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Valley Health Services Inc

690 West German Street, Herkimer, NY 13350 · Non profit - Corporation · 160 certified beds · (315) 866-3330 Medicare & Medicaid certified

Call the home — (315) 866-3330 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 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
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
201 E State St · (315) 574-2300 · Call to confirm hours
Pharmacy
103 N Caroline St · (315) 717-0219 · Call to confirm hours
Grocery
103 N Caroline St · (315) 717-0023 · Call to confirm hours
Park
4 N Park Pl · (315) 717-0219 · 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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased14.7%14.1%15.4%typical
Long-stay residents who lose too much weight4.1%5.8%5.4%better
Long-stay residents with a catheter left in their bladder2.2%0.5%0.9%worse
Long-stay residents with a urinary tract infection1.8%1.3%2.0%typical
Long-stay residents with depressive symptoms0.0%19.5%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.5%3.1%3.3%worse
Long-stay residents whose ability to walk worsened19.0%12.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.6%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine96.6%95.3%95.3%typical
Long-stay residents with pressure ulcers10.4%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control24.1%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.1%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine88.9%78.8%79.4%better
Short-stay residents rehospitalized after admission25.8%20.6%22.6%worse
Short-stay residents with an outpatient ER visit11.4%9.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.661.701.67typical
Long-stay outpatient ER visits per 1,000 resident days2.681.361.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

53.2% 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 185 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.2%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
64.0%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 64.0% 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 100 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.2%CMS range 44.7–60.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.3–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge64.0%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 discharge55.0%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 discharge69.0%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%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 worsened5.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.1%CMS range 5.9–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.64
RN hours/ resident / day
1.00
LPN hours/ resident / day
1.99
Aide hours/ resident / day
3.63
Total nurse hours/ resident / day
0.26
RN hoursweekends
40.9%
Total nursing turnover
35.0%
RN turnover

How full it usually is: this home is certified for 160 beds and averages 140.8 residents a day — about 88% occupied, or roughly 19 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 3.06 hrs/resident/day on weekends vs 3.85 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.79 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

12
deficiencies at the latest standard inspection (2026-01-09)
7
at the previous standard inspection (2024-01-12)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2021-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification and abbreviated surveys (NY00284242) conducted from 11/15/21- 11/18/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents for 2 of 4 residents (Residents #75 and #113) reviewed. Specifically, Resident #75 was provided a hot beverage that had been microwaved by staff, the resident spilled the beverage and the resident sustained burns to their abdomen and thigh. Resident #113 was provided hot water by a staff person without ensuring proper temperature before serving. This resulted in actual harm to Resident #75 that was not an immediate jeopardy. Findings include: The facility policy Hot Food/Beverage Temperatures of Microwaved Food dated 2/2016 documents hot foods and/or beverages heated in the microwaves must not be served to residents at a temperature greater that 165 degrees Fahrenheit (F) to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-09 · tag F0554 — pattern
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey the facility failed to ensure a resident's ability to safely self-administer medications was clinically appropriate for two (2) of (2) residents (Residents #4 and #137) reviewed, and three anonymous residents present at the resident group meeting. Specifically, Residents #4 and #137 applied their own prescription creams without an order or assessment for their ability to do so; and three anonymous residents present at the resident group meeting stated they wanted to administer their own medications or creams and were told by facility staff they could not be assessed to do so.Findings include:The pharmacy policy Self-Administration of Medications, effective date 05/2018, documented to maintain a resident's high level of independence residents who desired to self-administer medications were permitted to do so if the facility's interdisciplinary team determined the practice was safe and there was a medical order to do so. If a resident desired to self-administer medications, an assessment 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-09 · tag F0691 — failed to provide colostomy / ostomy care — pattern
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    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, the facility failed to ensure residents who required nephrostomy tubes (a tube that drains urine from the kidney through an opening in the skin) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #161) reviewed. Specifically, Resident #161 had a nephrostomy tube and the physician orders did not include specific instructions to document the description of the output, when to change the drainage bag, to monitor for tube patency or blockage, and to monitor for signs and symptoms of infection; the care plan did not include care instructions or indicate what to monitor for and report; and staff were unsure if licensed practical nurses or certified nurse aides were responsible the drainage bag was emptied, measured, and documented. The drainage was not consistently measured and documented as ordered. Additionally, medical was not notified when there was no output. Findings…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-09 · 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

    Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for two (2) of six (6) residents (Resident #5 and #137) reviewed, and for the facility legionella (a bacteria in water that can cause Legionnaire's disease) program. Specifically,-Resident #5 was on enhanced barrier precautions for a urinary catheter (drains urine from the bladder through a tube). Urinary catheter care was provided by Certified Nurse Aide #6 and precautions were not followed; Licensed Practical Nurse #5 did wear appropriate personal protective equipment when administering medications; and the resident's care plan did not include the use of enhanced barrier precautions.-Resident #137 was on contact precautions for conjunctivitis (pink eye). Precautions were not ordered until three days after symptoms appeared 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview during the recertification survey, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, for one (1) of one (1) resident (Resident #144) reviewed. Specifically, Resident #144 did not have their tap bell (manual device used to request assistance) in reach when out of their room as planned. Findings include:The undated facility policy Fall Prevention, documented when a resident was identified at risk for falls a plan of care would be implemented. All residents would have a fall risk assessment upon admission, quarterly, annually, and as needed. Once identified as a risk for falls the Nursing Care Coordinator and the interdisciplinary team would establish a comprehensive plan of care, addressing the individual needs of each resident.Resident #144 had diagnoses including dementia with behavioral disturbances, fractures of the arm and thigh bone. The 12/05/2025 Minimum Data Set…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · 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

    Based on observations, record review, and interviews during the recertification survey, the facility failed to provide ongoing programs to support each resident in their choice of activities, for one (1) of one (1) Resident (Resident #70) reviewed. Specifically, Resident #70 did not have a person-centered care plan that reflected their interests and preferences and was not offered meaningful activities that met their interests and preferences.Findings include:The facility policy Activities Program, last reviewed 8/2025, documented the Activities Program was a structured plan of social, recreational, cultural, spiritual and therapeutic events designed to enhance quality of life. Activities were to include cognitive stimulation, physical activity, creative expressions, spiritual practices, and social interaction. Activities would be adapted to meet the needs of residents with cognitive or physical impairments. Activities staff were to be trained and receive ongoing education in resident's rights, person-centered programming, and dementia-specific approaches. Residents were to be…

    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 · D2026-01-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one (1) of one (1) resident (Resident #115) reviewed. Specifically, Resident #115 was not re-evaluated by therapy for positioning in their Broda chair (a specialty positioning wheelchair) and staff used a wedge pillow in the chair which did not maintain proper body alignment. Findings include:The facility policy Adaptive Positioning Equipment, dated 7/10/2025, documented residents requiring wheelchairs, positioning chairs, splints, and other adaptive equipment will be assessed by rehabilitation staff, and issued adaptive equipment as needed. If concerns arise after admission regarding the resident's positioning needs, the Nursing Care Coordinator was responsible for documenting the concern/need and sending occupational therapy or physical therapy rehabilitation request for wheelchair, splints, and positioning devices. The resident would be…

    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 · D2026-01-09 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 that residents who required dialysis (used to filter waste products from the blood when the kidneys stop working properly) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #117) reviewed. Specifically, Resident #117 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site, and there was not consistent ongoing communication and collaboration between the facility and the dialysis center. Findings include:There was no documented evidence of a facility policy addressing dialysis.Resident #117 had diagnoses including end-stage kidney disease. The 10/19/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, did not reject care, and required hemodialysis treatments.The Comprehensive Care Plan…

    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 · D2026-01-09 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 residents who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (1) of one (1) resident (Resident #7) reviewed. Specifically, Resident #7 had a history of trauma with episodes of night terrors, and did not have a person centered care plan to address potential triggering events to avoid re-traumatization; and there was no social work follow up addressing the resident's night terrors.Findings include:The facility policy Trauma Informed Care, revised 05/23/2025, documented any care plan that referenced or discussed the resident's trauma must be clearly marked at the beginning of the care plan as confidential. All staff were to be trained on trauma informed care upon hire and annually. Training included defining and discussions of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interview during the recertification survey the facility failed to ensure that residents who displayed or were diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem to attain the highest practicable mental and psychosocial well-being for one (1) of one (1) resident (Resident #136) reviewed. Specifically, Resident #136 exhibited symptoms of depression following their admission to the facility and need for long-term care and did not receive mental health counseling or routine psychiatric evaluations. Findings include: The facility policy Provision of Social Services, dated 11/24/2009, documented the facility would provide a social service program to meet the psychological needs of the individual resident. Services were provided based upon a comprehensive assessment, which assured the residents' maximum attainable quality of life (i.e., emotional and physical well-being, self-determination, self-respect, and dignity).Resident #136 had diagnoses…

    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 · D2026-01-09 · 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

    Based on observations, record review, and interviews, the facility failed to ensure residents were free of any significant medication errors for one (1) of one (1) resident (Resident #5) reviewed. Specifically, Resident #5 was administered lispro insulin (a fast-acting insulin) that was opened and undated. Findings include:There was no documented evidence of a facility policy addressing insulin administration or storage. Manufacturer specifications for insulin lispro documented opened vials/ pens were discarded after 28 days.Resident #5 had diagnoses including diabetes. The 11/15/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact and received hypoglycemic (lowers blood sugar) medications (including insulin). The 10/24/2025 physician order documented insulin lispro was administered before meals and at bedtime based on the following sliding scale (amount of insulin administered based on blood glucose levels):-if glucose level 0-150 milligrams/deciliter give 0 units-if glucose level 151-200 milligrams/deciliter give 2…

    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
Show the remaining 14 citations
  • Potential for harm · D2026-01-09 · 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 observations and interviews the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one (1) of four (4) shower/tub units (2 [NAME] shower/tub unit) reviewed. Specifically, four anonymous residents present at the resident group meeting stated the shower/tub floors were a mess, the drains did not work, and the tubs leaked. The shower/tub unit on 2 [NAME] was observed to have standing, discolored water underneath it for multiple days of survey.Findings include:The undated facility policy Residents' [NAME] of Rights & Responsibilities, documented the residents had the right to dignified existence. The residents had the right to receive services in the facility with reasonable accommodations of their needs and preferences.During a resident group meeting on 01/05/2026 at 2:06 PM, four anonymous residents stated the resident shower floors were a mess, the showers and tubs did not work, the drains in the shower rooms did not work, and the tubs leaked.The 2 [NAME] Maintenance Request and Requisition forms from…

    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 · D2024-05-23 · 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 record review and interview during the abbreviated survey (NY00337472), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed. Specifically, Resident #3 sustained a head injury from a fall and neurological checks were not performed during the time the resident awaited transport to the hospital. Findings include: The Head Trauma Protocol reviewed 3/2007, documented: - the Registered Nurse Supervisor was responsible for notifying the physician of any resident with head trauma and to follow-up as warranted. - Neurological checks were to be performed per the instructions. The Registered Nurse was to obtain the physician's order to perform neurological checks per the policy (refer to Neurological Check policy). The Neurological Check policy reviewed 3/2007 documented: - any incident involving the head that resulted in an injury would initiate a monitoring schedule for neurological checks. The schedule was to be maintained for a minimum of 24 hours. Following 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
  • Potential for harm · E2024-01-12 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during the recertification and abbreviated (NY00310705, NY00312631, NY00313972, and NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure sufficient nursing staff was provided for nursing care to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 12 anonymous residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) 12 residents stated they had long wait times for receiving assistance with care. Additionally, deficiencies related to staffing were identified in the areas of Posted Nurse Staffing Information (F732), Resident Rights (F 550), and Infection Control (F 880). Findings include: The facility policy Staffing of Nursing Personnel dated 6/22/2009 documented all residents' needs were always met in a timely manner. The Director of Nursing set the staffing level for each unit and shift. The staffing…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification and abbreviated (NY00328391) surveys conducted 1/8/2024-1/12/2024, 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 3 of 3 staff members (certified nurse aides #17 and #28, and food service worker #18) observed. Specifically, certified nurse aide #17 did not don and doff personal protective equipment as required when entering and exiting rooms with COVID-19 positive residents, did not perform hand hygiene, and placed an unclean face shield on a kitchenette counter; certified nurse aide #28 removed a dinner tray from a COVID-19 positive resident room and placed the tray on top of the dinner cart with unserved meal trays; and food service worker #18 entered the closed COVID-19 area with a lunch cart. Additionally, Resident #45 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during the recertification and abbreviated (NY00290651, NY00310705, and NY00312631) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure residents were treated with respect and dignity for 3 of 5 residents (Residents #26, #38, and #110) reviewed. Specifically, Resident #26 had soiled clothing and an unclean wheelchair; Resident #38 was assisted with eating by registered nurse #9 and licensed practical nurse #10 who stood over them while feeding; and certified nurse aide #17 was observed speaking loudly about Resident #110's colostomy care and could be heard by anyone in the vicinity. Findings include: The facility policy, Accommodation of Resident Needs revised 9/2008 documented staff should call the resident by their first or last names and not honey, sweetie, dear; introduce yourself and explain all procedures to the resident and allow them to tell you what their needs are; review the care plan before providing assistance and always give the Resident a means to call for assistance by placing a call bell or tap bell…

    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 before2024-01-12 · 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 observation, record review, and interview during the recertification survey conducted 1/8/2024-1/12/2024, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet medical and nursing needs for 1 of 1 resident (Resident #46) reviewed. Specifically, Resident #46 had a physician order to elevate their legs when out of bed and the order was not implemented. Findings include: The facility policy Baseline Care Plan, reviewed 3/2023, documented the care plan included instructions needed for staff to provide effective and person-centered care and physician's orders. The baseline care plan would be evolved into the comprehensive plan of care by the care team and subsequent assessments. Resident #46 had diagnoses including Alzheimer's disease, hypothyroidism (underactive thyroid gland), and hyperlipidemia (elevated fat levels in the blood). The 12/13/23 Minimum Data Set assessment documented the resident had severely impaired cognition, did not exhibit behaviors, had functional limitation in both legs, and was dependent for most…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview during the recertification and abbreviated surveys (NY00310705 NY00312631, NY00313972, and NY00328391) conducted 1/8/2024-1/12/2024, the facility did not post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for 4 of 5 days. Specifically, the current daily resident census and nurse staffing schedules were located on the Unit 1 [NAME] nursing office door that was not easily accessible to visitors or residents. Findings include: The daily resident census and nurse staffing information was observed posted on the nursing office door outside of Unit 1 [NAME] across from the elevator: - on 1/8/2024 at 2:21 PM. - on 1/9/2024 at 7:50 AM. - on 1/10/2024 at 12:03 PM. - on 1/11/2024 at 9:27 AM. The posting was not legible, did not include the daily census, and was not readily accessible to residents or visitors. During an…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during the recertification and abbreviated (NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure a resident who displays or is diagnosed with dementia receives the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #45) reviewed. Specifically, Resident #45 who had a diagnosis of dementia, made suicidal statements that were not addressed by the facility. The facility policy Suicide Precautions reviewed 03/2023 documented immediate protective response would be provided, physically and emotionally, to any resident that expressed suicidal plans, thoughts, or attempts. Any employee who became aware that a resident had expressed suicidal thoughts, plans, or attempts would immediately notify the charge nurse on the resident's unit. The resident would be under direct supervision until a plan of care for the resident was determined. The registered nurse Supervisor, Director of Nursing, social services,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · 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, record review, and interview during the recertification survey conducted 1/8/2023-1/12/2023, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in 1 of 1 main kitchen. Specifically, the mechanical dishwasher was not maintained, clean utensils were not properly stored, uncleanable surfaces were present in the walk-in cooler, and the walk-in cooler was soiled. Findings include: The undated facility policy, Kitchen Cleaning documented all kitchen staff were responsible for cleaning and sanitizing the kitchen. Specifically, cooks were responsible for cleaning and maintaining their work area, steamers, fryers, sinks, slicers, stove tops, and general work areas; dietary aides were responsible for cleaning their tray line areas, walk-in cooler, refrigerator and dessert carts and dishwashers were responsible for cleaning the dishwashing area and cleaning/mopping floors. Garbage was removed by maintenance. 1) Mechanical dishwasher The mechanical dishwasher's specifications were not documented on 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 · Dcited before2021-11-18 · 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

    Based on observation, record review and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to ensure all residents were provided an ongoing program to support residents in their choice of activities and designed to meet their individual needs based on the comprehensive assessment and care plan and the preferences of each resident for 1 of 3 residents (Resident #10) reviewed. Specifically, Resident #10 was not provided meaningful activities as care planned. Findings include: Resident #10 had diagnoses including glaucoma, legal blindness, and heart failure. The 8/12/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive to total assistance with most activities of daily living (ADLs). The resident considered choice of listening to books on tape, listening to television, and listening to music important. The comprehensive care plan (CCP) initiated 8/18/21 documented the resident was alert and able to make leisure choices, enjoyed listening to books on tape, music, and television…

    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 · D2021-11-18 · 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 observation, interview, and record review during the recertification survey conducted 11/15/21-11/18/21 the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 unit medication rooms (Unit 2EE) and 1 of 4 medication carts (medication cart #8) reviewed. Specifically, the Unit 2EE and medication cart #8 had stock medications that were expired or outdated beyond the opened date. Findings include: The facility policy Storage and Maintenance of Medication dated 6/2016 documented medication should be checked regularly for expiration dates and deterioration. Expired medications are removed from use and destroyed. During an observation of the 2EE medication room on 11/16/21 at 9:54 AM, there was a vial of influenza vaccine with an expiration date of 6/30/20 and a handwritten date on the box labeled 12/2, and an open of box of bisacodyl suppositories (laxative) with an expiration date of 11/2020.…

    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 · D2021-11-18 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    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 observation and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to ensure each resident received food and drink that was palatable and at a safe and appetizing temperature for 2 of 2 meal trays (lunch and dinner) tested. Specifically, food was not served at a safe and appetizing temperature for a lunch and dinner meal. Findings include: The facility policy for Food Temperatures was requested and was not received. During an interview with Resident #50 on 11/15/21 at 1:42 PM, they stated food was generally served cold. During an interview with Resident #21 on 11/15/21 at 4:45 PM, they stated the food was served lukewarm or ice cold. During the resident group meeting on 11/17/21 at 10:00 AM, 1 anonymous resident stated their hot food items at meals were not always served hot. During an observation on 11/15/21 at 5:17 PM, the meal cart arrived at the Unit 2 Extension. At 5:22 PM, Resident #18 was served, and their dinner tray was used for temperature measurement and taste testing with a replacement provided. At 5:24 PM, the following…

    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 before2021-11-18 · 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, record review and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 8 unit pantry refrigerators (Units #1 East and 2 West) and 1 kitchen tray line refrigerator observed. Specifically, air temperatures were not maintained for Unit #1 East and 2 [NAME] pantry refrigerators at 40 degrees Fahrenheit (F) or lower. Additionally, the kitchen tray-line refrigerator air and food temperatures were not maintained. Findings include: The facility policy Proper Refrigeration Temperatures dated 11/2011 documents the following: - All dining room and nourishment pantry refrigerators will be maintained to standards set for proper storage of cold foods and beverages. The dietary aide/server will take temperatures of each refrigeration unit in dining room pantries on the day shift and record on the log sheet. The cook will take the temperature of each refrigerator in the kitchen and record on the log sheet. - If 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-01-09 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview during the recertification survey, the facility failed to post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for five (5) of five (5) days (01/05/2025-01/09/2025). Specifically, the current daily resident census, staffing hours, and nurse staffing schedules were located on the Unit 1 [NAME] nursing office door and window that was not easily accessible to all visitors or residents. Findings include: The facility policy Posting of Nurse Staffing Information, dated 01/16/2024 documented the facility complied with regulations including posting of nurse staffing information. The daily staffing information would be posted on the first floor next to the window of the nursing office at the beginning of each shift. Data would be legible and posted in a prominent place accessible to residents and visitors.During multiple…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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 / managerTypeRoleSince
BASLOE, ROBERTIndividualCORPORATE DIRECTORsince 08/19/2015
DUNN, KIRSTENIndividualCORPORATE DIRECTORsince 04/20/2022
ENEA, HARRYIndividualCORPORATE DIRECTORsince 06/15/2005
GORMAN, JUDITHIndividualCORPORATE DIRECTORsince 04/20/2022
HORN, KATHLEENIndividualCORPORATE DIRECTORsince 08/16/2017
JASTREMSKI, CONNIEIndividualCORPORATE DIRECTORsince 10/19/2016
LITTLE SMITH, MARYIndividualCORPORATE DIRECTORsince 08/17/2011
LYGA, ANNIndividualCORPORATE DIRECTORsince 04/16/2014
MAROLLO, KATHLEENIndividualCORPORATE DIRECTORsince 04/20/2022
MILITELLO, JOHNIndividualCORPORATE DIRECTORsince 07/18/2007
O'DONNELL, MARIANNEIndividualCORPORATE DIRECTORsince 08/15/2018
PEARSALL, CURTISIndividualCORPORATE DIRECTORsince 04/20/2022
WOEPPEL, JEFFREYIndividualCORPORATE DIRECTORsince 08/15/2018
BETRUS, LISAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/1998

CMS files one row per role, so the 15 rows in the source record cover these 14 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.

$12.7M
Net patient revenuemost recent cost report
-25.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 78%Medicare 6%Other / private 16%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. 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

$357per resident / day
operating cost
$10,848per month
≈ monthly operating cost
$285per 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 335672. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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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