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Fairport Rehabilitation and Nursing Center

4646 Fairport Nine Mile Point Road, Fairport, NY 14450 · For profit - Limited Liability company · 196 certified beds · (585) 377-0350 Medicare & Medicaid certified

Call the home — (585) 377-0350 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609, F0610) — most recent May 2025
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 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
2550 Baird Rd · (585) 395-1111 · Call to confirm hours
Pharmacy
1304 Fairport Rd · (800) 746-7287 · Call to confirm hours
Grocery
124 N Main St · (585) 388-1330 · Call to confirm hours
Park
9 Liftbridge Ln E · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

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 increased8.3%14.1%15.4%better
Long-stay residents who lose too much weight9.0%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection0.0%1.3%2.0%better
Long-stay residents with depressive symptoms44.5%19.5%6.5%worse 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 injury5.7%3.1%3.3%worse
Long-stay residents whose ability to walk worsened4.3%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.4%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine93.8%95.3%95.3%typical
Long-stay residents with pressure ulcers7.1%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control33.2%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.0%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine65.1%78.8%79.4%worse
Short-stay residents rehospitalized after admission17.8%20.6%22.6%better
Short-stay residents with an outpatient ER visit12.6%9.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.551.701.67typical
Long-stay outpatient ER visits per 1,000 resident days1.381.361.80better

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.

40.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.7%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
65.6%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 65.6% 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 151 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF40.7%CMS range 31.2–51.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.1–15.510.7%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 discharge65.6%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 discharge57.0%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 discharge57.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%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 worsened2.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 3.9–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.24
RN hours/ resident / day
1.36
LPN hours/ resident / day
2.04
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.14
RN hoursweekends
66.2%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 196 beds and averages 138.2 residents a day — about 71% occupied, or roughly 58 beds typically open. It usually has some room. 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.31 hrs/resident/day on weekends vs 3.77 on weekdays — 12% thinner on weekends. RN hours go from 0.27 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above the national median of 45%.

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

Inspection trend

13
deficiencies at the latest standard inspection (2025-05-13)
9
at the previous standard inspection (2023-11-20)

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Fcited before2025-05-13 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, the facility did not ensure they had an Infection Preventionist who was responsible for the facility's Infection Prevention Control Practices. Specifically, the facility could not provide verification and documentation of the Infection Preventionist designated onsite hours for the assessing, developing, implementing, monitoring, and managing the facility's Infection Prevention and Control Program. The findings include: The Facility Assessment, reviewed on 04/30/2025, included that the facility has an infection prevention and control program that is headed by a certified Infection Preventionist Registered Nurse who develops and monitor the systems needed for preventing, identifying, reporting, investigation, and controlling infections and communicable diseases for all residents, staff, and volunteers. The Infection Preventionist report to the QAPI committee each month For additional information see Centers for Medicare/Medicaid Services Form 2567, reference…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during the Recertification Survey 05/05/2025 to 05/13/2025, the facility did not appropriately label and store all medications in accordance with currently accepted professional standards of practice and in accordance with stated and federal laws for eight (8) of 14 medication carts and five (5) of eight (8) medication rooms reviewed. Specifically, medications were left unattended by staff, multiple expired medications were stored in medication carts and medication rooms, loose unlabeled and uncovered pills were stored in multiple medication carts, narcotic medications were kept for multiple deceased residents over an extended period of time (versus returning to pharmacy) and narcotic sheets were missing signatures to verify that the narcotic medication counts were completed, correct and signed by two nurses. The findings include but not limited to the following: Review of the facility policy Medication Storage/Med Cart, dated May 2024, documented the medication cart shall be secured during medication passes and must be securely locked…

    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 before2025-05-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/12/2025, for six (6) (Third Floor A, E, F, and G-units, Second Floor A and F-units) of 10 resident units, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were undated and unlabeled food items, microwaves and a freezer were dirty, there were outdated food items, food warming/holding units were not functioning properly, cups and lids were stored below sink plumbing, and there were moldy bread items. The findings are: The undated facility Food Storage Policy included all foods must be labeled with product name, date received/prepared, and expiration or use by date. Spills must be cleaned immediately, and housekeeping/maintenance maintain cleanliness and report any equipment issues. During observations and interview on 05/07/2025 from 12:05 PM to 12:40 PM, the Third Floor G-unit kitchenette had…

    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 · Ecited before2025-05-13 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    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 from 05/05/2025 to 05/13/2025, the facility did not maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff, one of who must be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide documented evidence the Infection Preventionist participated in the Quality Assurance and Performance Improvement meetings on a regular basis. This is evidenced by the following: The undated facility's Quality Assurance and Performance Improvement Program policy documented the quality and appropriateness of resident care, including the identification of trends in performance were monitored and evaluated in infection control. The policy did not include the Infection Preventionist as a committee member. The Facility Assessment, dated 04/30/2025, documented the facility had an infection prevention and control…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-13 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, the facility did not establish and maintain 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 seven (7) (Residents #9, #41, #45, #87, #94, #121, and #384) of 12 residents reviewed. Specifically, for Residents #45, #87, and #94, a Licensed Practical Nurse tested their blood glucose (sugar) levels using a glucometer (a machine used to test blood glucose levels using a drop of blood from the resident's finger) without cleaning the glucometer between each resident's use or after. For Resident #9, a Licensed Practical Nurse tested their blood glucose level at the dining room table without completing hand hygiene, without wearing gloves, and without cleaning the glucometer. For Resident #41 who as on enhanced barrier precautions…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-13 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for seven (7) (first floor E and F-units, second floor A, E, F, and H-units, and third floor E-unit) of 10 resident units, the facility did not properly maintain the resident call system. Specifically, the nurse call system did not function properly to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area from each resident's bedside and toilet/bathing facilities, and clean utility rooms lacked nurse call annunciators. The findings are: During an observation on 05/06/2025 at 10:27 AM, there was no centralized nurse call station panel or annunciator at the second floor H-unit nurses' station, and staff did not carry phones or pagers connected to the nurse call system. During an observation on 05/06/2025 at 10:59 AM, there was no centralized nurse call station panel or annunciator at the second floor F-unit nurses' station. During an interview on 05/08/2025 at 11:42 AM, 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 reviews and interviews conducted during a Recertification Survey from [DATE] to [DATE], for two (2) (Residents #124 and #332) of four (4) residents reviewed, the facility did not ensure that all residents had the right to request, refuse, or formulate an advance directive (a resident's wishes to be or not to be resuscitated in the event of an acute cardiac or pulmonary arrest) that would be honored. Specifically, Resident #124 and Resident #332 had current phyisician's orders regarding their advanced directive wishes in the event of cardiac or pulmonary arrest that was not consistent with their signed Medical Orders for Life Sustaining Treatment (MOLST) directives. The findings include: The facility policy Advance Directives and Medical Orders for Life Sustaining Treatment, dated [DATE], documented it shall be the responsibility of the nursing, medical and social work teams to determine each resident's preference for Advance Directives upon admission to the Facility. The Medical Orders for Life…

    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 · D2025-05-13 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for one (1) (Resident #110) of one (1) resident reviewed the facility did not ensure the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Specifically, Resident #121 who was able to self-propel (move themselves) in their wheelchair was observed on multiple occasions to have their wheelchair wheels locked, who was trying to self-propel, and was unable to. The finding includes: The facility policy Restraints, dated June 2023, documented the resident has a right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Restraints of any type will not be used as a punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-13 · 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 interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for two (2) (Residents #43 and #131) of 12 residents reviewed, the facility did not ensure that all alleged violations involving potential abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, for Resident #43, the resident reported potential abuse and neglect to a Licensed Practical Nurse who did not report the residents concerns to nursing leadership and the alleged incident was not reported to the Department of Health. For Resident #131, the facility did not report to the Department of Health an incident where the resident was found to have a femur fracture (broken thigh bone) of unknown cause. The findings include: The facility policy Abuse Prevention and Management, dated November 2024, included the facility has designed and implemented processes, which strive to ensure the prevention and reporting of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for 1 (Resident #131) of 12 residents reviewed, the facility did not ensure that an incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #131 had complaints of hip pain, was found to have a femur fracture (broken thigh bone) and the facility was unable to provide documented evidence (including statements from all involved staff members or potential witnesses) that the incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. The findings include: The facility policy Abuse Prevention and Management, dated November 2024, documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment. The shift supervisor was responsible for immediate initiation of the reporting process. The Administrator, Director of Nursing, and Risk Manager were responsible for completing an investigation 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
Show the remaining 17 citations
  • Potential for harm · D2025-05-13 · 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

    Based on observations, interviews, and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, it was determined that for one (1) (Resident #9) of one (1) resident reviewed, the facility did not ensure a resident's environment remained as free of accident hazards as possible. Specifically, there were multiple observations of medications left at the resident's bedside. The resident did not have an order for self-administration of medications, was not care planned for it, and had not been assessed by the interdisciplinary team to safely have medications left unsupervised at the bedside. In addition, Resident #9's room was directly next door from another resident who was identified as having wandering behaviors. This evidenced by the following: Resident #9 had diagnoses that included irritable bowel syndrome, deficiency of B group vitamins, and diabetes. The Minimum Data Set (a resident assessment tool), dated 03/08/2025, documented the resident was cognitively intact. Review of Resident #9's current Comprehensive Care Plan did not include 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-13 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for two (2) (Residents #110 and #335) of two (2) residents reviewed for adaptive equipment, the facility did not provide special eating equipment and utensils for residents who required them to maintain the ability to eat and drink independently. Specifically, Resident #110 had therapy recommendations and was care planned for built-up and curved utensils and was observed during meals without the adaptive equipment and had difficulty eating. Resident #335 was visually impaired, had a therapy recommendation and was care planned for a lipped plate (a plate with a lip to assist with scooping food on to silverware), and was observed during meals without the lip plate. The findings include: The facility policy Activities of Daily Living Care Dining - Eating Assistance and Restorative Dining (Eating/Swallowing), dated August 2024, included the resident will be given the appropriate treatment…

    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 before2023-11-30 · 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 interviews, and record reviews conducted during an Abbreviated Survey (#NY00304693) 11/14/23 to 11/30/23, it was determined that for five (Residents # 2,4,6, 8, and 10) of five residents reviewed for abuse, neglect, and/or mistreatment the facility did not ensure that an investigation to rule out potential neglect or mistreatment was completed. Specifically, there was inconsistent evidence that Residents #2, 4, 6, 8, and 10 had received their physician ordered pain medications on 10/22/22 evening shift and the facility could not provide evidence that any medication error reports or investigations had been completed. The evidence includes but not limited to the following: The facility policy Abuse Prevention documented that the facility will not tolerate any form of resident abuse or exploitation and will maintain policies, procedures, training programs. Abuse is defined as mistreatment which refers to inappropriate use of medication, isolation, physical or chemical restraints. Neglect is defined as…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record reviews conducted during an Abbreviated Survey (#NY00304693) 11/14/23 to 11/30/23, it was determined that for four (Residents # 2,4, 8, and 10) of nine residents reviewed the facility did not ensure that the services and care provided met professional standards of quality. Specifically, there was inconsistent evidence that the Residents had received their physician ordered pain medications on 10/22/22 evening shift and the facility could not provide any evidence that any medication error reports were initiated, or follow-up had been completed. The evidence includes the following: The facility Licensed Practical Nurse (LPN) job description documented that the primary purpose of the job position is to oversee the nursing duties of a household by implementing the plan of care as developed by the Primary Nurse, or designee. The nurse should participate in the administration of nursing care in accordance with current Federal, State, and local standards. guidelines and regulations that govern the homes, to ensure that the comprehensive needs of 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-20 · 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 observations, interviews, and record review conducted during the Standard Recertification Survey completed 11/13/23 to 11/20/23, it was determined that for one of one main kitchen the facility did not prepare, store, distribute, and serve food in accordance with professional standards for food service safety. Specifically: the dish machine in the main kitchen had two leaks, there was a significant buildup of ice on the walk-in freezer floor, a refrigerator gasket was in disrepair, and floors were soiled with standing water and food. The findings are: On 11/13/23 at 9:01 AM a buildup of ice on the pipe to the condenser in the walk-in freezer was observed in the main kitchen. Further observations included a significant build up of ice on the floor below this condenser, with masses of ice between approximately two and eight inches high. In an interview at this time, the Food Service Director (FSD) stated that this issue has been going on for over a year and that a vendor comes in to chip the ice off every few weeks but has not done anything to fix the issue. On 11/13/23 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-20 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey 11/13/23-11/20/23, it was determined that for 2 (Residents #4 and #64) of 12 residents reviewed for dining, the facility did not ensure the residents were given the appropriate treatment and services to maintain or improve their ability to carry out their activities of daily living (ADLs). Specifically, neither Residents #4 nor #64 were given the assist recommended at meal time to complete their meals. This is evidenced by the following: 1.Resident #64 had diagnoses including dysphagia (difficulty swallowing), macular degeneration (impaired eyesight), and heart failure. The Minimum Data Set (MDS) Assessment documented that the resident had severely impaired cognition and required assistance from staff with meals. The current comprehensive care plan (CCP) 11/29/22 and the [NAME] (care plan used by the certified nursing assistant (CNA) for daily care) included that the resident needed to be set up for meals. Current…

    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 · D2023-11-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review conducted during the Recertification and Abbreviated (NY00323359) Surveys from 11/13/23 to 11/20/23, it was determined that for nine (#12, 36, 41, 59, 61, 63, 76, 83, and 84) of nine residents reviewed that were assigned to Neighborhood 3E on 9/2/23, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was insufficient evidence in the residents' medical record to show that multiple physician ordered medications were administered to multiple residents at the scheduled times. Additionally, there was no documented evidence that the medical provider was notified of the late or not administered medications which included but is not limited to, anticoagulants (blood thinners), insulin, and multiple medications for blood pressure. This is evidenced by, but not limited to the following: The facility policy Medication Administration, Documentation, and Premedication, dated revised April 2021 included that medications are to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews conducted during the Recertification Survey 11/13/23 to 11/20/23 it was determined for four (2E, 2F, 2G, and 3E) of nine residential care units reviewed, the facility did not ensure that all medications used in the facility were stored and labeled in accordance with currently accepted professional standards. Specifically, expired medications were stored with active medications in two medication carts (2E and 2F) and expired stock (standard medications that may be used for multiple residents) medications were stored in three medication rooms (2E, 2G, 3E). This is evidenced by the following: During an observation of medication storage on 11/16/23 at 9:46 AM, the medication room for Unit 3E had a Ziplock bag that contained 58 individually wrapped loperamide (antidiarrheal medication) 2 milligrams (mg) tablets and one unopened box of 12 loperamide 2 mg tablets both with an expiration date of August 2023. During an observation of medication storage on 11/17/23 at 10:05 AM, the medication cart for Unit 2F had one bottle of aspirin 325 mg, approximately…

    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 · Dcited before2023-11-20 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review conducted during the Recertification Survey from 11/13/23 to 11/20/23, it was determined that for 1 (Resident #82) of 11 residents reviewed for dining that the facility did not provide special eating equipment and utensils for a resident who required them to maintain the resident's ability to eat and drink independently. Specifically, Resident #82 was observed on several occasions consuming meals without a two handled mug with concave anti-splash lip, a lip plate, or an angled utensil (all adaptive eating equipment) as recommended. This is evidenced by the following: The facility policy and procedure titled Care Plan Adherence, dated July 2021, stated the resident care team will follow the plan of care that is developed for each resident to provide direction for their individualized care using measurable and achievable goals and is consistent with the resident's needs. The resident care team must follow the care plan for the resident at all times. The Clinical Educator is to re-educate staff to ensure they understand 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-20 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY00323359) from 11/13/23 to 11/20/23, the facility was not administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure that all residents were free from significant medication errors, did not have the Infection Preventionist (IP) working at least part time in the facility, and did not have the IP attend Quality Assurance and Performance Improvement (QAPI) meetings. Refer to the following tags: F760: Residents are Free of Significant Medication Errors F868: QAA Meetings F882: Infection Preventionist Qualifications/Role The Facility assessment dated [DATE], documented that the facility would provide the care needed so that all resident's medications would be administered and in a timely manner. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-20 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review conducted during a Recertification Survey 11/13/23 to 11/20/23, the facility did not maintain a quality assessment and assurance (QAA) committee consisting at a minimum of the Director of Nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role, and the infection preventionist (IP). Specifically, the facility could not provide evidence that the IP attended the last two Quality Assurance Improvement Performance (QAPI) meetings. This is evidenced by the following: Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 7/28/23 and 11/13/23 did not include the presence of the IP. Review of an undated facility QAPI Attendee Sheet provided by the facility did not include the IP. When interviewed on 11/16/23 at 11:17 AM and at 2:07 PM the IP stated they are a full-time employee at another facility and come into this facility as needed. The IP…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey from 11/13/23 to 11/20/23, it was determined that for two (Resident # 21 and #23) of two residents reviewed for infection control, the facility did not ensure compliance with infection prevention and control national standards such as transmission-based precautions (TBP). Specifically, staff did not follow the guidelines for appropriately applying and removing Personal Protective Equipment (PPE) when encountering transmission-based precautions (TBP) residents and their environment or isolate a resident (Resident #23) with a communicable disease from a resident (Resident #21) who did not have a communicable disease. This is evidenced by the following: The facility policy, Surveillance for Infections when it pertains to PPE for contact precautions, directed staff to apply gloves and isolation gowns prior to any resident care to protect themselves against infectious agents. To prevent cross- contamination, staff should…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-20 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 interviews and record review conducted during the Recertification Survey, it was determined that the facility failed to ensure they had an Infection Preventionist (IP) who was responsible for the facility's Infection Control Program. Specifically, the facility failed to ensure that the IP worked at least part time in the facility. This is evidenced by the following: Review of the Facility assessment dated [DATE] listed an IP as a key staff member for the facility to provide support and care to the residents. During an interview on 11/16/23 at 11:17 AM the IP stated they are a full-time employee at another facility and only comes into the facility as needed. During a follow up interview on 11/16/23 at 2:07 PM the IP stated they have not been in the facility since August of 2023. During an interview on 11/17/23 at 1:03 PM the Director of Human Resources stated the IP works per diem remotely from home and was last full time in the facility 8/26/22. During an interview on 11/17/23 at 2:05 PM the Director of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-02-17 · tag F0924 — pattern
    Put firmly secured handrails on each side of hallways.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations conducted during the Standard Recertification Survey completed on 2/17/22, it was determined that for two (second and third floors) of four resident use floors the facility did not properly equip corridors with handrails on each side. Specifically, there were sections of corridor wall that lacked handrails. The findings are: 1. On 2/14/22 at 10:16 a.m. it was observed that there were no handrails along corridor walls at the following locations on the second floor: outside A2-07; approximately 2-foot long and 5-foot sections, outside A2-06; an approximately 2-foot section. 2. On 2/15/22 at 8:49 a.m. it was observed that the was no handrail along an approximately 3-foot section of corridor wall between A3-21 (training bathroom) and resident room A3-19. 3. On 2/16/22 from 10:10 a.m. to 10:23 a.m. it was observed that there were no handrails along corridor walls at the following locations on the second floor: across from A2-21 next to the stairwell door; an approximately 4-foot section, between A2-21 and A2-19; an approximately 3-foot section, and next to A2-07…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · 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

    Based on observations, interviews and record reviews conducted during a Recertification Survey completed on 2/17/22, it was determined that for one (Resident #2) of five residents reviewed, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented for each resident to meet their preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, Residents #2 's CCP did not address diagnoses of depression or insomnia and did not address use of a psychotropic medication (medications that that affect behavior, mood, thoughts and/or perceptions that may have severe side effects). This was evidenced by: Resident #2 was admitted to the facility with diagnoses that included corticobasil degeneration (a rare progressive neurological disorder characterized by deterioration of specific areas of the brain), Parkinson's disease, and diabetes. The Minimum Data Set (MDS) Assessment, dated 11/1/21, revealed that Resident #2 had no speech (absence of spoken words), was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-05-13 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 interviews and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, for nine (9) (Residents #8, #18, #26, #53, #63, #128, #282, #332, and #383) of 19 residents reviewed, the facility did not provide a written summary of a Baseline Care Plan (care plan required to provide effective person-centered care that meets professional standards of quality for the immediate needs of the resident following admission). Specifically, there was no documented evidence that any of the listed residents or their representatives had received a written summary or review of their Baseline Care Plan that they were able to understand prior to their comprehensive care plan meeting. The findings include but not limited to the following: 1. Resident #63 was admitted several months prior with diagnoses including a leg fracture, age-related osteoporosis (bones become thin and brittle making them prone to fractures), and dysphagia (difficulty swallowing). The Minimum Data Set (a resident assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-02-17 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews conducted during the Recertification Survey, completed on 2/17/22, it was determined that for one (Resident #194) of three residents reviewed, the facility did not provide the appropriate appeal notice to the Medicare beneficiary in order to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the Medicare A beneficiary with a Notice of Medicare Non-Coverage (NOMNC) letter prior to discharge from the facility. This is evidenced by: Resident #194 was admitted to the facility 10/25/21 under Medicare benefits and was discharged to the community on 11/8/21. There was no documented evidence that the resident or responsible party was provided with the required appeal notice prior to discharge. In an interview on 2/17/22 at 8:51a.m., the Administrator stated the Minimum Data Set (MDS) Coordinator was responsible for issuing the NOMNC letter (CMS form 10123) to the beneficiary or representative. The Administrator stated the current MDS Coordinator was new to the position and was training. In an interview…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
ZELMAN, ELIEZERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/17/2024
POLATOFF, JUDAHIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
NUSSBAUM, YEHUDAIndividualADP OF THE SNFsince 01/22/2025

CMS files one row per role, so the 5 rows in the source record cover these 3 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.

$11.2M
Net patient revenuemost recent cost report
-31.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 67%Medicare 2%Other / private 31%

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

$482per resident / day
operating cost
$14,645per month
≈ monthly operating cost
$366per 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 335576. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-13, 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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