve resident outcomes as…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-04 · 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, record review, and interviews conducted during a recertification survey, the facility did not ensure each resident was treated in a dignified manner for 4 (Resident #'s 46, 57, 59, and 74) of 24 residents reviewed. Specifically, (a.) for Resident #'s 46, 57, and 59, stated staff did not knock on their doors prior to entering their rooms. Specifically, (b.) for Resident #59, staff distributed meals to all residents at each table before serving residents eating in their rooms; and (c.) Certified Nurse Aide #13 delayed assisting the resident with their meal while using their personal phone in the dining room for over 20 minutes; and (d.) for Resident #74's personal items were disturbed by Resident #44. This is evidenced by: Finding #1: The facility did not ensure all residents were served timely at joining tables and that staff engaged with the residents requiring assistance at mealtime. Resident #59: Resident #59 was admitted with diagnoses Non-Alzheimer's Dementia, heart failure (a syndrome…

    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 · D2025-03-04 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure assessments were coordinated with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid for 1(Resident #78) of 24 residents reviewed. Specifically, Resident #78 with a new diagnosis of a serious mental disorder was not referred for a PASARR Level II Evaluation. This is evidenced by: The facility's Policy and Procedure titled, Pre-admission Screening and Resident Review (PASSAR), effective 9/10/2022, documented All individuals seeking admission will undergo a PASRR Level I screening prior to admission to determine if they have a mental illness or intellectual disability. Screening would be conducted in accordance with New York State Department of Health guidelines and Centers for Medicare and Medicaid Services regulations. Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation would be completed by a qualified mental health professional. The evaluation would…

    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
Show the remaining 14 citations
  • Potential for harm · D2025-03-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised by interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #20) of 3 residents reviewed. Specifically, for Resident #20, the Comprehensive Care Plan for Respiratory Therapy was not reviewed and revised to include changes in the resident's oxygen liter flow to reflect the medical order. This is evidenced by: A review of the facility policy titled Oxygen Administration dated 01/2019 documented the facility was to provide oxygen by oxygen mask/cannula to residents with deficiencies or abnormalities of pulmonary function, to prevent or reverse hypoxia, and improve tissue oxygenation. The procedure documented that the tubing was to be attached, labeled, and dated, as well as following the orders for oxygen in the electronic record system to guide staff. Resident #20 was admitted to the facility 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification survey, the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene for 1 (Resident #74) of 24 residents reviewed. Specifically, Resident #74 was observed in bed, without morning care provided on two separate dates, 2/28/2025 and 3/03/2025 at 11:10 AM and 10:20 AM respectively, while other residents on the unit were attending meals and activities. This is evidenced by: The facility's Policy and Procedure titled Resident's Rights, effective 5/28/2024, documented that the resident had the right to be dressed in clothing, accessories, or cosmetics that were permitted for other residents. The resident had the right to choose activities, schedules (including sleeping and waking times), healthcare and providers of healthcare consistent with his or her interests, assessments, and plan of care. Resident #74 was admitted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-04 · 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 observation, record review, and interviews during a recertification survey, the facility did not ensure each resident had an environment that was as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 (Resident #11) of 10 residents reviewed for accident hazards. Specifically, Resident #11 was left alone while in the bathroom despite signs posted in their room saying not to leave resident alone in the bathroom, care plan, and [NAME] (Certified Nurse Aide resident care card) documented resident was not to be left alone in the bathroom. This is evidenced by: Resident #11 was admitted to the facility with diagnoses of Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior), chronic systolic (congestive) heart failure (a condition in which the heart doesn't pump blood as well as it should) and history of falling. The Minimum Data Set (an assessment tool) dated 2/07/2025 documented the resident was cognitively…

    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 · D2025-03-04 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during a recertification survey, the facility did not ensure that a resident received routine and 24 -hour emergency dental care for 1 (Resident #76) of 1 resident reviewed for dental services. Specifically, Resident #76 reported having pain on their lower gum making it difficult for them to chew their food on 2/25/2025. Resident #76 was not assisted in obtaining emergency dental care and had not been seen by the dentist since 3/15/2023. This is evidenced by: Resident #76 was admitted to the facility with diagnoses of cerebral infarction (a medical condition where blood flow to the brain is interrupted, causing brain tissue to die), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and epilepsy (a brain disease where nerve cells do not signal properly that causes seizures). The Minimum Data Set (an assessment tool) dated 01/10/2025, documented the resident could be understood and could understand others and had intact cognition. The Policy and Procedure Manual titled Dental Services,…

    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 · D2025-03-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during a recertification and abbreviated survey (Case #s NY00367938 and NY00372837), the facility did not ensure they immediately consulted with the resident's physician and notify the residents representative when there was a significant change in condition for 2 (Residents #s #101 and #114) of 2 residents reviewed for significant changes. Specifically, (a.) for Resident #101 there was no notification to the physician, that the resident acquired a new moisture associated skin damage condition that required treatment. (b.) for Resident #114's representative was not notified on 6/25/2024 when the resident developed an open wound on their abdomen. This is evidenced by: A document titled Change in Condition (Notification of Resident, Physician, and Designated Representative) dated 02/2020 documented the following: It is the policy of the facility as a resident's condition changes, the licensed nurse would consult with the resident immediately and notify the designated…

    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 before2025-03-04 · 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 record review and interviews during a recertification and abbreviated survey (Case # NY00367938), the facility did not ensure allegations of abuse and neglect were immediately reported but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Agency, for 1 (Resident #101) of 9 residents reviewed for abuse, neglect, and mistreatment. Specifically, Resident #101 reported an allegation of verbal abuse and rough treatment by Certified Nurse Aide #5 to four facility staff on 1/03/2025. It was not reported to the New York State Department of Health until 1/06/2025. This is evidenced by: The facility's policy and procedure titled Abuse and Neglect, dated 6/27/2023, documented a report to the New York State Department of Health must be made immediately, but no later than 2 hours after forming the suspicion that…

    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 before2025-03-04 · 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 record review and interview during a recertification and abbreviated survey (Case #NY00367938), the facility did not ensure that all allegations of abuse were thoroughly investigated for 1 (Resident #101) of 9 residents reviewed for abuse and neglect. Specifically, Resident #101 reported an allegation of verbal abuse and rough treatment during care given on a night shift between 1/02/2025 and 1/03/2025 by Certified Nurse Aide #5 to four facility staff on 1/03/2025. The facility initiated an investigation on 1/06/2025, and did not interview Registered Nurse #5 who was in the facility at the time of the incident. This is evidenced by: The facility's policy and procedure titled Abuse and Neglect, dated 6/27/2023, documented the following: Nursing Supervisor/Nurse Manager shall initiate the investigation on the shift in which the incident was observed, the report was first received, or when abuse was suspected, and notify the Director of Nursing. The Director of Nursing or designee shall coordinate the investigation and review of facts concerning the incident. Any staff members…

    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 · D2025-03-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey and an abbreviated survey (Case #NY00344983), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident #s 76 and 112) of 2 residents reviewed. Specifically, for (a.)Resident #76, Certified Nurse Aide provided a saltwater rinse for residents. sore gums without medical order. (b.) for Resident #112, Assistant Director of Nursing #2 did not notify the facility health care practitioner after reviewing the radiology report verifying that the resident had a thoracic #12 vertebrae fracture. This is evidenced by: A review of the policy titled Change in Condition dated 2/2020 documented that the attending physician would be notified immediately as indicated by the significance of the change and need for medical intervention. Resident #76 Resident #76 was admitted to the facility with diagnoses of cerebral infarction (a medical condition where blood flow to the brain 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 · D2025-03-04 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during the recertification and abbreviated survey (Case # NY00344983), the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 2 (Resident #s 20 and 112) of 2 residents reviewed. Specifically, for Resident #20, staff observed and verified that the resident's oxygen flow rate was 2 liters per minute when the concentrator was set at 4 liters per minute. Specifically, for Resident #112, the medical records documented by the nursing staff that the resident did not have a fracture from a fall and the radiology report documented that the resident did have a fracture from a fall on 5/31/2024 at 5:38 PM. This is evidenced by: Resident #20 Resident #20 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs resulting in swelling and irritation inside the airways that limit airflow into and out of the lungs), dependence on supplemental oxygen, and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-04 · 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 record review and interviews during an abbreviated survey (Case #s NY00300299, NY00301951, NY00305167, NY00308021, NY00309028, and NY00309603), the facility did not ensure the resident had the right to be free from abuse, neglect, and mistreatment for 4 (Resident #s 1, 2, 4, and 5) of 14 residents reviewed for abuse. Specifically, the facility did not ensure that Certified Nurse Aide (CNA) #1 did not mistreatment Resident #1, mentally abuse Resident #2, and did not neglect Resident #s 4 and 5. This was evidenced by: The Policy and Procedure titled, Abuse Prevention and Investigation Protocol dated [DATE], documented residents have the right to be free from verbal, sexual, physical and mental abuse, neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation and misappropriation of property (hereafter abuse shall be understood to include all of the above). Resident #1 Resident #1 was admitted to the facility with diagnoses of a stroke, anxiety disorder, and chronic lung disease. 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 · Ecited before2023-08-04 · tag F0609 — failed to report abuse allegations — pattern
    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 record review and interviews during an abbreviated survey (Case #s NY00300299, NY00301951, NY00305167, NY00308021, NY00309028, and NY00309603) the facility did not ensure that all alleged violations involving abuse, neglect, and mistreatment are reported immediately but not later than 2 hours after the allegation is made for 5 residents (Resident #'s 1, 2, 4, 5 and #7) of 14 residents reviewed for abuse, neglect, and mistreatment. Specifically, the facility did not ensure abuse and neglect were reported to the New York State Department of Health (NYS DOH) within 2 hours for allegations of mistreatment for Resident #1, mental abuse for Resident #2, neglect for Resident #s 4 and 5, and for verbal abuse for Resident #7. This was evidenced by: The Policy and Procedure titled, Abuse Prevention and Investigation Protocol dated 11/10/2019, documented when abuse is suspected or alleged, the incident must be reported immediately to the Nursing Supervisor, Nurse Manager, Director of Nursing, and Nursing Home…

    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 · Ecited before2023-08-04 · tag F0610 — failed to investigate and act on abuse reports — pattern
    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 record review and interviews during an abbreviated survey (Case #s NY00300299, NY00301951, NY00305167, NY00308021, NY00309028, and NY00309603) the facility did not ensure in response to allegations of abuse, the facility must prevent further abuse while the investigation was in progress for 4 residents (Resident #s 1, 2, 4, and 5) of 14 residents reviewed. Specifically, the facility did not ensure that Certified Nurse Aide (CNA) #1 was sent home by a Registered Nurse Supervisor (RNS), Registered Nurse Manager (RNM), the Director of Nursing (DON), or other qualified member of administration following allegations of abuse, neglect, and mistreatment made on 8/1/2022. This was evidenced by: The Policy and Procedure titled, Abuse Prevention and Investigation Protocol dated 11/10/2019, documented when abuse was suspected or alleged, resident safety must be a priority. The employee shall be suspended, if deemed appropriate until completion of the investigation. Resident #1 Resident #1 was admitted to the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-12-31 · tag F0623 — isolated
    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 interview and record review conducted during the recertification survey, the facility did not ensure two (2) (Resident #'s 72 and 117) of three (3) residents reviewed for hospitalization, received written notice of discharge. Specifically, the residents and their representatives did not receive written notice of discharge to a hospital. This evidenced by: Resident #72: The resident was admitted to the facility with diagnosis of left hip fracture, Alzheimer's disease and dementia. The Minimum Data Asset (MDS- an assessment tool) dated 12/18/19, documented the resident had severe cognitive impairment. A progress note dated 12/8/19 at 12:03 PM, documented the resident was sent to the emergency room for evaluation related to change in mental status and to rule out sepsis. A hospital Discharge summary dated [DATE], documented the resident was diagnosed with an Intra-parenchyma brain hemorrhage (bleeding within the brain) and was discharged back to the facility with orders for comfort care. Resident #117:…

    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 · D2019-12-31 · tag F0625 — isolated
    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 interview and record review conducted during the recertification survey, the facility did not ensure written notice was provided to the resident's representative of the bed hold and return policy for two (2) (Resident #'s 72 and 117) of three (3) residents reviewed for hospitalization. Specifically, there was no documented evidence the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This evidenced by: Resident #72: The resident was admitted to the facility with diagnoses of left hip fracture, Alzheimer's disease and dementia. The Minimum Data Asset (MDS- an assessment tool) dated 12/18/19, documented the resident had severe cognitive impairment. A progress note dated 12/8/19 at 12:03 PM, documented the resident was sent to the emergency room for evaluation related to change in mental status and to rule out sepsis. A Hospital Discharge summary dated [DATE], documented the resident was diagnosed with 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-06-04 for 15 days

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

Part of a chain

This home belongs to TRINITY HEALTH — 19 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 1 of 53.3-2.3 vs chain
Health inspection 1 of 53.0-2.0 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 3 of 53.7-0.7 vs chain
The other 18 homes this chain runs (chain average 3.3★, 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
ST PETERS HEALTH PARTNERSOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 05/13/2025
BALA, GUHAIndividualCORPORATE DIRECTORsince 10/01/2022
HANKS, STEVENIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2023
ISACKSEN, DANIELIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 10/01/2011
LAPCZYNSKI, PATRICIAIndividualCORPORATE DIRECTORsince 04/01/2025
MCCORMICK, ROBERTIndividualCORPORATE DIRECTORsince 01/01/2021
MEATH, MICHAELIndividualCORPORATE DIRECTORsince 10/01/2022
MYERS, GINAIndividualCORPORATE DIRECTORsince 10/01/2022
POLLARD, MERRIETTEIndividualCORPORATE DIRECTORsince 10/01/2022
SULLIVAN, MARGUERITEIndividualCORPORATE DIRECTORsince 01/01/2025
SWEET ZAVAGLIA, KERRIIndividualCORPORATE DIRECTORsince 10/01/2022
TOFADE, OLUWATOYINIndividualCORPORATE DIRECTORsince 01/01/2024
FARRELL, ERICIndividualCORPORATE OFFICER; ADP OF THE SNFsince 07/01/2023
JIMINO, KATHLEENIndividualCORPORATE OFFICERsince 10/05/2022
MARSHALL, JOHNIndividualCORPORATE OFFICERsince 10/05/2022
SIGNOR, KRISTINIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
WILDRIDGE, WILLIAMIndividualCORPORATE OFFICERsince 10/01/2022
TRINITY HEALTH CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2025
BURKE, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2020
GUPTA, RENUIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
ILGNER, KAMRYNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2023
MAZZACCO, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/22/2021
BAKAR, MELISSAIndividualADP OF THE SNFsince 01/01/2025
BROUGHTON, JODIEIndividualADP OF THE SNFsince 03/28/1994
DUCREAY, KARENIndividualADP OF THE SNFsince 11/10/2024
TILGER, GREGGIndividualADP OF THE SNFsince 03/24/2025

CMS files one row per role, so the 38 rows in the source record cover these 26 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.

$15.7M
Net patient revenuemost recent cost report
-9.9%
Operating marginrevenue minus expenses
$983K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 62%Medicare 7%Other / private 31%

This home reported $983K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$424per resident / day
operating cost
$12,890per month
≈ monthly operating cost
$386per 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 335774. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-04, 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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