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Morningstar Residential Care Center

17 Sunrise Terrace, Oswego, NY 13126 · For profit - Corporation · 120 certified beds · (315) 342-4790 Medicare & Medicaid certified

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2 immediate-jeopardy citations$122,464 in federal fines
Insights

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

Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $122,464 in federal fines (most recent 2025-08-12)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • 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 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
110 W Utica St. · (315) 342-2024 · Call to confirm hours
Pharmacy
174 W Bridge St · (315) 342-6800 · Call to confirm hours
Grocery
7 3rd Ave · (315) 343-1010 · Call to confirm hours
Park
91 Lake St · (315) 342-8180 · Typically dawn to dusk
Place of worship
56 Franklin Ave · (315) 342-3330

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 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased14.3%14.1%15.4%typical
Long-stay residents who lose too much weight2.3%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 infection0.3%1.3%2.0%better
Long-stay residents with depressive symptoms2.5%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 injury1.1%3.1%3.3%better
Long-stay residents whose ability to walk worsened14.5%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.9%13.2%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers6.0%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control32.6%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.9%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine90.4%78.8%79.4%better
Short-stay residents rehospitalized after admission19.7%20.6%22.6%better
Short-stay residents with an outpatient ER visit12.6%9.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.861.701.67worse
Long-stay outpatient ER visits per 1,000 resident days1.491.361.80better

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.

37.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 125 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.2%U.S. median 51.5%
Got home and stayed home
12.0%U.S. median 10.7%
Went back to hospital
44.4%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 44.4% 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 81 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF37.2%CMS range 27.6–45.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 9.1–16.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge44.4%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 discharge38.3%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 discharge39.5%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 identified96.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge93.3%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 worsened1.1%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 hospitalization7.0%CMS range 4.2–10.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.201.02Oct 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

0.41
RN hours/ resident / day
0.81
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.21
RN hoursweekends
53.3%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 108.1 residents a day — about 90% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.61 hrs/resident/day on weekends vs 3.42 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

11
deficiencies at the latest standard inspection (2025-05-02)
10
at the previous standard inspection (2023-08-18)

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.

33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · J2025-08-14 · 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 (IQIES #2572456), the facility failed to establish consistent mechanisms for documenting and communicating a resident's choice regarding advance directives to the staff responsible for the resident's care for one (1) of three (3) residents, Resident #1. Specifically, Resident #1 was found without a pulse and without respirations, and staff did not initiate cardiopulmonary resuscitation (emergency procedure performed when someone's breathing or heartbeat has stopped) per the resident's wishes documented on their Medical Orders for Life Sustaining Treatment, resulting in the resident's death. Additionally, the facility failed to ensure there was a process for verification of medical orders related to residents' advance directives. The facility's failure to verify Resident #1's advance directives including the Medical Order for Life Sustaining Treatment form places all 104 residents in the facility who had advance directives in place at risk. This…

    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
  • Immediate jeopardy · J2024-03-04 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 abbreviated survey (NY00333772), the facility failed to administer cardiopulmonary resuscitation to 1 of 3 residents (Resident #1) who was found without a pulse and wished to be resuscitated. Specifically, on [DATE], Resident #1 was found without a pulse and without respirations, and staff did not initiate cardiopulmonary resuscitation (chest compressions) per the resident's wishes documented on their Medical Orders for Life Sustaining Treatment. Staff asked the resident's spouse (who was not the resident's decision maker ) if they wanted staff to initiate cardiopulmonary resuscitation and the spouse declined. The facility's failure to administer cardiopulmonary resuscitation, per the resident's wishes, placed all 108 residents in the facility who had Advance Directives in place at risk. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to resident's health and safety. Findings include: The facility's Cardio-Pulmonary…

    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 before2025-08-12 · 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

    Based on record review and interview during the abbreviated survey (NY00323539/IQIES 652830), the facility did not ensure residents with pressure ulcers or at risk of 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 1 of 3 residents (Resident #3). Specifically: Resident #3 developed a new pressure ulcer that was not assessed and was not treated timely. Two weeks after the wound developed, the facility investigated the pressure ulcer and concluded the wound was not assessed, there was no treatment order implemented, and was not documented.Findings include:The facility policy, Pressure Ulcer Prevention Program, revised 1/31/2017, documented the facility should have a system in place that assured assessments were timely and appropriate, interventions were implemented, monitored and revised as appropriate; and changes in condition were recognized, evaluated, reported to the resident's attending practitioner and other health 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2025-05-02 · 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

    Based on observations, record review, and interviews during the recertification and abbreviated (NY00370054) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for three (3) of three (3) nursing units (Units A, B, and C) reviewed. Specifically, water temperatures were not maintained at comfortable levels on Units A, B, and C between 2/4/2025-4/1/2025. Findings include: The facility policy Maintaining A Safe, Clean, Comfortable and Homelike Environment, dated 10/24/2024 documented the residents had the right to a safe, clean, comfortable, and homelike environment. The undated Daily Maintenance Rounds documented the water temperature range was acceptable between 90 degrees Fahrenheit and 120 degrees Fahrenheit. The 2/2025 through 4/2025 daily maintenance rounds water temperature logs documented the following temperatures at each of the three tested sites: Unit-A, Unit-B, Unit-C. - on 2/4/2025, 86.3 degrees Fahrenheit, 85.2 degrees Fahrenheit, 86.9 degrees Fahrenheit. - on 2/6/2025, 105.5 degrees Fahrenheit, no data…

    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 before2025-05-02 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification and abbreviated (NY00370054 and NY00327240) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of three (3) meals reviewed (dinner meal on 4/28/2025, and lunch meals on 4/29/2025 and 5/1/2025). Specifically, food was not served at palatable and appetizing temperatures and was not palatable. Additionally, five (5) anonymous residents during a resident council meeting and five (5) residents (Resident #31, 53, 59, 60, and 306) interviewed stated the food did not taste good, was bland, lacked flavor, and was cold. Findings include: The facility policy Food: Quality and Palatability, revised 9/2017 documented food was prepared by methods that conserved nutritive value, flavor, and appearance. Food was palatable, attractive, and served at safe and appetizing temperatures. During an observation on 4/28/2025 at 6:03 PM Resident #60's meal tray was tested, and a replacement was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-02 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025 - 5/2/2025, the facility did not ensure suitable, nourishing alternative meals and snacks were provided to residents who preferred to eat at non-traditional times or outside of scheduled meal service times for two (2) of three (3) nursing units (Units B and C). Specifically, residents did not have snack items available on nursing units B or C and were not offered anything to eat or drink when meal trays were not available at the scheduled and posted times. Additionally, meals were not served according to the posted mealtimes for all units. Findings include: The facility policy Dining Experience, revised 6/5/2024, documented the facility would make all efforts in providing a comfortable homelike meal experience for the residents. The facility would make all efforts to honor residents' meal preferences and choices. The facility policy Supplemental Nutritional Support and Snacks, revised 7/6/2024 documented all residents were offered a beverage in between meals and a nourishment…

    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 before2025-05-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification and abbreviated (NY00327240) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for three (3) of three (3) residents (Residents #31, #52, and #88) reviewed. Specifically, staff stood over Residents #52 and #88 while assisting them to eat; and Resident #31 was placed at a table that was above the level of their chin. Additionally, residents were referred to as feeders, and staff assisted residents with feeding while conversing amongst themselves and not including the residents. Findings include: The facility policy Resident Rights-Dignity and Respect, revised 3/18/2024, documented each resident was treated with dignity and respect, focusing on maintaining and enhancing their self-esteem and self-worth and incorporated the residents' preferences and choices. Staff should avoid standing over residents when assisting them to eat, conversing only with…

    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 before2025-05-02 · 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 observations, record review, and interviews during the recertification and abbreviated (NY00365859) surveys conducted 4/28/2025-5/2/2025, 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 four (4) of six (6) residents (Residents #24, #37, #60, and #68) reviewed. Specifically, Residents #24 and #60 did not receive toileting assistance when they were wet; Resident #37 was not provided with oral hygiene or shaving: and Resident #68 was not provided with oral hygiene. Findings include: The facility policy Oral Hygiene, revised 7/5/2024, documented the facility was committed to providing comprehensive oral hygiene to all residents ensuring their dental and overall health was maintained to the highest standard. The facility policy Activities of Daily Living Services, revised 1/19/2024, documented residents would receive assistance with activities of daily living…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure residents received respiratory care consistent with professional standards of practice for one (1) of one (1) resident (Resident #88) reviewed. Specifically, Resident #88 did not receive oxygen therapy as ordered, their portable oxygen tank was not replaced when it was empty, and their care plan did not include the need for oxygen therapy. Findings include: The facility policy Oxygen Administration, last reviewed 6/28/2022, documented oxygen therapy was delivered by way of an oxygen mask or nasal canula using a portable oxygen cylinder or oxygen concentrator and must be verified by a physician order. Once the appropriate setup was placed on a resident, observe the resident periodically thereafter for flow of oxygen and to be sure oxygen was being tolerated. Resident #88 had diagnoses including pneumonia due to COVID-19 and acute respiratory failure with hypoxia (low levels of oxygen in body tissues). The 3/13/2025 Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-02 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure that a resident who required dialysis (a process that filters blood when kidneys do not function normally) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #77) reviewed. Specifically, Resident #77 received hemodialysis and there was no documented evidence of ongoing communication and collaboration with the dialysis facility. Findings include: The facility policy Care of the Hemodialysis Resident, revised 3/30/2024, documented, prior to each hemodialysis treatment a report book would be completed and sent with the resident to the dialysis center. The report should include relevant information such as the resident's vital signs, lab results and any significant change in their condition. Resident #77 had diagnoses including, end-stage renal disease (kidney disease) and dependence on renal hemodialysis. The 4/25/2025 Minimum Data Set assessment documented the resident had moderate…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not review risks and benefits of bed rails, obtain informed consent, or remove enabler bars after physical therapy deemed them contraindicated for use for one (1) of one (1) resident (Resident #31) reviewed. Specifically, Resident #31 had enabler bars (used to assist with bed mobility) on both sides of their bed after a physical therapy assessment documented enabler bars were contraindicated for the resident; there was no documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use. Findings include: The facility policy Bed Rails, dated 11/20/2024, documented the facility would ensure bed rails, when provided, were used in compliance with federal and state guidelines to prevent and or reduce any risk of entrapment, restraint, or other injury. Informed consent was obtained from the resident or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure each resident received food that accommodated resident preferences for two (2) of two (2) residents (Residents #60 and #31) reviewed. Specifically, Resident #31 was missing food items at meals; Resident #60 was missing soda listed on their meal ticket and received hot chocolate instead. Findings include: The facility policy Menus, revised 9/2017, documented that a Registered Dietitian/Nutritionist or other clinically qualified nutrition professional would adjust individual meal plans to meet the individual requests of residents. Menus would be served as written, unless a substitution was provided in response to preferences. The facility policy Dining Experience, revised 6/5/2024, documented the facility would make all efforts to honor the residents' meal preferences and choices. 1) Resident #31 had diagnoses including cancer of the large intestine and rectum, fracture…

    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
Show the remaining 21 citations
  • Potential for harm · Dcited before2025-05-02 · 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 observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen and one (1) of three (3) dining room refrigerators and ice machines (B-wing) reviewed. Specifically, the B-Wing dining room refrigerator was not clean; the B-Wing dining room ice machine was not working; the main kitchen dry storage room floor was not cleanable; the main kitchen hand wash sink was leaking onto the floor; and the main kitchen walk-in freezer door did not close properly due to ice buildup. Findings include: There was no documented policy referencing kitchen cleaning, maintenance, or food storage. The main kitchen's Monthly Cleaning List completed from 4/27/2025 to 4/30/2025 documented the following: - the walk-in cooler floors were swept and mopped weekly. - the dry storage room was swept and mopped weekly. - the walk-in freezer was cleaned and sanitized monthly. 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 before2025-05-02 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the Facility Assessment, Medicare/Medicaid Application (CMS-671), Facility Survey Report (DOH-1550), New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325), Equipment Inventory Form, Legionella policies and procedures, and a list of employees whose date of hire was 4 months or less that was requested by the New York State Department of Health (NYS DOH) surveillance team in a timely manner as required. Findings include: The Centers for Medicare and Medicaid Services survey form Entrance Conference Worksheet provided to the Administrator/designee upon survey entrance documented the following items were required during the recertification survey: - 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-07 · 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 abbreviated survey (NY00347901), the facility did not ensure residents with pressure ulcers or at risk of 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 2 of 3 residents (Residents #1 and 3) reviewed. Specifically: -Resident #1 developed new pressure ulcers and there was no documented evidence that recommended treatment orders obtained or implemented timely and no documented evidence diagnostic tests were ordered or obtained timely. -Resident #2 developed a Stage 3 pressure ulcer on their coccyx and there was no documented evidence the registered dietitian reassessed the resident's nutritional needs. Additionally, the resident had a significant weight loss and there was no documented evidence the registered dietitian was made aware to reassess. Findings include: The facility's policy Weights,…

    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 before2024-09-03 · 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 record reviews and interviews during the abbreviated survey (NY00341925) the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 exhibited frequent exit-seeking behaviors, there were no documented interventions to address their behaviors, the resident exited the building and was found in the parking lot. Findings include: The facility policy, Comprehensive Care Plans, reviewed 3/24/2022 documented: - the facility would provide an individualized, interdisciplinary plan of care for all residents that was appropriate to the residents' needs, strengths, results of diagnostic testing, limitations, and goals. - The plan of care shall be individualized, based on diagnosis, resident assessment, and personal goals of the resident and their family. - The planning of care, treatment, and services shall include care planning based on data collected from assessments with integration of those findings into the care planning process. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-03 · 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 record reviews and interviews during the abbreviated survey (NY00341925) the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 exhibited frequent exit-seeking behaviors, was not supervised, had no care planned interventions in place, and exited the building to the parking lot. Findings include: The facility policy, Elopement/Wandering Risk, revised 3/20/2024 documented: - Assessment would be completed by the Charge Nurse/designee and elopement/unsafe wandering risk would be determined. - Upon completion of the Elopement/Wandering Risk Assessment, the Charge Nurse/designee would initiate/update the Elopement/Wandering Risk Care Plan based upon information/risk factors identified and interventions would be implemented as appropriate. - If a resident was considered high risk for elopement/unsafe wandering, initially and upon change in physical status, a care plan must be initiated with documented interventions. Resident #1 had diagnoses including dementia, psychotic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-18 · 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 interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 3 resident units (B Unit and C unit). Specifically, B Unit and C Unit had damaged walls and floors. Findings include: C Unit: During observations on 8/10/2023 at 10:40 AM, the tub room had peeling paint on the wall and the ceiling near the sink; and at 11:10 AM the shower room wall tiles had a black substance on them. During an interview on 8/16/2023 at 2:51 PM, the Environmental Services Director stated that they were not aware of the black substance on the tiled walls in the C unit shower room. They stated this shower area was actively used for residents. They expected staff entering the room to see the black substance and submit a work order through the computerized work order system. The Environmental Services Director stated that all staff had access to the work order system,…

    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 before2023-08-18 · 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 interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 7 residents (Residents #38, 51, 69, 75, and 105) reviewed. Specifically, Resident #38 was not ambulated or assisted with toileting as planned; Resident #75 was observed wearing a hospital gown and was exposed and visible from the hallway, their ADLs were not completed timely, and they did not have a hand splint and heel booties applied as ordered; Resident #105 was not provided oral care as planned; Resident #51 was not assisted with shaving; and Resident #69 was not turned and positioned or provided incontinence care as care planned. Findings include: The facility policy Activities of Daily Living (ADLs) revised 11/2022, documented residents should be provided care and treatment every shift…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-18 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview during the recertification and abbreviated (NY00311963) surveys conducted 8/10/2023-8/18/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, and at an appetizing temperature for 3 of 3 meals reviewed (8/10/2023 dinner meal, 8/10/2023 supper meal, and 8/11/2023 breakfast meal). Specifically, food was not served at palatable and appetizing temperatures. Findings include: The facility form Temperature Logs documented hot food should be held over 135 degrees Fahrenheit (F) and cold food should be held below 41 degrees F. A 2/19/2023 anonymous complaint documented the food at the facility did not taste good and was frequently cold. During an interview on 8/10/2023 at 10:27 AM, Resident #18 stated the food was not always served hot. During an interview on 8/10/2023 at 1:53 PM, Resident #41 stated the food was not appealing to look at. During an observation on 8/10/2023 at 2:30 PM, after all residents were served on B unit, a test tray was requested and included every item…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-18 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 8/10/2023-8/18/2023, the facility did not ensure each resident received at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plans of care for 3 of 3 nursing units (Unit A, Unit B, and Unit C) observed. Specifically, resident meal trays were served up to 2 hour and 29 minutes after the scheduled mealtimes on Units A, B, and C. Findings include: The facility policy Meal Distribution revised 9/2017, documented meals were transported to the dining locations, and were delivered in a timely, and accurate manner. A 2/19/2023 anonymous complaint documented meals were served late. The facility's 7/31/2023 Resident Council Meeting minutes documented there was a consensus from residents that some meals had been late on Unit B. The minutes documented dietary staff attended the meeting. The facility's signed 8/18/2023 Facility Survey Report documented the following mealtimes; - Breakfast on the A,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 3 of 3 resident units (A Unit, B Unit, and C Unit) and two isolated areas (the physical therapy space and the main kitchen). Specifically, fruit flies were observed on Units A, B, C, in the physical therapy space, and in the main kitchen. Findings include: The facility third party vendor pest control records dated 4/27/2023 to 8/1/2023 did not document the presence of fruit flies on the resident units or the physical therapy space. A low number of fruit flies were identified in the main kitchen. During an observation on 8/10/2023 at 10:50 AM, the C Unit dining room had 3 fruit flies. The following observations were made on 8/10/2023 on the B Unit: - at 11:30 AM, the tub room had 1 fruit fly; - at 11:32 AM, the dining room had 3 fruit flies; - at 11:39 AM, the kitchenette had 1 fruit fly; 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-18 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents were treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of quality of life for 2 of 3 residents (Residents #103 and 108) reviewed. Specifically, Resident # 103 was observed with their urinary drainage bag uncovered and visible to staff and visitors; Resident #108 was observed with hair on their face and chin. Findings include: The facility policy Dignity and Respect revised 11/20/2020 documented each resident had the right to be treated with dignity and respect. All staff activities and interactions would focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporated the resident's preferences and choices. Residents should be groomed as they wish to be groomed (hair styles, nails, facial hair etc.). Staff should promote dignity and assist…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 8/10/2023 to 8/18/2023, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 5 residents (Residents #101) reviewed. Specifically, Resident #101 had a history of suicide attempts and was planned to have safety checks every 15 minutes and not have access to items that could cause potential harm. Multiple hazardous items were observed in the resident's room and there was no documented evidence 15 minute safety checks were consistently completed. Findings include: The facility policy Suicide Precautions, revised 8/1/2023 documented if a resident expressed or displayed suicidal thoughts nursing personnel should observe and document specific statements or behaviors, use quotes, when possible, monitor the resident for behavioral changes or any signs of developing a plan, and document frequency of monitoring, be specific, and do not document as monitored…

    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 before2023-08-18 · 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 8/10/2023 - 8/18/2023, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #38) reviewed. Specifically, Resident #38 had an unlabeled topical medication (antifungal powder) in their room and shared bathroom, the medication was not ordered by a physician, and was applied by unlicensed staff. Findings include: The facility policy Drug Procurement/Storage/Inspection revised 7/2022, documented that medications and treatments shall be stored securely. The facility policy Medication Administration policy, revised 8/2022 documented medications shall be administered only upon the order of physicians and authorized members of the house staff under the guidelines of their respective scopes of practice. Administration shall be by a registered nurse (RN) or licensed practical/vocational nurse (LPN/LVN). Stock or house…

    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 before2023-08-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 1 of 1 resident (Resident #7) reviewed. Specifically, Resident #7 was not wearing their right hand splint/brace (a device to help prevent contractures) as planned. Findings include: The facility policy Small Adaptive Devices for Activities of Daily Living (ADLs), revised on 8/1/2022 documented that Rehabilitation Services staff shall ensure all small adaptive devices were used safely and correctly by all residents. Proper, safe, and consistent use of small adaptive devices could maximize the resident's level of independence. Therapy would make recommendations for adaptive devices. The Interdisciplinary Care Team (IDT) would ensure care planning was implemented. Resident and caregivers would be educated on their use. 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 · Dcited before2023-08-18 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 of 1 resident (Resident #63) reviewed. Specifically, Resident #63 received hemodialysis (HD, a process that filters blood when kidneys do not function normally) and there was no documented evidence of ongoing assessments and plans for monitoring of the HD access sites. Findings include: The facility policy Care of the Hemodialysis Resident revised 12/7/2021 documented all residents receiving dialysis would have interventions in place for appropriate care and treatment. Physician orders would be obtained for dialysis and frequency of treatments. The care plan and treatment record would be updated to reflect dialysis including restrictions on shunt (connections between blood vessels for dialysis access) arm, auscultation (listening with a stethoscope) of bruit and thrill (sounds made at the HD access site), dialysis frequency,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-24 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during the recertification survey completed on 5/24/21 the facility did not make prompt efforts to resolve grievances the resident may have for 1 of 2 residents (Resident #74) reviewed. Specifically, Resident #74 reported a missing shirt and the facility did actively work toward resolution to locate the missing item. This is evidenced by: The 2/2021 revised Resident Complaint and Grievance Process policy documents the policy is to support, encourage, and promote the resident's rights including the right to an easy to use and responsive grievance and suggestion procedure without fear of reprisal. The Director of Social Work is the facility's Grievance Officer. All verbal or written suggestions or grievances will be directed to the Grievance Officer for coordination and initial investigation. The Complaint/Recommendation form will be completed and entered into the log kept in the Social Services Department. Resident #74 had diagnoses including malignant neoplasm of esophagus and major depressive disorder and need for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-24 · 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 interview and record review during a recertification survey and abbreviated survey (NY00252289) completed on 5/24/21, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #146) reviewed. Specifically, Resident #146 was not assessed timely by a qualified professional after falling and complaining of pain and was sent to the hospital with a fractured femur (thigh bone) approximately 6 hours after the fall. Findings include: The facility policy Resident Incident/Report Documentation within Electronic Medical Record revised 4/19/2019 documented a fall was an unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). If the Nursing Supervisor is a LPN (licensed practical nurse) and there is suspected major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma) the resident is not to be moved. The LPN must contact a physician, RN (registered…

    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 before2021-05-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews during a recertification survey completed on 5/24/21, the facility did not ensure a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents (Resident #95) reviewed. Specifically, Resident #95 was observed without a towel in their left elbow crease to promote elbow extension as planned and did not have range of motion (ROM) interventions documented. Findings include: The 11/2014 Range of Motion Exercises facility policy documented residents confined to bed or limited in movement may not get the amount of exercise they need. Range of motion exercise is ordered by the resident's attending physician. The resident should be encouraged to participate in range of motion exercises. Resident #95 was admitted to the facility with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), contracture of the right and left hands, and intellectual disability. The 5/11/21 Minimum…

    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 before2021-05-24 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview conducted during the recertification survey completed on 5/24/21, the facility did not ensure the storage, preparation, distribution and service of food was in accordance with professional standards for food service safety for 2 isolated areas in the main kitchen (the walk-in cooler and the dry storage room). Specifically, the walk-in cooler floor was soiled and unclean and there was a large amount of ice buildup inside the cooler side of the door to the adjoining freezer. Additionally, the floor of the dry storage room beside the walk-in cooler was soiled with sticky spills, food packaging and products under the shelving. Findings include: When observed on 5/18/21 at 9:47 AM and on 5/19/21 at 12:28 PM, the walk-in cooler floor was soiled with dark liquid and broken eggs under the storage racks. There was a large amount of ice buildup on the walls of the cooler side of the door next to the adjoining freezer. There were 4 broken/cracked eggs in an egg carton on the right side of the walk-in cooler. On the left side of the walk-in cooler, a broken…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-24 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during the recertification survey ending 5/24/21, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 2 of 2 residents (Residents #34 and #56) reviewed. Specifically, Residents #34 and #56 did not have determination of medical decision-making capacity or a concurring determination of capacity completed prior to implementing advance directives to withhold life sustaining treatment as required by New York State law. Findings include: The 4/20/20 facility Advance Directives policy documents residents shall be encouraged and assisted to be active participants in the decision-making process regarding their care. Residents shall be encouraged to communicate their desires in regards to advanced directives to their significant others, to allow for guidance by significant others and healthcare providers in following the residents…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-24 · tag F0925 — failed to control pests — isolated
    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 concluded on 5/24/21, the facility did not maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen (the main kitchen) reviewed. Specifically, there were fruit flies observed within the main kitchen. Findings include: When observed on 5/18/21 at 9:55 AM and 5/19/21 at 11:12 AM, twenty or more fruit flies were observed flying around the coffee machine and the drain area behind the ice machine in the main kitchen. The 4/2021 and 5/2021 pest control records did not document fruit flies were identified or were treated. When interviewed on 5/19/21 at 11:12 AM, the Food Service Director stated the pest control company treated the kitchen area once a month. In addition, the drains were flushed with hot water. They stated staff were not consistent with getting rid of old coffee and cleaning the coffee machines in the mornings which may have contributed to the fruit flies. They have had fruit flies before. When interviewed on 5/19/21 at 2:00 PM, the Director 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.

    Environmental 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

$122,464 in federal fines across 2 penalties.

  • $102,216 — penalty dated 2025-08-12
  • $20,248 — penalty dated 2024-03-04

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

Who owns this facility

Owner / managerTypeRoleShareSince
MURABITO, JOSEPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL100%since 02/01/2012

CMS files one row per role, so the 3 rows in the source record cover these 1 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.

$11.4M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$1.6M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 11%Other / private 12%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$291per resident / day
operating cost
$8,849per month
≈ monthly operating cost
$289per 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 335489. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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