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Chestnut Park Rehabilitation And Nursing Center

330 Chestnut Street, Oneonta, NY 13820 · For profit - Corporation · 80 certified beds · (607) 432-8500 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Feb 20251 immediate-jeopardy citation
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 Associate Dr · (607) 432-5563 · Call to confirm hours
Pharmacy
Walgreens0.9 mi
99 Chestnut St · (607) 433-5101 · Call to confirm hours
Grocery
39 Main St · (607) 432-0173 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 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 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 increased20.2%14.1%15.4%worse
Long-stay residents who lose too much weight4.5%5.8%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection3.0%1.3%2.0%worse
Long-stay residents with depressive symptoms10.6%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 injury5.5%3.1%3.3%worse
Long-stay residents whose ability to walk worsened14.6%12.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication18.4%13.2%18.9%typical
Long-stay residents given the seasonal flu vaccine96.9%95.3%95.3%typical
Long-stay residents with pressure ulcers4.5%6.5%4.7%typical
Long-stay residents with worsening bladder/bowel control28.9%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.7%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.5%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine63.9%78.8%79.4%worse
Short-stay residents rehospitalized after admission23.2%20.6%22.6%typical
Short-stay residents with an outpatient ER visit20.9%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.021.701.67worse
Long-stay outpatient ER visits per 1,000 resident days4.211.361.80worse

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.

45.6% 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 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.6%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
34.0%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 34.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 100 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 SNF45.6%CMS range 37.2–51.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.7–15.310.7%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 discharge34.0%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 discharge30.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.1%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 discharge96.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.0%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 4.0–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.411.02Oct 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
0.96
LPN hours/ resident / day
1.73
Aide hours/ resident / day
3.28
Total nurse hours/ resident / day
0.29
RN hoursweekends
66.2%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 73.5 residents a day — about 92% occupied, or roughly 6 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 3.28 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 1.73 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 2.69 hrs/resident/day on weekends vs 3.51 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.70 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-12-12)
6
at the previous standard inspection (2023-05-22)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 13 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-10-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an abbreviated survey (Case #2635234), the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (2) of four (4) residents (Resident #1 and 3) reviewed for falls. Specifically, [a.] Resident #1 had severe cognitive impairment and had five (5) unwitnessed falls from [DATE] to [DATE]. The facility failed to develop appropriate interventions to mitigate falls when it was known that the resident was self-transferring. On [DATE] at 11:30 PM, Resident #1 was found on the floor unresponsive, unclothed and cold to the touch by Certified Nurse Aide #1. The resident's body temperature was unmeasurable on a facility thermometer, their oxygen saturation level was 73 percent (normal oxygen saturation levels are 95-100 percent), and they were sent to the hospital with symptoms consistent with hypothermia (occurs when core body temperature drops below 95 degrees Fahrenheit and is a medical emergency).…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-10-27 · 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 record review and interview conducted during an abbreviated survey (Case #2635234), the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) of four (4) residents (Resident #1) reviewed. Specifically, on [DATE] at 11:30 PM, Resident #1 was found unresponsive with an oxygen saturation of 73 percent (normal 95 to100 percent) and signs of respiratory distress. Emergency Medical Services documented 'extreme' wheezing in all lung fields and a clinical impression of pneumonia (an infection in one or both lungs). The resident was admitted to the hospital with septic shock (a progression from sepsis that causes a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. When the damage is severe, it can lead to death) secondary to pneumonia/acute hypoxic respiratory failure (a medical condition…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-05-22 · 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 record review and interview during the recertification survey and an abbreviated survey (Case #NY00316948) dated 05/15/23 through 05/22/23, the facility failed to protect the resident's right to be free from neglect for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, on 04/16/2023 Certified Nurse Aide (CNA) #2 did not use two staff for bed mobility as documented in Resident #23's Comprehensive Care Plan (CCP) . Subsequently, on 4/16/2023 Resident #23 rolled out of bed onto the floor sustaining a fracture of their left elbow and a gash requiring stitches on their left elbow. This resulted in actual harm that is not immediate jeopardy for Resident #23. This was evidenced by: Resident #23 was admitted to the facility with diagnoses of multiple sclerosis, Chronic Obstructive Pulmonary Disorder (COPD), and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 02/04/2023 documented the resident was able to make themselves understood, was able to understand others, and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-12 · tag F0755 — failed to provide safe pharmacy services — widespread
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, the facility did not document nursing unit narcotics were counted by two (2) licensed staff members and signed as appropriately done on the facility provided narcotic record sheets.This is evidenced by:The Policy and Procedure titled, Medications - Controlled Substance/Narcotic Management Protocol, effective 2/2021 and last revised 1/2025, documented it was the facility's policy to It is the policy of the facility to prescribe, administer, store and destroy all controlled substances within the accepted regulations of the responsible governing body. All narcotics will be counted and reconciled at the beginning of every shift with the outgoing and oncoming nurse. Both must sign…

    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 · F2025-12-12 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews during a recertification survey, the facility did not maintain an infection control program in accordance with professional standards of care. Specifically, a) for Resident #7, the licensed practical nurse removed a dressing without wearing gloves and b) the facility did not ensure signage and supplies for transmission-based precautions were readily available and visible.Resident #7The Policy and Procedure titled Wound Care dated 1/2025 stated hands should be washed and dried before and after a dressing change, and gloves should be wornResident #7 was admitted to the facility with the diagnoses of iron deficiency anemia (when there aren't enough healthy red blood cells to carry oxygen throughout the body), pressure ulcer of left buttock (damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear force, most commonly forming on bony areas like the tailbone, hips, heels, and back), and peripheral vascular disease (a circulation disorder where blood flow to the limbs and organs is reduced due 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-12 · tag F0756 — failed to review each resident's drug regimen — pattern
    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

    Based on record review and interview during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, time frames for the different steps in the process. Specifically, the facility policy, titled Medication Therapy, did not identify time frames for the steps in the process. This is evidenced by: The facility policy titled, Medication Therapy, reviewed 01/2025, stated the Consultant Pharmacist would review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected, and the Medical Director and Consultant Pharmacist would collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. The policy did not include time frames for each step in the process. During an interview on 09/25/2025 at 12:05 PM, Director of Nursing #1 agreed there should be time frames for each step of the medication review process and did not know why the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-12 · 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 observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Specifically, the automatic dishwashing machine was not operating within the manufacturer's instructions, sanitizing solution concentration could not be verified, and surfaces, equipment, and floors required cleaning or repair. This is evidenced by: During observations on 09/21/2025 at 10:56 AM: The automatic dishwashing machine final rinse was 197 degrees Fahrenheit at 7 (seven) pounds per square inch of water pressure; the dishwashing machine data plate states that the water pressure is to be between 15 and 25 pounds per square inch. The facility did not have a chemical test kit with graduations above 400 parts per million; the label on the bottle of sanitizer concentrate stated that when sanitizing food contact surfaces the dilution is to be between 200 and 400 parts per million. A wooden block-style knife-rack that cannot be disassembled was being used for knife…

    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 · E2025-12-12 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpster was heavily soiled below the side door and was not rodent proof. This is evidenced by: During observations on 09/21/2025 at 12:02 PM, the right dumpster was heavily soiled below the side door and was missing a drain hole plug and was not rodent proof. During an interview on 09/21/2025 at 12:07 PM, Assistant Food Service Manager #1 stated that they would speak with the maintenance department about having the dumpster cleaned and a drain hole plug installed. New York Codes, Rules, and Regulations Title 10 S415.14(h)

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 conducted during the recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident and in response to current interventions for two (2) (Resident #'s 11 and 20) of 19 reviewed. Specifically, Resident #11's Comprehensive Care Plan for Anticoagulants was not resolved after the resident's order for Plavix was discontinued in 2023 and Resident #20's Comprehensive Care Plan was not reviewed or revised to include the resident's diagnosis of constipation and treatment/orders for constipation. This is evidenced by: The facility policy titled, Care Plans, Comprehensive Person-Centered, last revised 01/2025, documented assessments of residents were ongoing, and care plans were revised as information about the resident and the resident's condition changed. The interdisciplinary team would review and update the care…

    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 · D2025-12-12 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey, the facility did not ensure food brought for residents by family or visitors was stored safely and in a way that is either separate or easily distinguishable from facility food on one (1) of two (2) resident units. Specifically, resident food was not properly labeled, and the facility did not have a policy to assist residents in accessing food brought in to them. This is evidenced by: During observations on the North Wing kitchenette on 09/21/2025 at 11:39 AM, deli chicken salad was not labeled with a resident name, and two (2) homemade sandwiches were not labeled. During an interview on 09/21/2025 at 11:46 AM, Assistant Food Service Manager #1 stated that the homemade sandwiches were likely for a resident, and food brought to residents should be labeled with the resident name and dated. There was no documented evidence that the facility had a policy to date and label with the resident name food brought in to residents. There was no documented evidence that the facility had a policy to ensure…

    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 before2025-10-27 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review conducted during the abbreviated survey (Case # 2635234), the facility did not thoroughly investigate accidents for 1 (one) of 4 (four) residents reviewed for accidents. Specifically, on 9/28/2025 at 11:30 PM, Resident #1 was found in their room on the floor next to their bed. Resident #1 was unresponsive except to painful stimuli and had uncontrollable shaking. Resident #1 was left for an undetermined amount of time without providing care. Subsequently, when assessing Resident #1's vital signs (key indicators of the body's essential physiological functions including temperature, heart rate, breathing rate, and blood pressure), Resident #1's body temperature was too low to be read by a thermometer. The facility did not have documented evidence of a thorough investigation to rule out if Resident #1 was abused and/or neglected.This is evidenced by:Cross-referenced to F689: Free of Accident Hazards/Supervision/DevicesThe Policy and Procedure titled, Accident and Incident-Investigating and Reporting-Resident, reviewed 01/2025, documented all…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case # 2635234), the facility did not ensure the development and implementation of a person-centered care plan that included measurable objectives and timeframes to meet the resident's needs for 2 (two) (Resident #s 1 and 3) of 4 (four) residents reviewed. Specifically, the facility did not ensure it developed, implemented, monitored, and evaluated appropriate person-centered care plan interventions to mitigate falls for Resident #'s 1 and 3, who had multiple unwitnessed falls in their rooms related to self-ambulation. This is evidenced by: Cross-referenced to F689: Free of Accident Hazards/Supervision/Devices The Policy and Procedure titled, Falls and Fall Risk Managing, reviewed 1/2025, documented that based on previous evaluations and current data, staff must identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling…

    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 before2025-02-03 · 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

    Based on observation, record review, and interviews during an abbreviated survey (Case #NY00357658), the facility did not ensure it protected the resident's right to be free from abuse and neglect for 1 (Resident #1) of 3 residents reviewed. Specifically, Registered Nurse #1 forcefully removed Resident #1 from the floor after the resident became unsteady and fell to the floor. Registered Nurse #1 did not assess the resident for injury prior to getting the resident up and ambulating them to their room. This is evidenced by: The Facility's Abuse Policy Prevention program updated on 10/20/2024 documented the following: Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Resident #1 was admitted to the facility with diagnoses of non-Alzheimer's dementia with behaviors (loss of memory, language, problem-solving…

    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 · Past Non-Compliance
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-05-31 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during an abbreviated survey (NY00326640), the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used for excessive duration and without adequate indication for 1 (Resident #10) of 1 resident reviewed. Specifically, Resident #10 was administered Atarax (an antihistamine used to treat anxiety, nausea, vomiting, itching and skin rash without obtaining a physician's order. This is evidenced by: Resident #10 was admitted to the facility with the diagnoses of hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), cerebral infarction (stroke), and depression. The Minimum Data Set (an assessment tool) dated 03/19/2024 documented resident was cognitively intact, could be understood and able to understand others. The Facility's Policy and Procedure Titled Administering Medication revised on 1/2023 documented Medications must be administered in accordance with the orders including any required time…

    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 · D2024-05-31 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during an abbreviated survey (Case #NY00316477), the facility did not ensure residents were free from significant medication errors for 1 (Resident #3) of 1 resident reviewed. Specifically, the facility did not ensure significant medications were accurately transcribed from Hospital Discharge instructions for Resident #3. Subsequently, Resident #3 did not receive orders for respiratory nebulizer treatments from 5/11/2023 to 5/13/2023 and was re-admitted to the hospital on [DATE] for respiratory distress. This is evidenced by: Resident #3 Resident #3 was admitted to the facility with diagnosis of metabolic encephalopathy (A problem in the brain caused by a chemical imbalance in the blood), acute and chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body. It can happen all at once (acute) or come on over time (chronic), and myocardial infarction (heart attack). The Minimum Data Set (an assessment tool) dated…

    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 · E2023-05-22 · 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, record review, and interviews during the recertification survey dated 05/15/23 through 05/22/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean and homelike environment on two (2) of 2 resident units. Specifically, on the South Wing Unit, the floors were soiled with dirt and a black build-up where the door frame meets the floor and along the wall in the dining room, corridor, ice machine area, Beauty Shop, and in resident room #'s 102, 104, 108, and #116; the floor was soiled with dust and dirt below the chests of drawers in room #'s 205, 222, and #226; the radiators were soiled with food drips in room #'s 215, 222, and #226; the radiator cover was falling off in room [ROOM NUMBER]; and the ½ size oxygen tanks in the oxygen tank storage area were dusty. On the North Wing Unit, the floors were soiled with dirt where the door frame meets the floor and along the wall in the the dining room, nurse's station, linen closet, left…

    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 · Ecited before2023-05-22 · 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 observation and interviews during the recertification survey dated 05/15/23 through 05/22/23, the facility did not prepare or serve food in accordance with professional standards for food service safety. Specifically, the test papers used to check the concentration of the chemical used to manually sanitize food equipment were expired (expiration dates 12/15/2022 and 04/01/2023). The food temperature thermometer being used by cook #1 was found out of calibration when checked by the standard ice-bath method (temperature registered less than the lowest graduation on the thermometer scale). In the main kitchen, the can opener holder, microwave oven, scale, stove, shelving, reach-in freezer door gaskets, walls by stove, kitchen window still, ceiling, kitchen floor under equipment, floor under dishwashing machine, dry storage area floor, fire extinguisher, and kitchen fire suppression system canister were soiled with food particles, grime, or dirt; in the North Wing kitchenette, the drawers and floor were soiled with food particles; and in the South Wing kitchenette, the freezer…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during the recertification survey and an abbreviated survey (Case #NY00316948), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, for Resident #23, the facility did not report that Resident #23 sustained a fractured elbow and a laceration on their left elbow requiring sutures when on 04/16/2023, the facility did not ensure that a staff member utilized 2 persons for bed mobility as documented both in their Comprehensive Care Plan (CCP) revised on 2/2/2023 and [NAME] dated 4/16/2023. This was evidenced by: Please refer to F600. Resident #23 Resident #23 was admitted to the facility with diagnoses of multiple sclerosis, Chronic Obstructive Pulmonary Disorder (COPD), and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 02/04/2023…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification survey and an abbreviated survey (Case #NY00316948), the facility did not prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, for Resident #23, the facility did not ensure to prevent further potential abuse, neglect, exploitation, or mistreatment when the facility did not remove a staff member from resident care on 4/16/2023 when the staff member did not follow Resident #23's Comprehensive Care Plan (CCP) revised on 2/2/2023 and [NAME] dated 4/16/2023 that documented the resident required 2 persons for bed mobility. This resulted in a a fracture and a laceration requiring sutures to the resident's left elbow from a fall out of bed. The facility did not identify that the residents fall out of bed resulting in injury when a staff member did not follow the care plan required an investigation when the incident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-22 · 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

    Based on record review and interviews during the recertification survey conducted from 5/15/2023 through 5/22/2023, the facility did not ensure drug regimen irregularities were reported by the pharmacist to the attending physician for 1 (Resident #67) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #67, the facility did not ensure an irregularity in the monitoring orders for Alendronate (used to prevent and treat certain types of bone loss (osteoporosis) in adults) was documented and reported to the physician by the consultant pharmacist on 5/2/2023. This was evidenced by: Resident #67 Resident #67 was admitted to the facility with the diagnoses of cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), and depression. The Minimum Data Set (MDS -an assessment tool) dated 04/11/2023, documented the resident had severely impaired cognition, could understand others, and could make themselves understood. The policy and procedure titled Medication Therapy/Drug Regimen Review, reviewed 1/2023, documented the Consultant Pharmacist would…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-07-12 · tag F0656 — failed to write and follow a full care plan — pattern
    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 the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 7 (Resident #'s 4, 20, 23, 29, 40, 66, and #170) of 17 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #4, the facility did not ensure an intervention on the CCP for an indwelling catheter to maintain the urine collection bag below the level of the resident's bladder was implemented; for Resident #'s 20, 23, 29, 40 and #66, the CCPs for psychotropic medications did not include non-pharmacological interventions and also for Resident #40, the CCP for alteration in comfort was person-centered and included non-pharmacological interventions; and for Resident #170, the facility did not ensure interventions documented on the CCP's for behavior symptoms 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-12 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 during a recertification survey, the facility did not ensure a follow up screen was developed based on a resident change of condition for one (Resident #66) of sixteen residents reviewed. Specifically, for Resident #66, whose pre-admission screen dated 3/05/2021 was checked no for the section for Danger to Self or Others, the facility did not ensure to perform a follow up screen when the resident exhibited violent behaviors at the facility. This was evidenced by: Resident #66 Resident #66 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (CVA), schizoaffective disorder and encephalopathy. The Minimum Data Set (MDS-an assessment tool) dated 6/20/2021 documented the resident had severe cognitive impairment. The resident usually understood others and could usually be understood by others. A Policy and Procedure for PRI (Patient review Instrument) and Screen (PASSAR) dated 6/30/2016 documented a Policy Statement: All NYS skilled nursing facility require…

    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 · D2021-07-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 2 (Resident #'s 40 and #42) of 2 residents reviewed for Activities of Daily Living (ADLs). Specifically, for Resident #'s 40 and #42, the facility did not ensure the residents, who were unable to carry out activities of daily living, received a weekly shower to maintain good personal hygiene. This is evidenced by: The Policy and Procedure (P&P) titled Shower/Tub Bath last revised 1/2021, documented the purpose of this procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. The P&P documented the following information should be recorded on the resident's ADL record: the date and time the shower/tub bath was performed, how the resident tolerated the shower/tub bath, and if the resident refused the shower/tub…

    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 before2021-07-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during a recertification survey and abbreviated survey (Case #NY00278577) the facility did not ensure residents received adequate supervision and assistive devices to prevent avoidable accidents for 1 (one) (Resident #38) of (1) one resident reviewed. Specifically, for Resident #38, the facility did not implement a care planned intervention for a 2 person assist required while using an assistive device to be used in the transferring of the resident from the wheelchair to the bed to reduce the resident's risk of falls. This resulted in a fall from the bed on 6/27/2021 with an injury, requiring a transfer to the hospital. This is evidenced by: Resident #38 Resident #38 was admitted to the facility with diagnosis of end stage renal disease (ESRD), morbid obesity and spondylopathy (disorder of the vertebrae). The Minimum Data Set (MDS- an assessment tool) dated 04/08/2021, documented the resident could understand and was understood by others and was cognitively…

    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 before2021-07-12 · 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

    Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed, maintained, and implemented for the monthly medication regimen review (MRR) process that addressed the time frames for the different steps in the process. Specifically, the facility did not ensure step #6 included time frames for the physician and staff to address medication related complications that require urgent action to protect the residents from harm. This is evidenced by: On 7/6/2021the facility provided a policy titled: Medication Therapy/Drug Regiment Review, with a revised date of 1/2021. The policy provided did not include timeframes for notifying the physician for clinically significant effects. Step #6 (medication follow up) of the policy documented the following: Every time circumstances are present that represent a greater risk for medication-related complications, a potential or actual clinically significant medication issue is identified throughout the resident's stay, it will be communicated to a physician and the physician -…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review during a recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, for 2 (Resident #'s 29 and 40) of 6 residents reviewed for unnecessary medications. Specifically, for Resident #29, the facility did not ensure an as needed blood pressure medication was administered when the resident's blood pressure was higher than the physician ordered parameter and for Resident #40, the facility did not ensure blood pressures were obtained prior to administering a blood pressure medication that included a physician ordered parameter. This is evidenced by: The Policy and Procedure (P&P) titled Administering Medication dated 1/2021 documented medications must be administered in accordance with the orders, including any required time frame and information must be checked/verified for each resident prior to administrating medications including vital signs, if necessary. Resident #29: Resident #29 was admitted to the facility with the diagnoses of heart disease, hypertension (HTN), and angina (chest…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-12 · tag F0885 — failed to notify residents/families about COVID-19 — isolated
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during a recertification survey, the facility did not ensure residents and were informed by 5:00 PM the next calendar day following the occurrence of a single confirmed infection of COVID-19 for 3 (Resident #'s 13, 16, and #30) of 3 residents reviewed for notification. Specifically, the facility did not ensure Resident #'s 13, 16 and #30 were provided with verbal or written notification by 5:00 PM the next calendar day after a resident tested positive for COVID-19 on 7/2/2021. This is evidenced by: The Center of Medicare and Medicaid Services (CMS) guidance titled, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (Ref: QSO-20-29-NH), dated May 6, 2020, provided that as part of a skilled nursing facility's COVID-19 reporting requirements, facilities must inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to UPSTATE SERVICES GROUP — 17 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 1 of 52.0-1.0 vs chain
Health inspection 1 of 52.1-1.1 vs chain
Staffing 2 of 52.6-0.6 vs chain
Quality measures 1 of 52.8-1.8 vs chain
The other 16 homes this chain runs (chain average 2.0★, 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
KOENIG, URIIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF60%since 02/28/2012
STEIF, EFRAIMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF40%since 01/01/2025
CAMEROTA, DAVIDIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/22/2010
DEMARIAIS, JENIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/20/2021
JAGANATHAN, DAISYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025

CMS files one row per role, so the 11 rows in the source record cover these 5 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.

$10.0M
Net patient revenuemost recent cost report
-2.0%
Operating marginrevenue minus expenses
$778K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 53%Medicare 26%Other / private 21%

This home reported $778K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$373per resident / day
operating cost
$11,347per month
≈ monthly operating cost
$366per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335243. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-12, 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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