Crown Park Rehabilitation And Nursing Center
28 Kellogg Road, Cortland, NY 13045 · For profit - Partnership · 200 certified beds · (607) 753-9631 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,278 in federal fines (most recent 2025-09-04)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.9% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.9% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.5% | 19.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.7% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.1% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.4% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.7% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.0% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.1% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.7% | 13.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.9% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.8% | 20.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.0% | 9.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.57 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.31 | 1.36 | 1.80 | worse |
‡ 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.
39.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.6% 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 58 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 0.25 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 39.0%CMS range 29.6–48.1 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 7.9–15.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 53.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 62.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 4.1–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 200 beds and averages 192.4 residents a day — about 96% occupied, or roughly 8 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.77 hrs/resident/day on weekends vs 3.47 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.40 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited beforedisputed · IDR2025-09-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the abbreviated survey (NY00370972, iQIES# 452008), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #2) reviewed. Specifically, Resident #2 was discharged from the hospital to the facility with atrial fibrillation (irregular heartbeat) and a mechanical heart valve replacement and was ordered weekly Prothrombin Time/International Normalized Ratio's (blood test that checks how long it takes for blood to clot) and anticoagulant (blood thinner) therapy. There was no documentation in the resident's electronic record of a diagnosis of a mechanical heart valve replacement and no documented evidence of a provider rationale for the reason International Normalized Ratios were not maintained at the recommended levels for mechanical heart valves (2.5-3-5). Additionally, there was no documented evidence the resident's Prothrombin Time/International Normalized Ratio was obtained as ordered on 10/22/2024 and no documented evidence the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based record review and interview during the abbreviated survey (iQIES #2707916) the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was observed to have a new onsite pressure ulcer of their sacrum (large triangular bone at the base of the spine). There was no documented assessment by a qualified professional, and no documented notification of a medical provider for treatment when it was identified, or during the following day shift. Findings include:The facility policy Notification of Change in Status, revised 05/2025 documented:-The Nurse Managers/Charge Nurse/Nursing Supervisor would be responsible for assessing a resident's condition for significant changes or with any accident/incident.-Any change in condition or accident/incident would be reported to the physician.-Change in condition or accident/incidents would be placed on the 24-hour report with the notification information and any related physician orders. The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-17 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 kitchen walk-in coolers. Specifically, the left walk-in cooler was not maintaining proper temperature. Findings include: The facility did not have a policy or procedure for preventative maintenance of the walk-in coolers. The facility policy, Food Storage, revised 7/2023, documented perishable food such as meat, poultry, fish, dairy products, fruits, vegetables, and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees Fahrenheit. All refrigerator units were kept clean and in good working condition at all times. Potentially hazardous food, or time/temperature control for safety food must be maintained at or below 41 degrees Fahrenheit unless…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-17 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews during the recertification survey conducted 1/13/2025-1/19/2025, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 5 resident units (Units 2 North, 2 South, and 3 South) reviewed. Specifically, Units 2 North, 2 South and 3 South had several walls with missing paint, patched up holes unpainted, resident room doors with missing thresholds where dirt/debris had collected, missing tiles, dirty linen on the resident room floors, and the 2 south dining room that was not decorated or homelike. Findings include: The facility policy, Resident Rights, revised 2/2022, documented the residents had rights to a dignified existence. The facility policy, Quality of Life- Homelike Environment, revised on 2/2022, documented the residents were provided a safe, clean and comfortable and homelike environment. The facility staff and management should to the extent possible, reflect a personalized homelike setting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-17 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview during the recertification and abbreviated (NY00322139) surveys conducted 1/13/2025-1/17/2025, the facility did not ensure prompt efforts were made to resolve grievances for 9 of 9 anonymous residents and 1 additional resident (Resident #446) reviewed. Specifically, 9 of 9 residents during the resident group meeting stated they did not know who the grievance official was or how to file a grievance. Long call bell wait times were a recurrent complaint in the monthly resident council meetings and Resident #446 had filed a grievance regarding long call bell wait times. Findings include: The facility policy, Grievance/ Complaint Procedure, reviewed 11/2023 documented the facility provided residents the means and assistance to file a grievance or complaint concerning their treatment. The Director of Social Services served as the facility's grievance official. The facility policy, Call Bell, reviewed 3/2024 documented call bells were answered promptly by all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-17 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards for expiration dates for 2 of 5 medication carts (3 North A side and 2 North A side carts) and 1 of 3 medication storage rooms (3 North) reviewed, and 1 medication cart (3 south B side cart) was observed unlocked and unattended. Specifically, the 3 North A Side cart had eye drops, multidose diabetic pens (device used to deliver injectable medication), a multidose insulin vial, and inhalers without opened or discard dates; the 2 North A side cart had multidose diabetic pens without opened dates or discard dates, and a multidose diabetic pen without a resident identifier or an opened or discard date; the 3 North medication refrigerator contained a multidose influenza vaccine vial and a multidose tuberculin vial that were expired; and an additional multidose influenza vaccine vial that did not have an opened date or discard date.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-17 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals (the 1/14/2025 1st floor lunch meal and the 1/15/2025 3rd floor lunch meal) reviewed. Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 1/14/2025 and 1/15/20254. Additionally, 9 of 9 anonymous residents present at the Resident Council meeting and Resident #103 stated the food was not appetizing. Findings include: The 1/2022 updated facility policy, Food Temperatures, documented all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, food stored in the walk-in freezer was not protected, kitchen lighting was not properly shielded, and there were multiple unclean and uncleanable surfaces. Findings include: The facility policy, Food Storage, last reviewed 7/2023 documented: - food was stored in an area that was clean, dry, and free from contaminants. - all foods should be covered, labeled, and dated. - all refrigerator units were always kept clean and in good working condition. - all freezer units were always kept clean and in good working condition. The light bulb specifications provided by the facility did not document the bulbs were coated or shatter resistant. The following observations were made in the main kitchen: - on 1/14/2025 at 10:47 AM, there was an uncovered open box of hamburgers, an open junction box 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.
- Potential for harm · Ecited before2025-01-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #17) reviewed and 1 of 5 medications rooms (2 South B). Specifically, Resident #17's urinary drainage collection bag was not stored in a manner to prevent contamination and was observed lying directly on the floor, and the 2 South B side medication room sink was not functional. Findings include: The facility policy, Infection Prevention and Control, revised 5/2024, documented to prevent the spread of disease, handwashing was encouraged. The facility policy, Urinary Catheter Care, revised 5/2024, documented catheter tubing and drainage bags were kept off the floor. 1) Resident #17 had diagnoses including urinary retention (difficulty emptying the bladder), obstructive and reflux…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the recertification and abbreviated (NY0035593 and NY00322139) surveys conducted 1/13/2025-1/17/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 1 resident (Resident #119) reviewed. Specifically, Resident #119 was not provided oral care as planned. Findings include: The facility policy, Activities of Daily Living Support, revised 1/2025, documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The facility policy, Mouth Care, dated 1/2022, documented residents' lips and oral tissues were kept moist, and the mouth should be cleansed and freshened to prevent oral infection. The equipment and supplies necessary included toothpaste, emesis basin, and applicators or gauze sponges. Resident #119 had a diagnosis including Parkinson's Disease (a progressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-19 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 1/11/23-1/19/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 7 isolated resident areas (resident rooms 224, 250, 262, 272, and 319, the third floor hall near the nursing station, and the second floor common area); and 2 pieces of resident equipment (Residents #27's and 47's wheelchairs). Specifically, the third floor hall, and Resident rooms 224, 250, 262, 272, and 319 had walls in disrepair, the second floor common area had three stained ceiling tiles, and the wheelchairs for Residents #27 and 47 had damaged/torn arms. Findings include: The housekeeping department Wheelchair and Equipment Cleaning Logs had been completed for the last two months. The log included the areas of the facility that was cleaned, the date it was completed, and the name of the person who completed the task. WHEELCHAIRS The following observations were made: - on 1/11/23 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.
Show the remaining 14 citations
- Potential for harm · Dcited before2023-01-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews during the recertification survey conducted 1/11/23-1/20/22, the facility failed to ensure the resident has the right to exercise their rights as a resident of the facility and as a citizen of the United States for all 145 residents of the facility. Specifically, mail from the United States Postal Service (USPS) was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Findings include: The undated facility Resident Orientation Handbook documented mail was to be distributed daily on each unit. If a resident had an outgoing letter, staff would assist in getting the mail to the Post Office During a resident group interview on 1/11/23 at 2:30 PM, seven anonymous residents in attendance stated personal mail was not delivered to them on Saturdays. Two residents stated the mail was received at the front desk, sent to the business office during the week for sorting during regular business hours, and Saturday's personal mail was not delivered to the residents. The residents stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-19 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 observations, record review and interview during the recertification and abbreviated surveys (NY00297359) conducted 1/11/23-1/20/23 the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported no later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury were reported to the New York State Department of Health (NYSDOH) for 1 of 3 residents reviewed (Resident #60). Specifically, Resident #60 was found with a blistered area on their abdomen and the injury was not reported timely to the NYSDOH as required. Findings include: The facility policy Abuse Prevention revised 2/2022 documented that reports of abuse, including injuries of unknown origin, were immediately and thoroughly investigated to rule out abuse. The facility would ensure injuries of unknown sources were reported to NYSDOH within 2 hours after the incident was discovered if serious bodily injury occurred or not later than 24 hours if the event did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based on observation, interview and record review during the recertification survey conducted 1/11/23 - 1/19/23, the facility failed to ensure the resident environment remained free of accident hazards as is possible for 2 of 5 point of use water dispensers (Unit 1 resident lounge and Unit 3 South nursing station water dispensers) reviewed. Specifically, the point of use water dispensers in the Unit 1 resident lounge and at the Unit 3 South nursing station had hot water spigots accessible to residents that dispensed hot water measuring 161-166 degrees Fahrenheit (F). Findings include: There was no facility policy on point of use water dispensers. During an observation on 1/13/23 at 2:10 PM, the water dispenser at the Unit 3 South nursing station had a functional hot water spigot accessible to residents. The dispensed hot water was measured at 166 F. During an observation on 1/13/23 at 2:30 PM, the water dispenser in the Unit 1 resident lounge had a functional hot water spigot. The dispenser was accessible to residents in the open common area resident lounge. The dispensed hot water…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review during the recertification survey conducted 1/11/23-1/19/23, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 3 of 5 medication carts (Units 1 South, 2 South, and 3 South) and 3 of 3 medication storage rooms (Units 1 South, 2 South, and 3 South) observed. Specifically, Unit 2 South had expired stock medications in the medication cart and expired biologicals in the medication room; Unit 1 had an expired stock medication in the medication cart and medication room, and the medication refrigerator contained an expired biological; and Unit 3 had expired biologicals and insulin pens in the medication cart and an expired biological in the medication room. The facility policy Insulin Administration last reviewed 2/2022, documented all insulin was to be dated when opened and was good for 28 days. The undated facility policy Storage of Medications documented: - Any opened vials would contain an opened date. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-19 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review during the recertification survey conducted 1/11/23-1/19/23, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 3 residential units (Unit 2) reviewed. Specifically, there were dead mice and mouse droppings found in multiple resident rooms. Findings include: The facility policy Pest Control revised 2/2022, documented staff would report pest sightings to the Maintenance Director via work order or email. If a pest situation was reported, maintenance may treat the area and would request the contractor come in as soon as possible to treat the area identified. The monthly facility pest control vendor reports dated 7/2022 to 10/2022 did not document the presence of mice. The General Comments section from the 11/1/22 monthly facility pest control vendor report documented customer also states mice activity is pretty heavy on the inside of the building. The 12/9/22 monthly facility pest control vendor report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 interview conducted during the recertification survey, the facility did not ensure each resident had a right to a dignified existence and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 4 residents (Resident #95 and 100) reviewed for dignity. Specifically, Resident #95 was observed with poorly fitted pants that exposed the resident's skin that was not addressed by staff and Resident #100 was not provided non-disposable dishware to assist with fluids at meals. Findings include: There was no policy on dining experience or adaptive equipment. 1) Resident #100 was admitted to the facility with diagnoses including dementia. The 11/4/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required limited assistance with eating. The 12/8/16 comprehensive care plan (CCP) documented the resident had an ADL (activities of daily living) self-care deficit;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-18 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews conducted during the recertification survey, the facility did not determine through the interdisciplinary team that for 1 of 1 residents (Resident #66) reviewed for self-administration of medications it was clinically appropriate for a resident to self-administer medications. Specifically, nursing left medications for Resident #66 to self-administer without documentation the resident was assessed as safe to self-administer medications. Findings include: Resident #66 was admitted with diagnoses including adult failure to thrive, anxiety disorder, and depression. The 10/15/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, had no behavioral symptoms and participated in her assessment. The resident received anti-anxiety, anti-depressant, anti-coagulant, diuretic, and opioid medications daily. The 12/2019 comprehensive care plan (CCP) did not document the resident self-administered medications. The 12/2019 physician orders had no documentation the resident could self-administer medications. On 12/12/19…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-18 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 promote and facilitate resident self-determination through support of resident choice including but not limited to the right to choose activities and schedules consistent with his/her interests, assessments and plan of care for 1 of 3 residents (Resident #24) reviewed for choices. Specifically, Resident #24 had a preference to eat meals in the dining area and was not assisted out of his room or bed during meal times. Findings include: The 11/2016 Your Rights as a Nursing Home Resident in New York State policy documented that as a nursing home resident, one had the freedom of choice to make their own independent decisions. The resident has a right to a dignified existence and self-determination. Resident #24 was admitted to the facility with diagnoses including morbid obesity and neuropathy (nerve disease causing numbness or weakness). The 9/26/19 Minimum Data Set (MDS) assessment 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.
- Potential for harm · Dcited before2019-12-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview during the recertification survey, the facility did not maintain a clean and home-like environment for 2 of 3 nursing units (Units 2 and 3). Specifically, there were stained ceiling tiles on Unit 2S, an unclean/damaged ice machine on unit 2N, damaged/broken bed foot boards in resident room [ROOM NUMBER], the gap between the air conditioner and the wall cut-out in resident room [ROOM NUMBER] was in disrepair, and a damaged/torn wheelchair in resident room [ROOM NUMBER]. Findings include: The undated Electrical Equipment/Quality Control Policy documented ice machines were not added as part of non-patient care electrical equipment. The 9/2019 to 12/2019 work orders did not include documentation for work orders for Resident #8's wheelchair, room [ROOM NUMBER]'s foot boards, room [ROOM NUMBER]'s air conditioner, or the ice machine in the 2N television/common area. On 12/12/19 at 10:08 AM, Resident 8's wheelchair was observed at his bedside while the resident was in bed. The foot…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure that 2 of 6 residents (Residents #141 and 164) reviewed for activities of daily living (ADLs) received the necessary services to maintain good grooming and personal and oral hygiene. Specifically, Resident #141 was not provided nail care and Resident #164 did not receive showers as care planned. Findings include: The facility did not have a policy specific to ADL nail or bathing care needs. 1) Resident #164 was admitted to the facility with diagnoses including an above the knee amputation. The 12/3/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance for activities of daily living (ADLs), and had moisture- associated skin damage. The 12/30/15 comprehensive care plan (CCP) documented the resident required extensive assistance with one staff member for showering. It was the resident's preference to be showered once per week. There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-18 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review during the recertification survey, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 4 meal trays conducted on 3 different units (Unit 1 dinner, Unit 2 North lunch, and Unit 3 North dinner and breakfast) tested. Specifically, mixed vegetables, mixed fruit, skim milk, soup, goulash, green beans, eggs, hashbrown, and orange juice were not within a palatable temperature range. The 4/2011 Meal Distribution and Tray Delivery Method policy documents food will be delivered promptly to assure quality of food for the residents. The food cart is taken directly from the kitchen to the unit by a dietary aide to ensure proper food temperatures. The 4/2011 Food Temperatures and Thermometer Calibration Policy documents the facility ensure that food temperatures are systematically checked to guarantee that foods are served at appropriate temperatures to reduce the risk of food-borne illness. Any food temperatures outside of the acceptable range of greater than 41 degrees…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-18 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification survey the facility did not ensure each resident received specialized rehabilitative services for 1 of 2 residents (Resident #70) reviewed for rehabilitation services. Specifically, Resident #70 was not provided a rehabilitation evaluation and treatment in a timely manner after it was ordered by the physician. Findings include: The Functional Impairment Policy dated 3/2018 documented that the medical provider will order a relevant therapy evaluation and include the reason for ordering the evaluation. Resident #70 was admitted to the facility on [DATE] with diagnoses including, type 2 diabetes, morbid obesity, chronic respiratory failure, chronic cellulitis. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, required extensive assistance with activities of daily living (ADLs), did not ambulate more than once or twice, was occasionally incontinent of urine and always incontinent of bowel.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey for 1 of 7 residents (Resident #134) observed for infection, the facility did not ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for Resident #169 staff did not disinfect the Apex (mechanical) lift after use in a contact precaution room. Findings include: The 9/2012 Multi-drug Resistant Organisms (MDROS) policy documented the purpose was to prevent transmission of MDROS. Prevention, containment and eradication measures including use of contact precautions are indicated to prevent the spread of resistant microorganisms that have been identified within a facility. Cleaning of environmental surfaces shall be consistently performed using recommended methods. The 10/2012 Methicillin-resistive Staphylococcus…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-18 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview conducted during the recertification survey, the facility did not maintain an effective pest control program for the main kitchen and 2 of 4 units (Units 3 South and 3D) inspected. Specifically, there were pest control issues (small flies) observed in the kitchen and on Units 3South and 3D. Findings include: During observation on 12/12/19 at 9:35 AM, there were approximately 15 small flies in kitchen near the dish washing area. During observation on 12/13/19 between 10:52 AM and 12:10 PM, there was a small fly in the conference room. During observation on 12/13/19 between 1:00 PM and 1:36 PM, there was a small fly on unit 3 South around the desk area. During observation on 12/15/19 at 3:10 PM, there was a small fly on unit 3D near the doorway to the dining room. During observation on 12/16/19 at 11:21 AM and 11:48 AM, there was a small fly in the Unit 3 South dining area. On 12/16/19 at 1:52 PM and 2:06 PM, a small fruit fly was observed in the 3D dining room at the small table underneath the cabinet which contained extra cups 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,278 in federal fines across 1 penalty.
- $8,278 — penalty dated 2025-09-04
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 UPSTATE SERVICES GROUP — 17 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 1 of 5 | 2.6 | -1.6 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 16 homes this chain runs (chain average 2.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KOENIG, URI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 60% | since 12/22/2010 |
| STEIF, EFRAIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 40% | since 02/12/2015 |
| AUGENSTEIN, JACK | Individual | CORPORATE OFFICER | — | since 10/24/2016 |
| WUERTZER, AMY | Individual | CORPORATE OFFICER | — | since 09/14/2017 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335392. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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