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Oneida Health Rehabilitation And Extended Care

323 Genesee Street, Oneida, NY 13421 · Non profit - Corporation · 160 certified beds · (315) 363-6000 Medicare & Medicaid certified

Call the home — (315) 363-6000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$16,153 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,153 in federal fines (most recent 2025-04-25)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
578 Seneca St · (315) 363-1110 · Call to confirm hours
Pharmacy
2018 Glenwood Shopping Plz · (315) 915-0866 · Call to confirm hours
Grocery
142 Genesee St · (315) 363-8927 · Call to confirm hours
Park
558 Broad St · (315) 363-3590 · 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 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased29.7%14.1%15.4%worse
Long-stay residents who lose too much weight6.9%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection1.7%1.3%2.0%better
Long-stay residents with depressive symptoms0.7%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 injury4.4%3.1%3.3%worse
Long-stay residents whose ability to walk worsened27.2%12.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication23.2%13.2%18.9%worse
Long-stay residents given the seasonal flu vaccine95.9%95.3%95.3%typical
Long-stay residents with pressure ulcers2.8%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control31.2%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.5%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine70.0%78.8%79.4%worse
Short-stay residents rehospitalized after admission17.7%20.6%22.6%better
Short-stay residents with an outpatient ER visit19.1%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.171.701.67better
Long-stay outpatient ER visits per 1,000 resident days2.251.361.80worse

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.

58.0% 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 161 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.0%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 82 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% 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 SNF58.0%CMS range 50.1–66.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 6.4–12.010.7%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 discharge50.0%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 discharge37.8%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 discharge54.9%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 identified97.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.4%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 stay0.0%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 worsened2.8%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 hospitalization8.2%CMS range 5.3–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 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

0.55
RN hours/ resident / day
0.94
LPN hours/ resident / day
1.68
Aide hours/ resident / day
3.17
Total nurse hours/ resident / day
0.36
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 160 beds and averages 150.2 residents a day — about 94% occupied, or roughly 10 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.554 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.68 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 2.71 hrs/resident/day on weekends vs 3.36 on weekdays — 19% thinner on weekends. RN hours go from 0.63 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Inspection trend

9
deficiencies at the latest standard inspection (2026-01-27)
15
at the previous standard inspection (2024-04-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-04-25 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the abbreviated survey (NY00377944), the facility failed to ensure that Advance Directives were implemented in a manner that was consistent with residents' wishes for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order for a Full Code (consent to receive life-saving measures in the event of cardiac or respiratory arrest). When the resident was found unresponsive, facility staff failed to timely initiate a Code Blue (signal indicating a medical emergency) and perform cardiopulmonary resuscitation (CPR). Resident #1 was subsequently transferred to the emergency department where they expired. This resulted in Resident #1's death that is Immediate Jeopardy past non-compliance, and likelihood of serious harm, serious injury, serious impairment, or death to all residents in the facility who had Advance Directives in place. Findings include: The facility policy, Advance Directives: Advance Care Planning for Healthcare…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2026-01-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for four (4) out of twelve (12) kitchen staff (Dietary Aides #14, #15, #16, and #17). Specifically, Dietary Aides #14, 15, 16, and 17 had improper hair restraints while preparing food and meal trays in the main kitchen. Findings include:The facility policy Sanitation and Infection Control, revised 05/2023, documented employees would wear hair restraints. Men with beards and/or mustaches would wear beard restraints. The following observations of improper hair restraints were made in the main kitchen on 01/20/2026 at 11:02 AM: -Dietary Aide #14 was walking through food preparation areas with an unrestrained long ponytail. -Dietary Aide #15 was preparing food in the front of the kitchen wearing only a cap on their head, with long, shoulder length hair untied or restrained.-Dietary Aide #16 was preparing lunch trays for residents wearing only a cap on their head, with long…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-27 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey, the facility failed to establish mechanisms for documenting and communicating the resident's choices regarding Advance Directives to the staff responsible for the resident's care for one (1) of thirty-three (33) residents (Resident #63) reviewed. Specifically, Resident #63's electronic Medical Orders for Life-Sustaining Treatment form (a medical order for wishes for life-sustaining treatment completed by a medical provider) documented the resident consented to do not resuscitate (allow natural death) and the resident's electronic medical record documented to attempt cardiopulmonary resuscitation (attempt to restart the heart). Findings include: The facility policy Advance Directives: Advance Care Planning for Healthcare Decisions, revised 7/2024, documented medically appropriate care would be provided to every patient and patient's wishes regarding cardiopulmonary resuscitation and do not resuscitate and other life sustaining treatment and end of life health care decisions would be honored.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey (complaint #466496) the facility failed to ensure a resident's designated representative was notified of changes in condition for one (1) of two (2) residents (Resident #175) reviewed. Specifically, Resident #175 was hospitalized , and their designated representative was not notified of their hospitalization.Findings Include:The facility policy Transfer and Discharges. dated 09/16/2016, documented the proper notification of a transfer or discharge would be made to the resident and/or representative. Notification included the reason for the transfer, and the reason would be documented in the resident's clinical record. The facility would provide the resident and/or representative notice of the bed-hold policies and readmission policies prior to the transfer for hospitalization or therapeutic leave. In the case of an emergency transfer, notice at time of transfer meant that the resident representative would be provided with a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of one (1) resident (Resident #144) reviewed. Specifically, Resident #144's person-centered comprehensive care plan did not include the diagnoses of type 2 diabetes mellitus (the body does not use insulin properly causing high blood sugars), the use of insulin (used to treat high blood sugars), or the use of an anticoagulant (blood thinner).Findings include:The facility policy Comprehensive Care Plans, revised 04/2024, documented the facility would develop a comprehensive individualized plan of care for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Care plans would be reviewed and updated at least quarterly, when there was a significant change in…

    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 before2026-01-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification and abbreviated (IQIES 466495) surveys, the facility failed to ensure residents' medications were administered in accordance with accepted professional standards and the prescriber's order for two (2) of two (2) residents (Residents #1 and #39) reviewed. Specifically, Resident #1's and #39's physician orders did not include the amount of fluid used with medication instillation; and Resident #1 was administered ginger ale with medications without a physician order.Findings include:The facility policy Enteral Nutrition, last revised 02/2025 documented adequate nutritional support through enteral nutrition (feeding tube) would be provided to residents as ordered. The dietitian, with input from the provider and nurse calculates the fluids to be provided. Complete orders include instructions for flushing (solution, volume, frequency, timing and 24-hour volume). Documentation of the feedings and flushes will be under the medication administration record in the electronic medical record. 1)Resident #39 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews during the recertification survey (Complaint #2699879), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of two (2) residents (Resident #76) reviewed. Specifically Resident #76 had two Stage 2 pressure ulcers (partial-thickness skin loss) on the buttocks and an unstageable (full thickness tissue loss in which the base of the ulcer is covered with dead tissue) pressure ulcer on the right heel that did not have timely treatment orders or interventions; the medical orders for wound treatments were not followed; and the resident was not turned and positioned as planned. Findings include: The facility policy Prevention and Treatment of Pressure Injuries, last reviewed 9/2025, documented the facility would develop and implement a comprehensive care plan that…

    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 · D2026-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during the recertification survey, the facility failed to ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for one (1) of six (6) residents (Resident #123) reviewed. Specifically, Resident #123 was at risk of falls, and their call light was not within reach as care planned.Findings include:The facility policy Falls, revised 08/2016, documented on admission, a fall risk assessment would be completed along with a fall care plan with specific individual interventions necessary to prevent resident falls. Fall interventions would be added to resident's care plan, certified nurse aide assignment sheet, and communicated through the 24-hour nursing office report. Nursing supervisors, unit managers, and team leaders would be responsible for ensuring the care plan was being followed.Resident #123 had diagnoses including right side paralysis and weakness and need for assistance with personal care. The 09/12/2025 Minimum Data Set assessment (screening tool) documented the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · 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

    Based on observations, record review, and interviews during the survey conducted 01/27/2026-01/27/2026, the facility failed to ensure an indwelling urinary catheter (removes urine from the bladder) was not used unless there was valid medical justification for one (1) of three (3) residents (Resident #18) reviewed. Specifically, Resident #18 had an indwelling catheter without an order, indication, or care plan for its usage.Findings include:Resident #18 had diagnoses including congestive heart failure (the heart does not pump efficiently), chronic kidney disease, and acute cystitis (inflammation of the bladder). The 12/05/2025 Minimum Data Set assessment (screening tool) documented the resident had severely impaired cognition, required maximum/dependent assistance for all activities of daily living and transfers, and did not have an indwelling catheter.Resident #18 was observed with a urinary catheter on 01/20/2026 at 11:58 AM and 01/21/2026 at 8:45 AM. The unsigned 01/16/2026 admission Assessment documented Resident #18 did not have an indwelling urinary catheter.There was no…

    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 · D2026-01-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of three (3) residents (Resident #101) reviewed. Specifically, Resident #101 had significant weight loss and did not have a timely nutritional assessment. Findings include: The undated facility policy Nutritional Assessment and Reassessment, documented residents would receive timely and accurate nutrition assessments, including residents with significant nutritional changes.The facility policy Weights, revised 03/2022, documented nursing staff measured resident weights on admission, and weekly for four weeks. If no weight concerns, weights were then measured monthly. Dietary and medical providers would be notified of any weight discrepancies. Weight loss greater than five percent in one month or greater than ten percent in six months were severe.Resident #101 had diagnoses including dementia, chronic respiratory failure, and vascular disease. The 08/19/2025 Minimum Data Set (assessment tool)…

    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 · E2024-04-12 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Residents #12, #38, #40 and #58) reviewed. Specifically, Resident #12 had unclean and untrimmed fingernails; Resident #40 was not assisted out of bed for toileting; Resident #58 was not assisted with toileting every 2 hours as care planned; and Resident #38 had unclean fingernails. Findings include: The facility policy Activities of Daily Living (ADL) revised 10/2023 documented appropriate care and services would be provided for residents who were unable to carry our activities of daily living independently in accordance with the plan of care, including support and assistance with hygiene, mobility, elimination, dining, and communication. 1) Resident #12 was admitted to the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · E2024-04-12 · 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 survey conducted 4/9/2024-4/12/2024 the facility did not ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 12 anonymous residents. Specifically, during a confidential resident group meeting residents stated their call bells were not answered timely and meals were not hot when served due to the lack of staff. Additionally, deficiencies related to staffing levels were identified in the areas Activities of Daily Living (F 677), Food Palatability (F804), and Activities (F 679). Finding include: The facility policy Nursing Service Staffing Schedule revised 6/2021 documented the facility would provide a working schedule for each member of nursing services that would meet staff needs and the needs of all the patient care units. The Nurse Managers were responsible for coordinating with shift supervisors regarding the scheduling of nursing personnel, collaborating with the supervisors regarding transfers…

    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 · E2024-04-12 · 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 interview during the recertification survey conducted 4/9/2024-4/12/2024, 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 5 residents (Resident #37, #105, and #280) reviewed. Specifically, Resident #280 was admitted to the facility with a diagnosis of COVID-19 and transmission based precautions were not maintained; and Residents #37 and #105 had indwelling medical devices and were not placed on enhanced barrier precautions as required. Additionally, during a medication administration observation licensed practical nurse #8 did not perform hand hygiene between residents. Findings include: The facility policy Extended Care Facility Transmission Based Precaution Guidelines revised 2/2024 documented standard precautions would be used with every resident in the facility.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-12 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not maintain an effective pest control program so that the facility was free of pests in four isolated areas (the main kitchen, and the 2nd, 3rd, and 4th floor tub rooms) reviewed. Specifically, there were fruit flies in the main kitchen and drain flies in the 2nd, 3rd, and 4th floor tub rooms. Findings include: The third-party pest control vendor service inspection reports from 11/17/2023 to 4/10/2024, did not include documentation of the presence of fruit flies or drain flies in the facility. The facility's Pest Activity/Sightings Log documented that fruit flies were present in the main kitchen on 1/4/2024, 2/12/2024, 3/22/2024, 4/2/2024, and 4/5/2024. The following observations were made: - on 4/9/2024 at 9:30 AM, the main kitchen had 15 live fruit flies by dish machine area. - on 4/9/2024 at 11:55 AM, the 4th floor tub room had 3 live drain flies and multiple dead drain flies on the floor. - on 4/9/2024 at 12:18 PM, the 2nd floor tub room had 15…

    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 · D2024-04-12 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 4/9/2024-4/12/2024, the facility did not ensure residents' right to privacy and confidentiality of medical records was maintained for 3 of 3 residents (Residents #44, #118, and # 381) reviewed. Specifically, the electronic medication administration records that displayed health information for Residents #44, #118, and # 381 were left open on the medication cart and were visible to passersby in the hallway. Findings include: The facility policy Patient Confidentiality revised 5/2021 documented every patient would be assured that their right to privacy was maintained and every aspect of their visit was held in strict confidence. Patient information was never disclosed to any unauthorized person (s) without the consent and authorization of the patient or the patient's legal representative (when applicable), except when required by law. During a continuous observation on 4/11/2024 from 8:34 AM through 9:07 AM, the Unit 4 medication cart was unattended in the hallway next to the nurse's…

    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 before2024-04-12 · 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 interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 5 of 6 residents (Resident #43, #58, #92, #97 and #102) reviewed. Specifically, Resident #58's care plan did not include the use of a video monitoring device in their room; Resident #43's care plan did not include the use of anticoagulants (blood thinner) or insulin (a medication to control high blood sugar); Resident #102's care plan did not include the use of anticoagulants; Resident #97's care plan did not include the use of antipsychotics (medication used to treat psychosis); and Resident #92's care plan did not include the use of antidepressants or anticoagulants. Findings include: The facility policy Comprehensive Care Plans revised 4/2024 documented the interdisciplinary team developed a comprehensive, individualized plan of care for each resident that included measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-12 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #40 and #79) reviewed. Specifically, Residents #40 and #79 were not provided meaningful activities that met their interests and preferences. Findings include: The facility policy Activities revised 3/2019 documented the main purpose of the activity program was to enable the individual to continue to enjoy the experience of life and to enable the individual to participate successfully in whatever pursuits they preferred. Pursuits included recreational, spiritual, intellectual, and other activities which were basic to a balanced and rewarding life. The April 2024 Activity Calendar documented: -On 4/9/2024: at 8:15 AM Talk to Me, at 10:00 AM BINGO in the central…

    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 before2024-04-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #278) reviewed. Specifically, Resident #278 was admitted to the facility with congestive heart failure (the heart does not pump efficiently often causing fluid buildup) with hospital discharge orders for torsemide (diuretic, water pill) and instructions for monitoring weights; the torsemide was not ordered until 5 days after admission; and weights were not monitored as recommended. Findings include: The facility policy Extended Care Facility: Admission/readmission Documentation revised 6/2023 documented the multidisciplinary team obtained information from the resident's most recent hospital records, resident and/or legal representative, transfer/discharge summary and the most recent history and physical information from the resident's attending…

    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 before2024-04-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00336433) surveys conducted 4/9/2024-4/12/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 3 residents (Resident #119) reviewed. Specifically, Resident #119 developed facility acquired pressure ulcers and had a physician order for a specialty mattress (a powered pressure reducing air mattress). There was no documented evidence the mattress was checked for function for 14 days after it was ordered, and the mattress was observed not connected to the pump and the pump was not operational. Findings include: The facility policy Prevention and Treatment of Pressure Ulcer revised 12/2020, documented the facility ensured residents that developed pressure ulcers received the necessary treatment and services 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 · D2024-04-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #278) reviewed. Specifically, Resident #278 received continuous positive airway pressure therapy (a machine used to keep the airway open by delivering continuous air through the nose and mouth) without a plan to regularly clean the machine to prevent contaminations. Findings included: The facility policy Noninvasive Ventilation BiPAP (bilevel positive airway pressure) /CPAP (continuous positive airway pressure) last revised 10/2021 documented noninvasive ventilation was a means of delivering ventilation support through a noninvasive interface rather than an invasive artificial airway. Setup, maintenance, and monitoring was the responsibility of the respiratory therapist. An indication for use was sleep apnea (breathing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-12 · 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 observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure that residents were free of any significant medication errors for 2 of 5 residents (Residents #44 and #118) reviewed. Specifically, Resident #118 did not receive sacubitril-valsartan (used to treat heart failure) as ordered; and Resident #44 did not receive brimonidine tartrate (used to treat glaucoma) eye drops, ammonium lactate (used to treat dry skin) lotion, docusate sodium (stool softener), and Juven (a protein supplement) as ordered. Findings include: The facility policy Medication Transcription and Administration reviewed 10/19/2020 documented medications were provided to patients accurately and safely. It assured a standard method that medications were transcribed and administered safely and reduced the potential of error. The process for medication administration included medications were opened just prior to administration and the medications were compared to the medication administration record when opened. The licensed…

    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 · D2024-04-12 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    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 4/9/2024-4/12/2024, the facility did not assist residents in obtaining routine and emergency dental care for 1 of 1 (Resident #102) resident reviewed. Specifically, the facility did not obtain dental services for Resident #102 when they complained of tooth pain and concerns about tooth decay. Findings include: The undated facility policy Dental Care documented the dental services provided consisted of but were not limited to a complete oral examination of each resident by a licensed and currently registered dentist or dental hygienist within fourteen (14) days of admission. Emergency dental care was provided by the contracted dentist or arrangements would be made to obtain dental care from the dentist as designated upon admission. Resident #102 had diagnoses including complete quadriplegia (paralysis of all 4 limbs), acute and chronic respiratory failure, and ventilator (breathing machine) dependence. The 1/23/2024 Minimum Data Set documented the resident had intact cognition, 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 · D2024-04-12 · 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 4/9/2024-4/12/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 1 of 2 meals reviewed (4/12/2024 lunch meal). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meal on 4/12/2024. Findings include: The facility policy Food Holding Temperature Requirements revised 5/2023 documented food temperatures were taken prior to service and ensured that a holding temperature of 135 degrees Fahrenheit or greater was maintained. All cold foods were held at 40 degrees Fahrenheit or below. During an interview on 4/9/2024 at 11:33 AM, Resident #66 stated they preferred to eat their meals in their room and by the time they received their meals they were usually cold. During a resident meeting on 4/9/2024 at 1:35 PM 12 anonymous residents voiced concerns of the meal carts arriving to the units as scheduled, but there was not enough staff to pass…

    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 before2024-04-12 · 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 4/9/2024-4/12/2024, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety for 1 of 1 kitchen (the main kitchen) reviewed. Specifically, the main kitchen floors had food debris and were stained; and the clean drying rack had pans that were improperly stacked. Findings include: The undated Food Service-Receiver Performance Evaluation Form documented that receivers were responsible for weekly freezer cleaning. The undated Dietary Supervisor Job Procedure/Description documented from 7:30 PM-8:30 PM the Supervisor would complete a walk-through of the cafe, kitchen, and dish room area, ensuring that all equipment was turned off and clean. Check and lock coolers and doors. The Master Cleaning Schedule revised 6/1/0222 documented that a checker was responsible to ensure the walk-in refrigerators were cleaned weekly, and a receiver was responsible to ensure the walk-in freezer was cleaned weekly. 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 before2022-01-25 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey conducted 1/20/22 through 1/25/22 the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 3 of 3 residents (Residents #347, 348 and 349) reviewed. Specifically, Residents #347, 348 and 349 were discharged to home and the facility did not provide the residents with Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (expiration date 8/31/23) documents a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-04-12 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification survey conducted 4/9/2024 - 4/14/2024 the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #229) reviewed. Specifically, Resident #229 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident or resident representative with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (expiration date 1/31/26) documented that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 must be issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$16,153 in federal fines across 1 penalty.

  • $16,153 — penalty dated 2025-04-25

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

Who owns this facility

Owner / managerTypeRoleSince
SWEET, JEREMIAHIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 07/31/2017
BACH, JANICEIndividualCORPORATE DIRECTORsince 01/01/2013
BELL, NADINEIndividualCORPORATE DIRECTORsince 01/01/2012
DUGAN, CHRISIndividualCORPORATE DIRECTORsince 09/01/2023
HEDGLON, PETERIndividualCORPORATE DIRECTORsince 01/01/1985
KALLET, MICHAELIndividualCORPORATE DIRECTORsince 01/01/1987
KOERNIG, FELISSAIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
POTTER, STEVENIndividualCORPORATE DIRECTORsince 01/01/2005
RATNARAJAH, DANIELIndividualCORPORATE DIRECTORsince 01/01/2009
SCHAAL, TODDIndividualCORPORATE DIRECTORsince 09/01/2023
WELLS, MARGARETIndividualCORPORATE DIRECTORsince 09/01/2023

CMS files one row per role, so the 14 rows in the source record cover these 11 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.

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 335427. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-27, 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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