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Pontiac Nursing Home

303 East River Road, Oswego, NY 13126 · For profit - Limited Liability company · 80 certified beds · (315) 343-1800 Medicare & Medicaid certified

Call the home — (315) 343-1800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Feb 2024
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 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
Erie St · (315) 207-0670 · Call to confirm hours
Pharmacy
192 W 1st St · (315) 342-6822 · Call to confirm hours
Grocery
Bosco's0.6 mi
343 East Ave · (315) 343-5421 · Call to confirm hours
Park
237 E 7th St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 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 rating3★
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 increased18.0%14.1%15.4%worse
Long-stay residents who lose too much weight3.6%5.8%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.5%0.9%better
Long-stay residents with a urinary tract infection0.5%1.3%2.0%better
Long-stay residents with depressive symptoms0.6%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.5%3.1%3.3%better
Long-stay residents whose ability to walk worsened22.7%12.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.5%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine95.2%95.3%95.3%typical
Long-stay residents with pressure ulcers4.3%6.5%4.7%typical
Long-stay residents with worsening bladder/bowel control23.5%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.3%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine72.3%78.8%79.4%typical
Long-stay hospitalizations per 1,000 resident days1.171.701.67better
Long-stay outpatient ER visits per 1,000 resident days1.541.361.80better

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.

0.24U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 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

0.35
RN hours/ resident / day
0.83
LPN hours/ resident / day
1.91
Aide hours/ resident / day
3.09
Total nurse hours/ resident / day
0.30
RN hoursweekends
50.0%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 59.0 residents a day — about 74% occupied, or roughly 21 beds typically open. It usually has some room. 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 3.09 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 2.76 hrs/resident/day on weekends vs 3.22 on weekdays — 14% thinner on weekends. RN hours go from 0.37 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

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

Inspection trend

12
deficiencies at the latest standard inspection (2025-09-12)
8
at the previous standard inspection (2024-02-15)

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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Fcited before2025-09-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 and abbreviated survey (reference # 532839 [NY00357482]) conducted 9/8/2024 - 9/12/2024, the facility did not ensure food was prepared, distributed, stored, and served in accordance with professional standards for the facility's food services. Specifically, the facility did not ensure prepared foods were cooled properly, stored properly, the food on the steam tables were served at an appropriate temperature during meal service, and nutrition rooms and storage areas were maintained in a clean sanitary condition. Findings included: The facility policy General Sanitation of Kitchen, reviewed 10/8/2024, required defined cleaning tasks, assigned responsibilities, and staff training. The facility did not follow this policy, as nutrition rooms and storage areas had not been maintained in clean and sanitary conditions.The facility did not have a food storage policy, food service policy, food handling policy, or pest policy as requested on 9/10/2025. Improper cooling:The facility's Cooling Log Sheet documented…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #52) reviewed and twelve (12) of twelve (12) anonymous residents present during a resident group meeting. Specifically, Resident #52 had intact decision-making ability, and the facility involved the resident's family in financial decisions without asking the resident and informed the resident they could not utilize another cognitively intact resident's cellphone even with permission; and twelve residents present at the resident group meeting voiced concerns they were not allowed to go to the enclosed area outside. Findings include:The facility was unable provide a resident rights and resident cellphone policy as requested.The facility admissions packet documented the residents as nursing home residents in New York State had the right to retain and use…

    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 · E2025-09-12 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for four (4) of four (4) residents (Residents #6, #21, #41, and #44) reviewed. Specifically, Resident #6 did not have a care plan that included the use of bed rails; Resident #21 did not have a current care plan addressing behaviors and diabetes with insulin use; Resident #41's care plan was not reviewed and/or revised after Minimum Data Set assessments; and Resident #44's care plan did not include the use of a urinary catheter (a tube to drain urine from the bladder). Findings include: The facility policy Comprehensive Care Planning, reviewed 9/16/2019, documented an individualized care plan was initiated by a registered nurse upon admission for all residents. The interdisciplinary team reviewed the care plan quarterly following the Minimum Data Set assessment completion;…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for two (2) of five (5) residents (Resident #13 and 41) reviewed. Specifically, Residents #13 and #41 were administered long-acting insulin greater than 3 hours past the scheduled administration time and the insulin pens were not primed (removing trapped air) prior to dialing in the ordered dose. Findings include:There was no documented evidence of a facility policy on medication administration or insulin administration. 1) Resident #13 had diagnoses including diabetes. The 8/5/2025 Minimum Data Set assessment documented the resident had intact cognition and did not receive daily insulin injections. There was no documented Comprehensive Care Plan addressing the resident's diabetes or administration of insulin. During an interview on 9/8/2025 at 7:27 PM, Resident #13 stated they did not get their medications…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of one (1) resident (Resident #20) reviewed. Specifically, Resident #20 had a change in condition and was not assessed timely by a qualified professional; Licensed Practical Nurse #25 notified Nurse Practitioner #9 via text message and there was no documented evidence of orders received for a chest x-ray and the application of oxygen; Licensed Practical Nurse #25 did not document a change in condition or that a medical professional and family were notified; and there was a delay in notifying the provider of the radiology results. Findings include: The facility policy Notification of Significant Changes, last reviewed 6/30/2023, documented the facility notified the resident, the resident's physician(s), and if known, 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 · D2025-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025 the facility did not ensure the resident environment remained free of accident hazards for one (1) of four (4) residents (Resident #41) reviewed. Specifically, Resident #41 had a physician order for nectar thick consistency liquid and was provided thin liquid consistency hot cocoa. Additionally, Resident #41 was unhappy with their thickened liquids diet, was occasionally non-compliant and was not referred to speech language pathology for their new diet or care planned for their non-compliance. Findings include:The facility policy Dysphagia and Diet Consistency Changes, last reviewed 2/17/2022, documented dysphagia (difficulty swallowing) diets would be individualized with modifications made by the Speech-Language Pathologist, Occupational Therapist, Registered Dietitian, and physician as needed. Residents with observed indicators of dysphagia would be referred to the Speech-Language Pathologist for an evaluation. The evaluation would determine diagnoses, proper fluid…

    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 before2025-09-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for two (2) of two (2) residents (Residents #7 and #8) reviewed. Specifically, Resident #7 had a significant weight loss that was not assessed timely, interventions were not reviewed after continued weight loss, and the resident was not provided with the ordered nutritional supplement; and Resident #8's tube feeding orders did not meet the calculated nutritional needs of the resident and did not include free water flushes. Additionally, Resident #8 was self-administering their tube feeding without a physician order or determination of physical and mental competency to self-administer the feeding. Findings include: The facility policy Self-Medication Administration, last reviewed 2/2022, documented the comprehensive care team would evaluate the resident to determine if they met the self-administration criteria to include physical and mental ability; the attending physician…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one (1) of two (2) residents (Resident #48) reviewed. Specifically, Resident #48 received continuous positive airway pressure therapy (a machine used to keep the airway open by delivering continuous air through the nose) without a physician order with a supporting diagnosis, a plan to regularly clean the machine to prevent contamination, and a care plan for use of the device. Findings include: There was no documented evidence of a policy for positive airway pressure therapy. Manufacturers recommendations for maintenance of continuous positive airway pressure equipment included daily cleaning of the mask cushion and the humidifier tub (reservoir for placing water), and weekly cleaning of the tubing. Resident #48 had diagnoses including anxiety, depression, and trisomy (a genetic condition causing developmental delays,…

    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 before2025-09-12 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents were provided food and drink that was palatable and flavorful, and at an appetizing temperature for one (1) of two (2) meals reviewed (lunch meal on 9/9/2025). Specifically, the 9/9/2025 lunch meal entree was soft and had a soggy texture and the replacement entree was burnt. Findings include:There was no documented evidence of a food palatability or meal test tray policy. During an observation on 3/9/2025 at 12:38 PM, Resident #52's meal tray was tested, and a replacement tray was ordered. The grilled cheese sandwich was soft and had a soggy texture. At 12:43 PM, a replacement grilled cheese sandwich was provided to Resident #52. The sandwich was black in color on both sides, one side was darker than the other. During an interview on 9/12/2025 at 10:17 AM, [NAME] #27 stated they would not allow food to leave the kitchen if it did not look good. The burnt grilled cheese sandwiches should not have been served to the residents.During an interview on…

    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 · D2025-09-12 · tag F0840 — isolated
    Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
    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 9/8/2025-9/12/2025, the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for one (1) of one (1) resident (Resident #13) reviewed. Specifically, Resident #13 had a recommendation for an ankle-brachial index test (a test to diagnosis poor blood flow) that was not followed up in in a timely manner. Findings include:There was no documented evidence of an outside appointment/consult policy.Resident #13 had a diagnosis of diabetes and peripheral vascular disease (insufficient blood flow). The 8/5/2025 Minimum Data Set assessment documented the resident had intact cognition and two non-pressure related skin ulcers. The 7/29/2025 Comprehensive Care Plan, revised 9/10/2025, documented a wound management problem. Interventions included provide wound care per treatment order.The 7/29/2025 Registered Nurse Supervisor #4's clinical admission assessment documented a skin issue on both the left and right lower leg…

    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
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-09-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025 the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of two (2) residents (Resident #55) reviewed. Specifically, Resident #55 was on transmission-based precautions (contact precautions) and Housekeeper #22 cleaned Resident #55's room without wearing required personal protective equipment and did not perform appropriate hand hygiene upon leaving the room; and Certified Nurse Aide #23 provided care to Resident #55 without appropriate personal protective equipment or washing their hands upon leaving the resident's room. Findings include:The facility policy Isolation and Transmission Based Precautions, revised 12/2023 documented the facility would use standard precautions based on the Center for Disease Control guidelines in patient care areas. When there were reasons to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-15 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not electronically submit encoded, accurate and complete Minimum Data Set assessment data to the Centers for Medicare and Medicaid Services System within 14 days after the assessment completion date for 11 of 11 residents (Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50) reviewed for resident assessments. Specifically, the Minimum Data Set assessments for Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50 were not transmitted to the Centers for Medicare and Medicaid Services system within 14 days of completion. Findings included: The Centers for Medicare and Medicaid Services Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented that assessments must be transmitted electronically to the Quality Improvement Evaluation System Assessment Submission and Processing system using the Centers for Medicare and Medicaid Services wide area network within 14 days of the care plan completion date and all other Minimum Data Set assessments must…

    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 · Ecited before2024-02-15 · 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 survey conducted 2/12/2024-2/15/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch on 2/13/2024 and breakfast on 2/14/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 2/13/2024 and the breakfast meal on 2/14/2024. Findings include: The facility policy, Monitoring Food and Liquid Temperatures, reviewed by the facility 9/08/2023, documented the dietary department was to maintain acceptable food temperatures during serving. Temperatures of the food were to be taken and recorded prior to serving. Hot foods were to be held at least 140 degrees (Fahrenheit) and cold foods were to be held at 45 degrees or below. If food items were out of acceptable range, they would be returned to the kitchen to be reheated or cooled to accurate temperature. During the resident council meeting on 2/12/24 at 2:03 PM, there…

    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 · D2024-02-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification and abbreviated (NY00326851 and NY00327641) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated and did not prevent further potential abuse for 1 of 4 residents (Resident #17) reviewed. Specifically, Resident #17 reported an allegation of abuse that was not investigated timely and did not remove the alleged perpetrator from access to residents pending the results of the investigation. Findings included: The facility policy Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property reviewed by the facility 6/23/2023 documented the facility was committed to providing residents with an environment that was free from verbal, physical, and mental abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. All staff would be trained during orientation and annually on what constitutes abuse, neglect, and misappropriation 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification and abbreviated (NY00306949) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Residents #6) reviewed. Specifically, Resident #6 was observed with dirty and untrimmed fingernails and was not provided a shower as planned. Findings include: The facility policy Activities of Daily Living Care Guidelines, reviewed by the facility 11/17/2021, documented residents received routine morning and evening activities of daily living care to have their hygienic and comfort needs met. Caregivers were to review resident nursing care instructions at the beginning of the shift to ensure the residents were provided care according to their plan of care. All residents received a partial bed bath daily which included washing the resident's face, hands, back, underarms, and peri area. A shower or whirlpool bath replaced 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 before2024-02-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 2 medication carts (Unit 2) reviewed. Specifically, prescribed controlled drugs on the second-floor unit were stored in an untethered (free-moving) medication cart and not returned to the double-locked medication room narcotic storage cabinet after the medication passes were completed. Findings include: The facility policy Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles revised 6/2022, documented in New York, controlled substances must be securely locked in a double-locked cabinet, affixed to the wall or floor until the beginning of the medication pass. Upon completion of the medication pass, controlled substances must be returned to the cabinet. During an observation on 2/13/2024 at 11:18 AM, the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-15 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 2 of 3 food preparation areas (the main kitchen and the first-floor kitchenette). Specifically, in the main kitchen there was expired and undated food, a dented can of fruit cocktail in the dry food storage, and the clean drying rack had two unclean cooking pans with food debris; the first-floor kitchenette had expired and undated food. Findings include: Food Storage: The following observations were made in the main kitchen on 2/12/2024: - At 9:00 AM, there was a 64-ounce jar of peanut butter on a shelf with a best by date of 11/19/2023, and a 108-ounce can of pre-made pasta with sauce with a best by date of 2/28/2023. - At 9:20 AM, there was a loaf of cinnamon raisin bread in the reach-in freezer with an expiration date of 9/08/2023, four loafs of cinnamon raisin bread with an expiration date of 2/03/2024, two packages 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/15/2024 the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #11, and #32). Specifically, Residents #2, #11, and #32 were on droplet and contact precautions and staff were observed not applying appropriate personal protective equipment when entering the resident rooms, not removing personal protective equipment in a safe, or sanitary manor to prevent the spread of infectious organisms, and not performing appropriate hand hygiene. Findings include: The facility Infection Prevention and Control Program Manual revised 12/2023 documented standard and transmission-based precautions would be followed to prevent the spread of infections: - Handwashing with soap and water or hand hygiene with hand sanitizer (when hands are not visibly soiled) would be expected…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey conducted 2/12/2024 through 2/15/2024, the facility did not ensure each resident was offered influenza immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 6 residents (Residents #11 and #43) reviewed. Specifically, there was no documented evidence Residents #11 or #43 were offered, educated, received, or declined the influenza immunization for the 2023-2024 influenza season. Findings include: The facility policy Immunizations: Influenza Vaccination of Residents, Staff and Volunteers updated 3/2020 documents all residents should receive the influenza vaccine annually unless there is a documented contraindication or declination. Education shall be provided to all individuals; they have the right to refuse vaccinations, and this will be properly documented. All immunizations will be documented in the medical record. Current and newly admitted residents will be offered influenza…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 3 residents (Resident #21) reviewed. Specifically, Resident #21 was not provided timely nail care. Findings include: The facility policy ADL Care Guidelines dated 4/25/19 documents caregiver will review resident nursing care instructions at the beginning of each shift to assure that care is given according to the individual's plan of care. Staff will perform hand hygiene at this time and as indicated throughout care. Resident #21 had diagnoses including depression and bipolar disorder. The 8/14/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive assistance for personal hygiene. The 6/14/21 comprehensive care plan (CCP) documented the resident required supervision with grooming. The CCP was updated on 7/19/21 to include nail…

    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 before2021-10-14 · 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 observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents (Residents #4 and 26) reviewed. Specifically, Resident #4 had an excoriated (abraded or chaffed) area on their skin that was not addressed timely by qualified nursing staff and Resident #26 was not provided with physician ordered TED (thrombo-embolus deterrent, compression) stockings. Findings include: The facility policy Urinary Incontinence dated 8/2009, documented residents will be kept clean and dry. Resident's skin condition will be monitored and assessed for signs and symptoms of skin irritation and skin breakdown during cares. Any skin breakdown will be reported to charge nurses and to the skin nurse via 24-hour Report. All incontinent and/or residents with incontinent dermatitis will be treated with moisture barrier ointment (A & D ointment) for every incontinence or during cares. If excoriations persist after 48 hours…

    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 · D2021-10-14 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    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 10/12-10/14/21, the facility failed to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities for 1 of 1 resident (Resident #19) reviewed. Specifically, the facility did not make arrangements for Resident #19's physician ordered optometry consult. Findings include: Resident #19 had diagnoses including dry eye syndrome, history of falls, and diabetes. The 5/11/21 admission Minimum Data Set (MDS) assessment documented the resident had intact cognition, impaired vision, and used corrective lenses. The resident required extensive assistance of one staff with most activities of daily living (ADLs). The 5/4/21 Director of Social Services progress note documented the resident liked to play cards, play games, watch TV, and complete puzzle books. The note documented the resident had poor eyesight, the resident said their eyeglasses were lost by staff at the previous facility and the plan was to have a scheduled eye appointment. The 5/4/21 resident…

    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 before2021-10-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview during the recertification survey conducted from 10/12/21 -10/14/21, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 2 of 4 residents (Residents #26 and 236) reviewed. Specifically, Resident #26 had a significant weight gain and was not re-assessed timely, and Resident #236 had a preference to gain weight and the facility did not monitor the resident's weight to ensure they met the resident's nutritional goals. Findings include: The facility policy Weight Monitoring Program dated 8/2015 documented weight monitoring is used to assure that residents maintain acceptable parameters of nutritional status when clinically possible and that appropriate interventions are put into place. Evaluation by the registered dietitian (RD) and/ or physician will determine the need for appropriate interventions. This will take into account the resident's usual body weight (UBW), fluid status, medication, functional status, cognition, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview during the recertification survey conducted 10/12/21-10/14/21, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 nursing unit medication rooms (Unit 1) reviewed. Specifically, the facility had expired stock medications (Tylenol suppositories) and biologicals (influenza vaccine) in the Unit 1 medication room refrigerator. Findings include: The facility Medication Storage policy dated 5/2018 documented medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy documents outdated, contaminated medications are immediately removed from inventory and discarded according to procedures. Some medications have a shorter shelf life than…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-14 · 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 observation, interview, and record review during the recertification survey conducted from 10/12/21 - 10/13/21, the facility failed to provide carbon monoxide (CO) detection in compliance with Federal, State, and Local Laws and Professional Standards on 1 of 3 Units (basement) reviewed. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection (adopted by New York State), requires carbon monoxide detection in all areas with fuel burning/gas operated equipment. Specifically, carbon monoxide detection was not installed in the basement level where there was fuel burning equipment. Findings include: There was no documented policy and procedure for a CO activation incident in the facility. During observations on 10/12/21 and 10/13/21 between 9:00 AM and 3:00 PM, there was no carbon monoxide detection installed in the basement level of the facility. The basement level contained a generator room (boiler room) with a natural gas generator, and a main kitchen fuel/gas burning appliances (stove and oven). When interviewed on 10/13/21 at 11:50 AM, 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-09-12 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every three months for two (2) of four (4) residents (Residents #25 and #52) reviewed. Specifically, Residents #25's and #52's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gather information about a resident's condition when completing the assessment).Findings include: There was no documented evidence of a Minimum Data Set assessment policy.Resident #52's Minimum Data Set assessment documented an Assessment Reference Date of 5/10/2025 and was not completed. Resident #25's Minimum Data Set assessment documented an Assessment Reference Date of 5/5/2025 and was not completed.During a telephone interview on 9/11/2025 at 1:54 PM, Minimum Data Set Coordinator #16 stated they kept track 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
KNOLL, CHARLESIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST33%since 01/01/2000
MASTROPIERRO, COSIMOIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST67%since 01/01/2000
AMIDON, JEFFREYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2024
MALLO, ARLYNIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/05/2019
VIVENZIO, JOHNIndividualADP OF THE SNFsince 01/01/2000

CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

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

$4.1M
Net patient revenuemost recent cost report
-16.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 71%Medicare 6%Other / private 23%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$309per resident / day
operating cost
$9,380per month
≈ monthly operating cost
$266per 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 335590. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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