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Groton Community Health Care Ctr Res Care Fac

120 Sykes Street, Groton, NY 13073 · Non profit - Corporation · 80 certified beds · (607) 898-5876 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Feb 2026Resident-funds citation (F0565)2 immediate-jeopardy citations$132,948 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $132,948 in federal fines (most recent 2024-12-04)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (63%) 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.

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2127 Dryden Rd · (607) 844-9979 · Call to confirm hours
Pharmacy
44 North St · (607) 844-8273 · Call to confirm hours
Grocery
209 Peru Rd · (607) 221-1175 · Call to confirm hours
Park
Sykes Park<0.1 mi
124 Sykes St · 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 1 of 5
Long-stay residentspeople who live here 1 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 fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.4%14.1%15.4%worse
Long-stay residents who lose too much weight14.4%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder1.9%0.5%0.9%worse
Long-stay residents with a urinary tract infection1.8%1.3%2.0%typical
Long-stay residents with depressive symptoms30.9%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 injury6.8%3.1%3.3%worse
Long-stay residents whose ability to walk worsened17.4%12.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication11.8%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine95.1%95.3%95.3%typical
Long-stay residents with pressure ulcers6.6%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control21.1%19.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table27.3%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.5%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine78.1%78.8%79.4%typical
Short-stay residents rehospitalized after admission31.4%20.6%22.6%worse
Short-stay residents with an outpatient ER visit16.2%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.851.701.67worse
Long-stay outpatient ER visits per 1,000 resident days3.061.361.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.4% 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 130 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.4%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
55.8%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 55.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 52 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.4%CMS range 40.0–56.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.5–13.610.7%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 discharge55.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.9%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 discharge59.6%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 identified90.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.3–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.52
RN hours/ resident / day
1.20
LPN hours/ resident / day
2.14
Aide hours/ resident / day
3.86
Total nurse hours/ resident / day
0.19
RN hoursweekends
62.8%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 68.5 residents a day — about 86% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 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 3.15 hrs/resident/day on weekends vs 4.14 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% 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

7
deficiencies at the latest standard inspection (2026-02-06)
16
at the previous standard inspection (2024-12-04)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 13 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · L2024-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification and extended surveys conducted 11/21/2024-12/4/2024, the facility failed to ensure the residents' environment remained free of accident hazards 2 of 2 resident units (First and Second Floors). Specifically, hot water temperatures in resident sinks and common shower rooms on the First and Second Floors exceeded temperatures of the 110 degree Fahrenheit standard. This resulted in no actual harm with likelihood of serious harm, serious injury, serious impairment, or death that is Immediate Jeopardy and Substandard Quality of Care for all 70 residents residing in the facility. Findings include: 42 CFR 483.470 (d)(3) PART 483-REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES 483.470 Condition of Participation: Physical environment. (d) Standard: Client bathrooms. The facility must ensure: (3) In areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2024-12-04 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification and extended surveys conducted 11/21/2024-12/4/2024, the facility failed to ensure correct installation, use, and maintenance of bed rails to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for 5 of 5 residents (Residents #2, #14, #29, #33, and #46) reviewed. Specifically, Resident #2's bed was against the wall, with one bed rail and no bracket to hold the mattress in place (mattresses with bedrails should have a bracket or device to hold the mattress on the frame and in place. This is the component that keeps the mattress snugly against the rail. The bracket could be a strap around the end. or an actual raised metal bar. Resident #14 had an air mattress with bilateral side rails that were not monitored to account for changes in air pressure of the mattress; Resident #46 had a bed rail on one side and no bracket to hold the mattress in place against the bedrail; and Residents #2, #14, #29, #33, #46 did not have routine inspections of their…

    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
  • Actual harm · G2024-12-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 (NY00322525 and NY00322126) surveys conducted 11/21/2024-12/4/2024, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 1 resident (Resident #30) reviewed. Specifically, Resident #30 experienced a decline in physical mobility and developed an unstageable pressure wound (full thickness tissue loss in which the base of the ulcer is covered with non-viable tissue) and cellulitis to their heel. There was no documented evidence that preventative measures were implemented to prevent skin breakdown when the resident's mobility declined. Additionally, the resident's heels were observed resting directly on the mattress, their mattress was deflated, and the resident was not provided with timely incontinence care. This resulted in actual harm to Resident #30 that was not Immediate Jeopardy. Findings include: The undated facility policy, Pressure Ulcer/Injury, Prevention, documented preventing skin breakdown and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-06 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations and interviews conducted during the recertification survey, the facility failed to ensure residents were free from abuse for one (1) of two (2) residents (Resident #11) reviewed. Specifically, Resident #11 had multiple incidents of physical and verbal behaviors directed toward others and interventions to protect other residents from abuse by Resident #11 were not implemented.Findings include:The undated facility policy Resident Rights, documented residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation.The undated facility policy Resident to Resident Incident Policy & Procedure, documented a Resident to Resident Incident was any interaction between two (2) or more residents that involved (or had the potential to involve): aggressive or unwanted physical contact; verbal aggression, threats, intimidation; or behavior that created fear, disruption, or psychosocial harm. Additionally, both resident's care plans would be updated to include a behavior monitoring plan and interventions to prevent…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-06 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the recertification survey the facility failed to ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every three months for twenty-one (21) of twenty-one (21) residents (Residents #5, #6, #8, #12, #16, #19, #24 #29, #30, #31, #35, #53,#54, #56, #58, #59, #63, #65, #67, #69, #72) reviewed. Specifically, Residents #5, #6, #8, #12, #16, #19, #24 #29, #30, #31, #35, #53, #56, #58, #59, #63, #65, #67, #69, and #72's Minimum Data Set assessments were completed later than fourteen days after the Assessment Reference Date (the final day of the observation period to gather information about a resident's condition when completing the assessment).Findings included:The facility policy Minimum Data Set Assessment Policy, revised 06/2023 documented a registered nurse signed the completed Minimum Data Set assessment and the facility submitted completed assessments electronically per the Centers for Medicare and Medicaid…

    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 · E2026-02-06 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (lunch meals on 02/05/2026 and 02/06/2026); seven (7) of seven (7) anonymous residents; and one (1) of one (1) resident (Resident #63). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 02/05/2026 and 02/06/2026; seven (7) anonymous residents during a resident council meeting and Resident #63 stated the food did not taste good and was cold. Findings include:The facility policy Food Palatability Policy and Procedure, dated 03/2024, documented the facility would ensure all meals served were palatable, visually appealing, and met the dietary, cultural, and sensory needs of consumers, while maintaining compliance with food safety and quality standards. Food was flavorful, well-seasoned, appropriately textured and served at correct temperature for safety and enjoyment.The undated…

    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 before2026-02-06 · 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, record review, and interviews during the recertification survey, the facility failed to ensure food was stored, distributed and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen. Specifically, the main kitchen dishwasher's water temperature was not maintained at the vendor recommended level.Findings include:The 10/29/2007 Installation and Operation Manual for the ES-2000 and ES-4000 Series dishwasher documented the minimum water temperature required for Model ES4000 wash and rinse cycle was 120 degrees Fahrenheit.The 01/2026 facility's dishwasher sanitizer level log documented the water temperatures never reached 120 degrees Fahrenheit for either the rinse or wash cycle.During an observation and interview on 02/05/2026 11:02 AM, Food Service Worker #29 stated a water temperature below 100 degrees Fahrenheit was too low. The empty dishwasher was run, and during the wash cycle the temperature reached a high of 92 degrees Fahrenheit.During an interview on 02/05/2026 11:10 AM, Food Service Coordinator #26…

    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 before2026-02-06 · tag F0582 — isolated
    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 record review and interviews during the recertification survey, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #33) reviewed. Specifically, Resident #33 remained in the facility after discontinuation of Medicare Part A services, and the facility did not provide the resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) as required. Findings include:The facility policy, Medicare Beneficiary Notices: NOMNC (CMS 10123), DENC (CMS 10124), SNF ABN (CMS 10055) & ABN (CMS R 131), dated 11/23/2025, documented when a resident on Part A services had days remaining, but was being cut, and remained in the facility under custodial care, they must be provided with a Notice of Medicare Non-coverage and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The Notice of Medicare Non-Coverage 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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, the facility failed to ensure the accuracy of resident assessments reflective of the resident's status during the observation period of the Minimum Data Det assessment for two (2) of two (2) residents (Residents #5 and #48) reviewed. Specifically, Resident #5's 12/12/2025 Minimum Data Set assessment did not include the use of oxygen or a noninvasive mechanical ventilator; and Resident #48's 11/10/2025 Minimum Data Set assessment inaccurately documented the resident was rarely understood and had moderate cognitive impairment.Findings include:The facility policy Minimum Data Set Assessment Policy, revised 06/2023, documented the Minimum Data Set was an assessment system that was comprehensive, accurate, standardized, and reproducible for each resident.1) Resident #5 had diagnoses including congestive heart failure, chronic respiratory failure, and morbid obesity. The 12/12/2025 Minimum Data Set assessment documented the resident was cognitively intact, was not on oxygen, and did not have a…

    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 · D2026-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the resident's physician orders for one (1) of one (1) resident (Resident #5) reviewed. Specifically, Resident #5 used a continuous positive airway pressure machine (delivers a continuous flow of air to open the airway) and oxygen that were not included on the care plan or the Minimum Data Set (an assessment tool); and the resident had an unclean continuous positive airway pressure mask. Findings include: The undated facility policy Oxygen Use, documented the facility ensured safe, compliant oxygen therapy through detailed procedural controls, staff training, equipment maintenance, and rigorous safety precautions. The provider order included the flow, humidification, targeted oxygenation level, and titration parameters. The Registered Nurse verified the order in the electronic medical record, checked contraindications, and posted an oxygen in use…

    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 · F2024-12-04 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, and interviews during the recertification and abbreviated (NY00359606) surveys conducted 11/7/2024-12/4/2024, the facility did not ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 2 nursing units. Specifically, there was no hot water in the facility from 10/29/2024-11/8/2024. Additionally, resident's or resident representatives were not immediatley notified of the lack of hot water. Findings include: The undated facility policy, Safety of Water Temperatures, documented tap water in the facility should be kept within a temperature range to prevent scalding of residents. Water heaters that serviced resident rooms, bathrooms, common areas, and tub/shower areas were set at temperatures of no less than 105 degrees Fahrenheit and no more than 120 degrees Fahrenheit. Maintenance staff conducted daily tap water temperature checks using a calibrated digital thermometer at various locations in the facility and recorded the water temperatures in a safety log. If water temperatures fell outside the specified range, the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-12-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024 the facility did not store, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and for 1 of 1 resident (Resident #34) reviewed. Specifically, Resident #34's food was handled directly by staff without the use of gloves. In the main kitchen foods in the kitchen walk-in cooler were not properly labeled; floors had debris and uncleanable surfaces; there were unclean surfaces and equipment; walls were in disrepair; and the dishwasher sanitizer was not maintained at the vendor recommended level. Findings include: The facility policy, General Kitchen Cleaning Policy, dated 2/2019, documented all food contact surfaces would be properly cleaned and sanitized. The undated facility policy, Food Storage, documented food would be kept safe, wholesome, and appetizing; food would be stored at appropriate temperature and by methods designed to prevent contamination or cross contamination; food would be dated as it 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-12-04 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the abbreviated survey (NY00359606) conducted 11/7/2024, and the recertification and extended surveys conducted 11/21/2024-12/4/2024, the facility did not ensure it was administered 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, administration failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death, F 689 Accident Hazards and F 700 Bedrails; failed to ensure policies and procedures were properly identified, communicated, and consistently implemented; was not aware of the extent of the deficient practices cited; and did not report equipment failure when the facility did not have hot water for 10 days. Additionally, administration did not provide surveyors with requested and required documents (form CMS-802, Matrix for…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · E2024-12-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 3 of 4 medications carts (First Floor 1-2 and 3-4 carts and Second Floor 3-4 cart), and 2 of 3 medication rooms (First Floor medication room and Second Floor Omnicell room). Specifically, the First Floor medication room refrigerator temperatures were not consistently monitored; medications in First Floor carts 1-2 and 3-4 were expired; the First Floor room refrigerator had unlabeled multidose vial medications; and the Omnicell (medication storage tower) medication room and the First Floor 1-2 and Second Floor 3-4 medications carts were unlocked. Findings include: The facility policy, Storage of Medications, updated 9/2018, documented medications and biologicals were stored safely, securely, and properly per the manufacturer's recommendations or those 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-04 · tag F0940 — failed to train staff — pattern
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification and extended survey conducted [DATE]-[DATE], the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment for 4 of 5 staff (Licensed Practical Nurses #13, #16, #39, and #43) reviewed Specifically, there was no documented evidence Licensed Practical Nurses #13, #16, #39, and #43 had general orientation and required training in accordance with the facility assessment. Findings included: The Facility-Wide Self-Assessment completed [DATE], documented staff competency and care area requirements as identified in the Resident Population Assessment included incontinence/toileting program, dementia care, pressure ulcer prevention and treatment, technical skills, and pain management. Annual training requirements per regulatory authority and/or facility policy included job responsibilities and line of authority, facility policies and procedures, and other…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-04 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure a private space for monthly Resident Council Meetings. Specifically, 5 of 5 anonymous residents present at the resident group meeting stated the facility arranged monthly Resident Council meetings in the first floor dining room where uninvited staff were also present. Findings include: The facility policy, Resident Rights, documented all residents had the right to self-determination, confidentiality, and to communicate in person with privacy. The facility policy, Resident Council, dated 2/2021, documented staff, visitors, and other guests may attend resident council meetings if they were invited by the respective resident group. The resident council group was provided with space, privacy, and support to conduct meetings. During a resident group interview on 11/21/2024 at 1:59 PM, 5 of 5 residents stated the monthly Resident Council meetings were not held in a private space. The meetings were held in the first floor dining room and staff, usually the Director of Social…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-04 · tag F0582 — isolated
    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 record review and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 3 of 3 residents (Residents #28, #38, and #223) reviewed. Specifically, Residents #28 and #38 remained in the facility after discontinuation of Medicare Part A services with benefits remaining and the facility did not provide timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) as required; and Resident #223 was discharged from the facility and was not provided timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) as required. Findings include: The Center for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055, expiration date 1/31/2026, documented a Skilled Nursing…

    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 · D2024-12-04 · 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, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 resident (Resident #31) reviewed. Specifically, Resident #31 did not have an individualized person-centered care plan that addressed dementia with behavioral symptoms or use of psychotropic medications (medications used to treat mood disorders). Findings include: The facility policy, Psychotropic Medication Policy and Procedure, dated 3/2017, documented the facility ensured appropriate use, evaluation and monitoring of psychotropic medication use; nursing monitored psychotropic drug use daily noting any adverse effects such as increased somnolence (sleepiness) or functional decline; and the facility's goal was to determine the underlying cause of behavioral symptoms so appropriate treatment of environmental, medical, and/or behavioral interventions could be utilized and met the needs of the individual resident. The facility policy, Behavioral Health…

    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 · D2024-12-04 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (Resident #35) reviewed. Specifically, Resident #35 was not provided meaningful activities that met their interests and preferences. Additionally, Resident #35's room was not personalized with preferred activity items, such as a television or radio. Findings include: The facility policy, General Activity Department Guidelines, effective 2/21/2023, documented the facility provided, based on the comprehensive assessment, care plan, and preferences of each resident, an ongoing program to support residents in their choices of activities. The program of activities met the individual needs of each resident and fulfilled basic psychological, social, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification and abbreviated (NY00356968) surveys conducted 11/21/2024-12/4/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 3 of 3 residents (Resident #16, #17, and #30) reviewed; and for 1 of 2 emergency carts (Second Floor dining room emergency cart) reviewed. Specifically, the emergency cart in the dining room on the Second Floor was not checked daily to ensure emergency supplies were available; Resident #30 had a discontinued anti-fungal cream administered by Certified Nurse Aide #34; Resident #16 had three separate orders for as needed acetaminophen (Tylenol, pain reliever/fever reducer); and Resident #17 had two orders for as needed acetaminophen, and Percocet (an opioid pain medication) was administered outside of ordered pain parameters. Findings include: The facility policy, Medication Management, effective 8/2020, documented the facility provided…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-04 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure a safe, functional, sanitary, and comfortable environment for staff, visitors, and residents on 1 of 2 units (First Floor), and 1 of 1 resident (Resident #30) reviewed. Specifically, the large shower room on the first floor had a strong smell of feces, the bathroom located in the main hallway by the administrative office had a strong smell of urine, and Resident #30 was observed in a wheelchair that was in disrepair. Findings include: The undated facility policy, Resident Rights, documented all residents were provided a dignified existence. During an observation on 11/23/2024 at 10:16 AM, the large shower room on the First Floor had a strong smell of feces, the toilet was filled with brown liquid, and there were multiple small flying insects in the area. During an observation on 11/24/2024 at 3:17 PM, the First Floor large shower room had a strong urine and feces smell, the floor tiles under the toilet and under the shower bed were discolored. There were…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-24 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification survey conducted 2/21/23-2/24/23, the facility failed to ensure assessment of residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 35 of 65 residents (Residents #1, 4, 5, 6, 7, 8, 11, 12, 13, 15, 17, 20, 21, 22, 23, 24, 26, 27, 29, 30, 31, 35, 39, 40, 42, 43, 44, 45, 46, 47, 48, 50, 51, 52, and 57) reviewed for resident assessments. Specifically, Residents #1, 4, 5, 6, 7, 8, 11, 12, 13, 15, 17, 20, 21, 22, 23, 24, 26, 27, 29, 30, 31, 35, 39, 40, 42, 43, 44, 45, 46, 47, 48, 50, 51, 52, and 57 had Minimum Data Set (MDS) assessments that were completed later than 14 days following the Assessment Reference Date (ARD). Findings include: The undated facility policy Resident Assessment documented a comprehensive assessment of every resident's needs was made at intervals designated by the Omnibus Budget Reconciliation Act (OBRA) and Prospective Payment Systems (PPS) requirements. The Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 from 2/21/23-2/24/23, the facility failed to ensure results of the most recent Federal/State survey and Advocate Agency Information were posted in a place readily accessible to residents, family members and legal representatives of residents for 2 of 7 anonymous residents in attendance at the Resident Council meeting. Specifically, the results of the most recent recertification survey, the New York State Department of Health (NYS DOH) Nursing Home complaint hotline, and Ombudsman contact information were not posted in a location that would allow individuals access without having to ask to see them. This is evidenced by: The facility policy Your Rights and Protections as a Nursing Home Resident dated 8/1/21documented residents had the right to be free from abuse and neglect per federal law. The resident should be able to report abuse to the local Long-Term Ombudsman or the state survey agency. The undated facility Resident Handbook documented each resident had the right to call the Long…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview during the recertification survey conducted 2/21/23-2/24/23 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one isolated area in the main kitchen (the walk in cooler). Specifically, the flooring of the main kitchen's walk in cooler was not smooth and easily cleanable as required. Findings include: During observations on 2/21/23 at 10:05 AM, and 2/22/23 at 1:00 PM, the walk in cooler floor in the main kitchen was rusted, not smooth, and not easily cleanable. Two large sections of metal panel flooring with a metal transition strip in between had raised edges. The raised front edge was a tripping hazard and allowed food debris underneath. During an interview with the Food Service Director on 2/21/23 at 10:05 AM, they stated the walk in cooler flooring was replaced about a year ago by maintenance. They were not sure why the flooring rusted so quickly. They stated the flooring was difficult to clean and they were not sure that was the right type of metal used for…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-12-04 · tag F0550 — failed to protect resident dignity and rights — widespread
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure residents exercised their rights as a citizen or resident of the United States for 70 of 70 residents residing in the facility. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens and residents of the community. Additionally, 2 of 5 anonymous residents present at the resident group meeting stated their mail was opened prior to it being delivered to them. Findings include: The facility policy, Mail and Electronic Communication (Residents), dated 5/19/2021, documented residents received their mail promptly and unopened unless requested in writing by the resident or designated representative. Mail was received and sorted by the receptionist. Mail and packages were delivered by the activity staff to the resident within twenty-four hours of delivery on premises and included Saturday deliveries. The undated facility policy, Resident Rights, documented residents had a right to access mail. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-12-04 · tag F0585 — failed to handle grievances — widespread
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure a process was in place for residents to have their grievances addressed appropriately for 70 of 70 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms were not available to the residents and an official grievance officer was not identified. Additionally, 5 of 5 anonymous residents present at the resident group meeting stated they did not know who the grievance officer was or how to file a grievance. Findings include: The undated facility document, Resident Grievance/ Complaint Procedures, documented the resident grievance complaint form was obtained from the nurse's station or the business office. Residents signed the form or filed anonymously. The completed form was given to the Administrator or their designee. If the Administrator was not available, the form was given to the supervisor on duty, or it could be submitted anonymously to the person the resident wished to handle the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“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

$132,948 in federal fines across 1 penalty.

  • $132,948 — penalty dated 2024-12-04

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.

Who owns this facility

Owner / managerTypeRoleSince
BLOODGOOD, MARY ELLENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 09/01/2022
DUSO, MATTIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 09/01/2022
HAUKENES, ELAINEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 09/01/2022
SMITH, MICHAELIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 09/01/2022
WANNAL, JEANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 09/01/2022
WISSINK, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; TRUSTEE OF THE SNFsince 09/01/2022
PATEL, DARSHANIndividualCONTRACTED MANAGING EMPLOYEE; ADP OF THE SNFsince 01/01/2018
DEPTULA, PATRICKIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICER; ADP OF THE SNFsince 09/01/2022
WILLIAMS, RICHARDIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2022
SHURTLEFF, LEEIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; TRUSTEE OF THE SNFsince 09/01/2022

CMS files one row per role, so the 30 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$8.4M
Net patient revenuemost recent cost report
-10.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 59%Medicare 15%Other / private 26%

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

$347per resident / day
operating cost
$10,540per month
≈ monthly operating cost
$314per 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 335658. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-06, 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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