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Eddy Village Green

421 W Columbia Street, Cohoes, NY 12047 · Non profit - Corporation · 192 certified beds · (518) 237-5630 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0610) — most recent Apr 2025Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$97,383 in federal fines
Insights

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

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0610) — most recent Apr 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $97,383 in federal fines (most recent 2025-02-24)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing 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) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 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 — 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
6 Wellness Way · (518) 881-1109 · Call to confirm hours
Pharmacy
Rite Aid1.2 mi
308 Ontario St · (518) 233-1518 · Call to confirm hours
Grocery
218 Columbia St · (518) 326-3218 · Call to confirm hours
Park
204 Berkley Ave · 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 5 of 5
Short-stay residentsrehab / post-hospital 1 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 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 increased9.2%14.1%15.4%better
Long-stay residents who lose too much weight2.9%5.8%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.5%0.9%better
Long-stay residents with a urinary tract infection1.0%1.3%2.0%better
Long-stay residents with depressive symptoms0.6%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 injury5.8%3.1%3.3%worse
Long-stay residents whose ability to walk worsened13.0%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.9%13.2%18.9%typical
Long-stay residents given the seasonal flu vaccine99.5%95.3%95.3%typical
Long-stay residents with pressure ulcers2.5%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control29.2%19.5%21.2%worse
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 medication6.2%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine100.0%78.8%79.4%better
Short-stay residents rehospitalized after admission5.7%20.6%22.6%better
Short-stay residents with an outpatient ER visit13.3%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.171.701.67better
Long-stay outpatient ER visits per 1,000 resident days1.141.361.80better

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.

9.6%U.S. median 10.7%
Went back to hospital
15.2%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 15.2% 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 33 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 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.3–13.810.7%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 discharge15.2%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 discharge15.2%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 discharge24.2%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 dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.9%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 worsened11.4%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 hospitalization6.5%CMS range 3.1–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 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

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
39.1%
Total nursing turnover
42.1%
RN turnover

How full it usually is: this home is certified for 192 beds and averages 186.6 residents a day — about 97% occupied, or roughly 5 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.

Weekend coverage: total nurse staffing is 4.03 hrs/resident/day on weekends vs 4.41 on weekdays — 9% thinner on weekends. RN hours go from 0.78 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

14
deficiencies at the latest standard inspection (2025-04-03)
2
at the previous standard inspection (2022-04-28)

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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-02-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #'s NY00370986, NY00359919, NY00359950, and NY00360114), the facility failed to ensure the residents' right to be free from abuse and neglect for four (4) (Resident #'s 1, 2, 3, and 4) of four (4) residents reviewed for abuse and neglect, which included physical, verbal and mental abuse. Specifically, (1.) Video footage documented Resident #1 was pushed to the floor on 2/02/2025 at 5:03 PM by Shahbaz (Certified Nurse Aide) #1, transferred off the floor by Licensed Practical Nurse #1 without an assessment by a Registered Nurse, and suffered a broken hip. (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off the toilet and subsequently fell and suffered an injury to their right shoulder. (3.) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F* down. (4.)…

    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
  • Immediate jeopardy · J2025-02-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #s NY00370986, NY00359919, NY00359950, and NY00360114), the facility failed to ensure all allegations of abuse were thoroughly investigated for three (3) (Resident #'s 1, 2, and 3) of four (4) residents reviewed for abuse investigation. Specifically, (1.) video surveillance footage revealed Shahbaz (Certified Nurse Aide) #1 pushed Resident #1 to the floor on 2/02/2025 at 5:03 PM. There was no documented evidence the facility initiated an investigation on 2/02/2025 (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off of the toilet and subsequently fell and suffered an injury to their right shoulder. (3.) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F* down. This resulted in Immediate Jeopardy and substandard quality of care to resident health 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-03 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, the posting of daily nurse staffing levels for staff working in the facility on each shift was displayed on one (1) resident unit, and not accessible to residents and visitors on the other resident units of the facility. This is evidenced by: During an observation from 3/25/2025 through 4/03/2025, the doorway to the administration suite was labeled with a sign documenting that no one was allowed in the building except staff. During an observation on 4/03/2025, at 11:10 AM, the daily nurse staffing postings were located on the wall by the reception desk in the administration building, which was not readily visible or accessible to all residents and visitors. There was no nurse staffing levels posted at any of the 16 residential units where residents and visitors from other units would walk through. During an interview on…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-03 · tag F0761 — failed to label and store drugs safely — widespread
    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 two (2) (House 21 and House 24) of 8 medication carts reviewed, and 8 (Houses 1, 2, 3, 4, 19, 21, 22, 24) of 8 medication rooms reviewed. Specifically, (a.) opened medications had no open and or expiration dates; (b.) one active medication had expired; (c.) medication rooms were left open and unattended; (d.) unlicensed staff had key/access code to medication rooms. This is evidenced by: The facility's Policy and Procedure Titled, Medication Administration effective [DATE] documented, each patient/resident/elder would receive medications according to provider orders and accepted professional standards. Under General Considerations, Responsibility and Procedure: The nurse is responsible for: #3: NOTE carefully the name, dose, amount of administration and expiration date. Be sure 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-03 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect, cared for in a manner, and in an environment that promotes maintenance or enhancement of their quality of life for three (3) (Resident #s 110, 136 and 145) of 36 residents reviewed for dignity. Specifically, (a.) Resident #110 was administered medications in a common area with other residents and individuals present without resident's permission; (b.) Certified Nurse Aide stood over the dining room table instead of sitting with resident, while assisting Resident #136 with their meal; (c.) Resident #145 was served meals at dining room table with the use of plastic utensils. This is evidenced by: The facility's Policy and Procedure titled Resident Rights, effective 5/28/2024, documented it is the policy to ensure residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-03 · tag F0644 — pattern
    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

    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 assessments were coordinated with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid for eight (8) (Resident #s 16, 22, 65, 70, 115, 130, 145, and 166) of 36 residents reviewed. Specifically, (a) Resident # ' s 22, 65, 70, and 145 received new diagnoses of mental illness and no Level I screening was done to determine if a Level II screen needed to be done and (b) Resident # ' s 16, 22, 115, 130, and 166 were admitted with diagnoses of mental illness and Level I screen was not accurately completed to indicate the need for Level II. This is evidenced by: The facility Policy and Procedure titled, Pre-admission Screening and Resident Review (PASSAR), effective 9/10/2022, documented all individuals seeking admission would undergo a Pre-admission Screening and Resident Review Level I screening prior to admission to determine if they have a mental illness 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-03 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for three (3) (Resident #s 16, 22, and 25) of 36 residents reviewed. Specifically, (a.) Resident #22 was unable to make their needs known, and there were several dates with no documented activities. (b.) For Resident #s 16 and 25, there were no consistent activities planned to meet the resident's needs and/or preferences. This is evidenced by: The facility Policy and Procedure titled, Activities, effective 10/15/2021, documented: (a) the Residential Services Activities Departments provided ongoing programs of activities designed to meet, in accordance with the comprehensive resident assessment, the interest and the physical, mental and psychosocial well-being of each resident; (b) activities…

    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 before2025-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 interview conducted during the recertification and abbreviated (Case #NY00347510) survey, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents, and did not ensure that the resident environment remained as free of accident hazards as is possible. This was evident for one (1) (Residents #146) of the 36 residents reviewed, and for House #s 10, 16, and 21. Specifically, (a.) Resident #146, who had a prior incident of being found outside of the home unsupervised, was found to have an electronic monitoring device alarm on their walker that was not functioning as it should. There was no documented evidence that the electronic monitoring device was checked daily for placement and function to prevent further accidents. Additionally, (b.) alcoholic beverages within spaces and rooms of House #s 10, 16, and 21 were observed to be open and unattended. The facility did not identify the risk and the provision 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 · E2025-04-03 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case #NY00368845), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, (1) an analysis of the actual staffing schedule showed that on multiple occasions from 3/25/2025 through 4/02/2025, the facility was below the minimum levels required; (2) staff reported a lack of sufficient staffing; and (3) residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered timely and long wait times for care to be provided. This is evidenced by: Upon entrance to the facility on 3/25/2025, there were 170 residents residing in 16 housing units. The Facility Assessment, last reviewed on 7/31/2024, documented that the facility's bed capacity was 190. The section titled Staffing Plan documented the following: • The day shift required 1…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-03 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for five (5) (Resident #s 53, 89, 145, 161, and 166) of nine (9) residents reviewed for unnecessary medications. Specifically, for Resident #s 53, 89, 145, 161, and 166, as needed psychotropic medication orders did not include end dates. This is evidenced by: The Policy and Procedure titled, Psychotropic Medication Management, effective 3/06/2024, documented as needed orders for anti-psychotic and anti-anxiety medications were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. If the attending physician or prescribing practitioner believed that it was appropriate for the as-needed order to be extended beyond 14 days,…

    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 · Ecited before2025-04-03 · 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

    Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety for four (4) of 16 resident central kitchens. Specifically, (a.) bulk food items were not labeled for their contents; (b.) bulk food items and outside items were not date-labeled after opening or labeled with an expiration date; (c.) appliances were not cleaned and had dirt, grime, and unknown substances within them; and (d.) chicken was improperly being thawed. This is evidenced by: An undated policy titled Food Safety Labeling Procedure documented that all food or beverage items stored, opened, prepared, or leftover in our kitchens/storage areas and/or delivered to areas such as Nursing Stations or pantries would be clearly identified by the item name/product, the production or opened date, and the use-by date. A document titled Important Foodservice and Sanitation Guidelines described that any prepared food that was opened or stored must be labeled and dated for discard within…

    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 · D2025-04-03 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure residents could safely self-administer medication when clinically appropriate for one (1) (Resident #84) of one (1) resident reviewed for medication administration. Specifically, Resident #84 was observed with a medicine cup of pills while eating breakfast in the dining area on 3/26/2025 and independently taking the pills. There was no documented evidence that Resident #84 was assessed to determine their ability to safely self-administer medications, or physician orders for self-administration of medications. This is evidenced by: Resident #84 was admitted to the facility with diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (occurs when blood flow to the brain is disrupted, leading to tissue death due to lack of oxygen and nutrients) affecting a dominant side, atrial fibrillation (an irregular, often rapid heart rate 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-04-03 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review conducted during the recertification survey, the facility did not ensure that it made prompt efforts to resolve a grievance and to keep the resident appropriately apprised of progress towards resolution for one (1) (Resident #28) of 36 residents reviewed. Specifically, Resident #28 and their representative did not receive prompt resolution when a grievance was filed regarding missing hearing aids on 2/19/2025. The facility did not follow up with this grievance until 4/01/2025. This is evidenced by: Resident #28 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), hypertensive heart disease (a condition arising from prolonged high blood pressure), and dependence on supplemental oxygen. The Minimum Data Set (an assessment tool) dated 1/03/2025 documented that the resident could be understood, could understand others, and had moderately impaired cognition.…

    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 · D2025-04-03 · 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

    Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that one (1) (Resident # 130) of four (4) residents reviewed for hospitalization received notice of the bed-hold policy and return prior to or within 24 hours of an emergency transfer. Specifically, Resident #130 was not given written notice of the bed hold policy prior to or within 24 hours of transfer to the hospital on 1/18/2025. This is evidenced by: The Facility's Policy and Procedure titled Bed Hold Policy, effective 6/27/2023 documented facility support the resident's right to retain their bed when they are hospitalized or take a therapeutic leave. The policy promotes continuity of care and ongoing psychosocial support for residents. Procedure, The Bed Hold Policy Summary form must be provided to the resident, or resident's representative, at the time of transfer, or in cases of emergency transfer within 24 hours. a. Facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to contact 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · 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 observations, record review, and interviews conducted during the recertification survey, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (2) (Resident #s 28 and 89) of three (3) residents reviewed. Specifically, (a.) Resident #28 order for continuous oxygen was not administered. The oxygen nasal cannula was placed on the resident, but the oxygen concentrator was off, therefore not delivering oxygen to the resident; (b.) Resident #89's order for 2 liters of oxygen were not followed consistently. This is evidenced by: The facility Policy and Procedure titled, Oxygen Management, effective 5/13/2024 documented, it was policy to administer oxygen per provider order in a safe manner. Responsibility of Licensed Nursing Staff: Procedure: (1) Review orders; (2) Identify resident and explain procedure; (3) Plug in power cord; (4) Keep concentrator at least 12 inches from walls, draperies and avoid confined…

    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 before2025-04-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for one (1) (Resident #54) of the 36 residents reviewed. Specifically, for Resident #54, the physician's ordered alcohol administration was not documented in the Medical Administration Record. This is evidenced by: Resident #54 was admitted to the facility with diagnoses of Friedreich Ataxia (a progressive neurodegenerative disorder that primarily affects the nervous system, causing impaired muscle coordination), gastro-esophageal reflux disease (occurs when stomach contents persistently flow back into the esophagus, causing symptoms like heartburn), and essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause). The Minimum Data Set (an assessment tool) dated 2/14/2025 documented that the 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-03 · 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 conducted during the recertification and abbreviated (Case #NY00358717) survey, the facility did not ensure that residents were free from neglect for four (4) (Resident #s 16, 25, 99, and 115) of five (5) residents reviewed for neglect. Specifically, Residents #s 16, 25, 99, and 115 were not provided toileting care by staff on evening and night shift of 10/27/2024. Some of these residents were left overnight in the same clothes they had been dressed in the day before, and some with their incontinence garment, clothes, and bedding saturated with urine. This is evidenced by: The Policy and Procedure titled Abuse Prevention and Investigation Policy effective 3/25/2025, neglect is defined as the failure to provide timely, consistent, safe, adequate and appropriate services treatment, and care necessary to avoid physical harm, mental anguish or mental illness. The Resident [NAME] (Resident care card followed by Certified Nurse Aide) dated 10/29/2024, documented Resident #16…

    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 before2025-03-12 · 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 record review and interview conducted during an abbreviated survey (NY00373673), the facility did not ensure the environment remained as free of accident hazards as possible for 1 (Resident #1) of 1 resident reviewed for accident hazards. Specifically, for Resident #1 the facility did not ensure the resident's bed was positioned away from the heating unit resulting in a second degree burn to the resident's arm. This is evidenced by: Resident #1 was admitted to the facility with diagnoses of Alzheimer's Disease (a degenerative neurological disease-causing memory loss), peripheral vascular disease (disorder of the blood vessels), and psychotic disorder with delusions (mental health condition in which a person can't tell what's real from what's imagined). The Minimum Data Set, dated [DATE] documented the resident could usually understand, could be understood, and was severely cognitively impaired. The Care Plan dated 2/15/2024 and titled, Safety awareness deficit related to confusion/decreased memory,…

    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 · Past Non-Compliance
  • Potential for harm · D2025-02-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #s NY00370986, NY00359919, NY00359950, and NY00360114), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, 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 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 4 (Resident # ' s 1, 2, 3 and 4) of 4 residents reviewed for abuse and neglect. Specifically, (1) an allegation of abuse of Resident #1 –…

    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 before2022-04-28 · 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

    Based on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, automatic dishwashing machines (dish machine) in 6 (six) of 13 Houses inspected were not operating within the manufacturer's specifications; the concentration of chemical sanitizing rinse (QAC) was less than that required by the manufacturer in 1 of 13 Houses inspected; cabinetry was in disrepair in Houses 4, 6, and 8; and cabinetry and floors in Houses 3, 14, 19, and 21 required cleaning. This is evidenced as follows: During observations of the resident House (House) kitchens on 04/24/22 at 10:44 AM and on 04/25/22 at 10:41 AM, the following items were noted. The automatic dishwashing machine (machine) in resident House 7 was rinsing at 180 degrees Fahrenheit (F) and 50 pounds per square inch water pressure (psi), the machine in…

    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 · Dcited before2022-04-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during the recertification survey on 4/24/2022 through 4/28/2022, the facility did not ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices for 5 (Resident #'s 9, 30, 80, 113, and #125) of 28 residents reviewed. Specifically, the facility did not ensure the electronic medication administration record (EMAR) accurately reflected that residents received their medications as ordered by the physician. This was evidenced by: The Policy and Procedure (P&P) titled Medication Administration/Documentation System dated 04/2014, documented the medication nurse immediately signs for all medications given by checking the Y box on the computer screen. The P&P documented Be sure to hit the SAVE button when all medications have been accepted by the resident. Resident #30: Resident #30 was admitted with the diagnoses of diabetes mellitus, atherosclerotic heart disease (ASHD), and macular degeneration…

    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 before2019-10-09 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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

    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 medical records were maintained on each resident that were complete, accurately documented, readily accessible and systematically organized for 5 (Resident #s 45, 54, 55, 128, 141, and 165) of 35 residents reviewed. Specifically for Resident #s 45, 54, 128, 141 and 165 the facility did not ensure activity participation records were documented in accordance with professional standards, and for Resident #55, the facility did not ensure documentation of a physician order for an indwelling catheter. The Policy and Procedure (P&P) titled Activities and dated 7/19/19 documented activities and recreation in the house should resemble the patterns and types of activities commonly found in the home and outside of the home. The responsibility of the Activities Director/Recreational Therapist evaluates the effectiveness of the program and activities. Maintains documentation in accordance with the organization'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs for 6 (Resident #'s 1, 9, 10, 48, 148, and 170) of 35 residents reviewed for comprehensive care plans. Specifically, for Resident #1, the facility did not ensure the CCP addressed the resident refusal a physician ordered treatment for edema; for Resident #9, the facility did not ensure a comprehensive care plan was developed to address the resident's behaviors that put him at risk to be victimized; for Resident #10, did not ensure a CCP for psychotropic medications had individualized, person-centered interventions; for Resident #48, did not ensure a CCP for alteration in communication had individualized, person-centered interventions and a CCP was developed for the residents behaviors that put her at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-09 · 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 — the official record, unedited, may be distressing

    Based on observation and staff interview during the recertification survey the environment was not free from accident hazards over which the facility has control. Specifically, wardrobes in resident rooms were not secured to the walls. This is evidenced as follows. A selection of resident rooms was inspected on 10/07/2019 at 9:15 AM. Wardrobes were observed in resident rooms in all 16 resident houses that were free-standing and toppled over when tested with normal body weight. The Facilities Manager stated in an interview on 10/07/2019 at 2:15 PM that he understands that the unsecured wardrobes in resident rooms could cause an accident, and he will secure all the wardrobes to the wall. 10 NYCRR 415.12(h)(1)

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #65) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #65, the facility did not ensure a PRN antianxiety medication (Ativan) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #65: The resident was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, psychotic disorder with hallucinations, and adjustment disorder with anxiety. The Minimum Data Set (MDS - an assessment tool) dated 6/28/19 documented the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-10-09 · tag F0813 — widespread
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. This is evidenced by: A Policy and Procedure (P&P) titled Food Brought to Residents from the Outside dated 4/2018, did not include documentation of a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. During an interview on 10/09/19 at 2:26 PM, the Director of Dining Services stated the outside food policy in effect throughout the facility at the present time did not include documentation of a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. 10 NYCRR 415.14(h)

    Nutrition and Dietary 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

$97,383 in federal fines across 1 penalty.

  • $97,383 — penalty dated 2025-02-24

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 1 of 54.0-3.0 vs chain
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 06/10/2025
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 09/05/2025
BURKE, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2020
DOUGHERTY, SAMANTHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/14/2025
FREDA, KYLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/14/2025
MAZZACCO, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/22/2021
BAKAR, MELISSAIndividualADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 35 rows in the source record cover these 23 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.

$21.8M
Net patient revenuemost recent cost report
-16.7%
Operating marginrevenue minus expenses
$1.6M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 1%Other / private 39%

This home reported $1.6M 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

$448per resident / day
operating cost
$13,621per month
≈ monthly operating cost
$384per 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 335697. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-03, 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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