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Houghton Rehabilitation & Nursing Center

9876 Luckey Drive, Houghton, NY 14744 · For profit - Limited Liability company · 100 certified beds · (585) 567-2207 Medicare & Medicaid certified

Call the home — (585) 567-2207 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 2024Resident-funds citation (F0568)Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$65,052 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0568)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $65,052 in federal fines (most recent 2024-10-07)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (58%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Urgent care / clinic
 
Pharmacy
Grocery
44 S Genesee St · (585) 567-2701 · Call to confirm hours
Park
Moss Lake2.2 mi
Sand Hill Road · (703) 841-5300 · 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 3 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

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

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 increased10.9%14.1%15.4%better
Long-stay residents who lose too much weight5.0%5.8%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection0.3%1.3%2.0%better
Long-stay residents with depressive symptoms12.0%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.1%3.1%3.3%better
Long-stay residents whose ability to walk worsened8.5%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.6%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers7.5%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control31.0%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.3%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.0%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine97.6%78.8%79.4%better
Short-stay residents rehospitalized after admission23.9%20.6%22.6%typical
Short-stay residents with an outpatient ER visit10.8%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.291.701.67worse
Long-stay outpatient ER visits per 1,000 resident days2.941.361.80worse

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.

43.2% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.2%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
45.7%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 45.7% 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 35 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.2%CMS range 30.5–56.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.3–16.410.7%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 discharge45.7%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 discharge42.9%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 discharge45.7%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 identified98.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.0%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 hospitalization6.6%CMS range 3.6–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.781.02Oct 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

0.58
RN hours/ resident / day
0.46
LPN hours/ resident / day
1.65
Aide hours/ resident / day
2.69
Total nurse hours/ resident / day
0.42
RN hoursweekends
57.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 92.7 residents a day — about 93% occupied, or roughly 7 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 2.69 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.65 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.34 hrs/resident/day on weekends vs 2.84 on weekdays — 18% thinner on weekends. RN hours go from 0.64 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above 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

8
deficiencies at the latest standard inspection (2025-05-02)
6
at the previous standard inspection (2023-03-31)

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2024-10-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00340465) the facility failed to protect residents from sexual abuse for one (Resident #2) of three residents reviewed for abuse. Specifically, Resident #1 with a history of sexually aggressive behaviors was found engaged in sexual activity with Resident #2. Resident #2 wandered into Resident #1's room without staff's knowledge. Resident #1 and Resident #2 both lacked the ability to consent due to their cognitive impairment and inability to express their feelings. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, it was determined psychosocial harm occurred that is not immediate jeopardy. The finding is: The policy titled Abuse - Investigation, Protection and Reporting dated 10/24/2022 documented each resident has the right to be free from verbal, sexual, physical/mental abuse, involuntary seclusion, exploitation in any…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-02 · tag F0725 — failed to have enough nursing staff — widespread
    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 interview and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure that there was sufficient nursing staff with the appropriate competencies on a 24-hour basis to provide care to all residents for one of one facility reviewed for sufficient staffing. Specifically, the facility did not meet their minimum staffing levels for Certified Nurse Aides to meet the needs of each resident as they utilized non-certified Resident Assistants to meet their established minimums. The findings are: REFER TO: F 561 - Self Determination F 728 - Facility Hiring and Use of Nurse The policy titled Staffing dated 4/1/22, documented in accordance with current federal law the facility will ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Development of the staffing plan shall include consideration of the following including: the scopes of practice of Registered Nurses, Licensed Practical Nurse,…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-02 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure there were services of a Registered Nurse for at least eight (8) consecutive hours, seven (7) days a week unless when waived. Specifically, the facility did not have eight (8) consecutive hours of Registered Nurse coverage on 3/30/25, 4/5/25, 4/12/25 and 4/13/25 as required and did not have a waiver. The finding is: The policy and procedure titled Registered Nurse Coverage & Full-Time Director of Nursing revised April 2025 documented, the facility ensures compliance with federal regulations by ensuring a registered nurse is onsite for a minimum of eight (8) consecutive hours each day, seven (7) days per week. Scheduling of Registered Nurse coverage will be handled by the Staffing Coordinator or designee to ensure compliance. During an entrance conference interview on 4/28/25 at 12:27 PM, the Administrator stated the facility had no nursing staff waivers. The daily staffing sheets dated 3/28/25 through 4/27/25, documented they did not have a Registered Nurse 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-02 · tag F0728 — failed to protect against nurse-aide misconduct — widespread
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview conducted during a Standard survey completed 5/2/25, the facility did not ensure any individual working in the facility as a nurse aide for more than 4 months was competent to provide nursing and nursing related services and that individual has completed a training and competency evaluation program or a competency evaluation program approved by the State for six (6) (Resident Assistant #1, #3, #4, #5, #6, and #7) of seven (7) resident assistants reviewed. Specifically, Resident Assistants #1, #3, #4, #5, #6 and #7 worked greater than 4 months (120 days) as a nurse aide without receiving nurse aide certification. The finding is: Review of the New York State Nursing Home Nurse Aide Training Program and Certification dated January 2017, documented the Nurse Aide Training Program is responsible for scheduling the certification examination for its successful trainees within ten (10) business days of the last day of the Nurse Aide Training Program. The trainee must pass both the clinical skills test and the written (or oral) test in order to obtain New…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-02 · 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 interview and record review conducted during the Standard survey completed on 5/2/2025, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure nurse aide trainees were removed from providing hands on care within the required timeframe. The findings are: REFER TO: F725 -…

    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 · D2025-05-02 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for two (2) (Resident #18 and #52) of two (2) residents reviewed for choices. Specifically, Resident #18 was not provided with the frequency of showers they preferred and Resident #52 was not offered or provided with a shower as scheduled. The findings are: The policy titled Activities of Daily Living-Bathing and Bathing Preferences reviewed 3/25 documented the facility would bathe/shower resident based upon his/her preferences, needs and choices. A licensed nurse/activities/designee will gather information about residents' personal preferences for bathing/showers upon initial assessment and periodically thereafter. Bathing/shower schedules will be developed according to resident's needs, schedule and routine and not for staff convenience. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the Standard survey completed on 5/2/25, the facility did not provide services consistent with professional standards of quality for one (1) (Resident #6) of one (1) resident reviewed for dialysis. Specifically, Resident #6 did not receive Torsemide 40 milligrams as ordered by the physician on non-dialysis days, and it was given on dialysis days. The finding is: The policy titled Orders dated 3/19 documented, it is the facility's policy that all orders are accurately transcribed and executed in a timely manner per physician/Nurse Practitioner orders. The healthcare provider will provide timely and appropriate medical orders, and the healthcare provider will verify the accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident. Resident #6 had diagnoses that included end stage renal disease (receiving dialysis), lymphedema (a buildup of lymph fluid in the fatty…

    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 · D2025-05-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure that residents who had a suprapubic catheter (tube inserted into the bladder, through the abdomen, to drain urine) received the appropriate care and services to manage catheters for one (1) (Resident #20) of three (3) residents reviewed. Specifically, staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) during care, improperly emptied the drainage bag, did not offer Resident #20 a leg drainage bag and did not ensure the catheter drainage bag and tubing remained off the floor. The finding is: The policy and procedure titled Catheter Care - Male/Female Urinary and Suprapubic reviewed 2/2025 documented staff were to ensure the drainage bag was not touching the floor and to place in a bag for dignity. If the resident 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a Complaint investigation (#NY00375024) during a Standard survey completed on 5/2/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #28, #42, and #67) of five (5) residents reviewed for infection prevention and control and one (1) (Resident #31) of three (3) residents observed for pressure ulcers. Specifically, Residents #28, #42, and #67 started experiencing cold signs and symptoms (wet cough, raspy voice, sore throat), were tested for influenza A, respiratory syncytial virus, and COVID-19 on 4/29/25, and were not placed on transmission based precautions pending their test results; staff did not ensure hand washing after changing their gloves, after cleansing wounds, prior to the application of treatment and between draining wound sites…

    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 before2024-02-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during an Abbreviated Survey (Complaint #NY00324791) completed on 2/12/24, the facility did not ensure residents had the right to be free from sexual abuse for one (Resident #1) of four residents reviewed. Specifically, Resident #2 was observed by staff engaged in non-consensual sexual contact with Resident #1. The finding is: The policy and procedure titled Abuse- Investigation, Protection, and Reporting dated 10/24/22 documented a policy of zero tolerance will be enforced if any violations of these rights occur. Residents shall not be subjected to abuse and mistreatment by anyone including but not limited to: facility employees, medical staff, other residents. The policy and procedure documented residents should be evaluated to determine whether the resident has the capacity to consent to sexual activity. Resident #1 had diagnoses that included dementia, hypertension (high blood pressure), and hyperlipidemia (elevated fat levels in the blood). 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-31 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 3/31/23, the facility did not ensure that residents had a right to a safe, clean, comfortable, and homelike environment for four (100 Unit, 200 Unit, 300 Unit, 400 unit) of four resident units. Specifically, there was a lack of hot water in resident rooms and care areas. Sink faucets that did not function properly. Floor transitions between the hallway and resident living spaces in poor condition. Poor lighting in resident living spaces and safety floor mats soiled and in poor condition (Resident #29). The findings are: The facility P&P titled Daily Domestic Hot Water Testing dated 4/2018 documented to test the domestic hot water supply daily to provide safe, comfortable levels of hot water within all areas of the facility. The daily testing of the domestic water supply to ensure it is regulated within 90-120 degrees Fahrenheit (°F). Turn on hot water faucet and let the water run approximately 10 seconds. Keep…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2023-03-31 · tag F0836 — pattern
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review during a Standard survey starting on 3/27/23 and completed on 3/31/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide (CO) detectors shall be maintained in good working order and tested per Section 915 and the manufacturer's instructions/ recommendations. This affected the Basement and two (Main Street and 200 Wing) of five resident use wings and the South Nurse's station (nurses station located at the center point between the building's five wings). The findings are: According to the 2020 Fire Code of New York State, carbon monoxide (CO) detection shall be installed in residential buildings and commercial buildings in all rooms, occupiable space, dwelling units, sleeping areas, and sleeping units that contain a fuel burning appliance. Additionally, the 2020 Fire Code of New York State documented carbon…

    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 · D2023-03-31 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the Standard survey completed on 3/23/23, the facility did not ensure that the individual financial record was available to the residents through quarterly statements and upon request for two (Residents #14 and #41) of two residents reviewed. Specifically, the facility did not provide quarterly statements of their individual financial record for personal funds. The findings are: The policy and procedure (P&P) titled Accounting and Records of Resident Funds dated 6/2022 documented; The individual financial record will be available to the resident through quarterly statements and upon request. 1.Resident #14 has diagnoses that include chronic obstructive pulmonary disease (COPD a group of lung diseases that block airflow and make it difficult to breathe), anxiety disorder and major depressive disorder. The Minimum Data Set (MDS - a resident assessment tool) dated 1/1/23 documented the resident was moderately cognitively impaired, understands and was understood.…

    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 · D2023-03-31 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 3/31/23, the facility did not implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for two residents (Resident #2 and #62) of 2 residents reviewed. Specifically, Residents (#2, #62) had a history of falls, and did not have safety floor mats in place next to their beds as planned. The findings are: The policy and procedure (P&P) titled Comprehensive Care Planning dated 11/8/22 documented an interdisciplinary team approach is utilized in care plan development that includes the resident, their representative and all appropriate disciplines. The policy did not include information regarding the implementation of the care plan. 1. Resident #2 had diagnoses that included schizoaffective disorder, anxiety disorder and morbid obesity. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-22 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review conducted during a Standard Survey completed on 11/22/19, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for one (Resident #140) of four residents reviewed for abuse. Specifically, there was a lack of an investigation of the resident with scabs on the top of both hands and bruising of the left index finger. The finding is: The undated facility Policy and Procedure (P&P) titled Weekly Skin Assessment revealed weekly skin assessments will be completed on each resident in the Electronic Medical Record (EMR). Best practice is to do skin check on shower day. The licensed nurse will examine the skin of each resident weekly on a specified day. If an abnormality is found, then a weekly wound form is initiated and the physician, Director of Nursing (DON) /designee, and family are notified. The P&P titled Accident and Incident Reporting and Follow-Up dated 3/2019 revealed incidents and accidents (A&I) will be reported and report forms completed in a timely manner consistent with federal…

    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 · D2019-11-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during the Standard survey completed on 11/22/19, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #53) of three residents observed for ADL's. Specifically, a resident who was dependent on staff for ADL's, had long, jagged fingernails with brown debris under multiple fingernails and preferred them clean and cut. The finding is: Review of the facility policy and procedure titled Nail Care with a revision date of 2/18 revealed nail care should be provided on bath/shower day and as needed. 1. Resident #53 had diagnoses which included diabetes, Parkinson's (a nervous system disorder that affects movement, often including tremors), and hypertension (high blood pressure). Review of the Minimum Data Set (MDS- a resident assessment tool) dated 9/15/19 documented the resident was cognitively intact and required the assistance of one staff for personal hygiene. During an observation 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 · D2019-11-22 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 interview and record review conducted during a Standard survey completed on 11/22/19, the facility did not ensure the attending physician documented in the resident's medical record an identified irregularity was reviewed and what if any, action had been taken to address it for one (Resident #27) of five residents reviewed for unnecessary medications. Specifically, the physician did not document a rationale for not decreasing a resident's psychotropic medications per the pharmacist's recommendation. The finding is: The facility policy titled Medication Regimen Reviews dated 10/2018 documented the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what actions were taken, if any. If no action is to be taken and the medication not changed, the attending physician should document his/ her rationale in the resident's medical record. 1. Resident #27 had diagnoses including dementia with behavioral disturbance, heart failure, and major…

    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 · D2019-11-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a Standard survey completed on 11/22/19, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for two (Residents #27, 37) of five residents reviewed for unnecessary medications. Specifically, a resident admitted with an antipsychotic medication did not have an order for a psychiatric evaluation, did not have documented psychotic behaviors, and was not reviewed by the interdisciplinary team psychotropic medication committee (Resident #37); and a resident on an antipsychotic medication since April 2017 had no documented psychotic behaviors to support ongoing use and lacked an adequate indication for use (Resident #27). The findings are: Review of the facility policy and procedure titled Psychotropic Medication Use dated 10/2018 revealed that an evaluation will be completed if 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-03-31 · 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 observation, interview, and record review conducted during the Standard survey completed on 3/31/23, the facility did not post, on a daily basis: the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility did not ensure staffing sheets were completed daily and that they were updated at the beginning of each shift to reflect changes in the schedule. The finding is: The policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers dated 4/1/2018 documented the information recorded on the form shall include: The resident census at the beginning of the shift for which the information is posted; The actual time worked during that shift for each category and type of nursing staff; Total number of licensed and non-licensed nursing staff working for the posted shift. Within two hours of the beginning of each shift, the shift supervisor shall review and revise when applicable (account for cancellations and call-outs) the number of direct-care staff and complete 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-03-31 · tag F0914 — pattern
    Provide bedrooms that don't allow residents to see each other when privacy is needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 3/7/23 the facility did not ensure resident rooms were equipped to assure full visual privacy for four (100 Unit, 200 Unit, 300 Unit, 400 Unit) of four resident units. This involved Resident Rooms #114, #221, #304, #306, #411, and #414. The findings are: The policy and procedure (P&P) titled Room of the Day dated 4/2018 documented inspect curtains for visible soiling and remove, send to laundry, and replace as indicated. a. During intermittent observations on the 100 Unit from 3/28/23 to 3/30/23 between 8:06 AM and 3:36 PM, 3/29/23 revealed Resident room [ROOM NUMBER] A (semi -private) was not equipped with a privacy curtain for full privacy. During an interview on 3/28/23 at 3:26 PM, the resident residing in room [ROOM NUMBER] A stated they do not have a privacy curtain surrounding their bed and would like one for privacy. During an interview on 3/30/23 at 7:52 AM, Certified Nursing Assistant (CNA) #10 stated…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2019-11-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the Standard Survey completed on 11/22/19, the facility did not assess the resident using the quarterly review instrument not less frequently than once every three months for four (Residents #2, 15, 19, 20) of four residents reviewed for quarterly resident assessments. Specifically, the residents did not have quarterly Minimum Data Set (MDS - a resident assessment tool) completed timely as required. The findings are but not limited to: The facility policy titled MDS - Resident Assessments dated 10/2018 revealed in accordance with regulatory grouping 483.20 (Quarterly Review Assessment is an Omnibus Budget Reconciliation Act (OBRA) '87- required, non-comprehensive assessment that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items…

    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

“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

$65,052 in federal fines across 1 penalty.

  • $65,052 — penalty dated 2024-10-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PERSONAL HEALTHCARE MANAGEMENT — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 2 of 53.3-1.3 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 20 homes this chain runs (chain average 2.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BEIM, ESTHERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST35%since 07/10/2017
CREEDON, TERESAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 07/10/2017
WALDEN, CHAYAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 07/10/2017
ZAGELBAUM, BATIAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST40%since 07/10/2017
BARTH, ALEXANDERIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2023
MAYHLE, DOUGLASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
SAWYER, CHELSEAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
OSTROVITSKY, ISRAELIndividualADP OF THE SNFsince 01/23/2023

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.8M
Net patient revenuemost recent cost report
-14.2%
Operating marginrevenue minus expenses
$1.1M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 3%Other / private 19%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$296per resident / day
operating cost
$9,001per month
≈ monthly operating cost
$259per 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 335641. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-02, 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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