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Meadowbrook Healthcare

154 North Prospect Avenue, Plattsburgh, NY 12901 · For profit - Corporation · 287 certified beds · (518) 563-5440 Medicare & Medicaid certified

Call the home — (518) 563-5440 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Oct 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 (F0604) — 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • about 17% of its spending goes to commonly-owned related companies

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 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
210 Cornelia St · (518) 562-7337 · Call to confirm hours
Pharmacy
Grocery
316 Cornelia St · (518) 310-3702 · Call to confirm hours
Park
141 Boynton Ave · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 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 improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.1%14.1%15.4%better
Long-stay residents who lose too much weight9.0%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.5%0.9%better
Long-stay residents with a urinary tract infection0.8%1.3%2.0%better
Long-stay residents with depressive symptoms28.2%19.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury5.3%3.1%3.3%worse
Long-stay residents whose ability to walk worsened7.2%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.3%13.2%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers4.6%6.5%4.7%typical
Long-stay residents with worsening bladder/bowel control34.0%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.9%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine91.9%78.8%79.4%better
Short-stay residents rehospitalized after admission21.0%20.6%22.6%typical
Short-stay residents with an outpatient ER visit16.7%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.931.701.67worse
Long-stay outpatient ER visits per 1,000 resident days2.471.361.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 476 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.9%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
55.2%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 55.2% 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 201 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF46.9%CMS range 43.3–51.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 7.1–11.710.7%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 discharge55.2%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 discharge49.2%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 discharge51.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.3%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 hospitalization7.5%CMS range 5.3–9.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.691.02Oct 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

0.74
RN hours/ resident / day
0.57
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.48
RN hoursweekends
49.0%
Total nursing turnover
26.5%
RN turnover

How full it usually is: this home is certified for 287 beds and averages 236.0 residents a day — about 82% occupied, or roughly 51 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 2.98 hrs/resident/day on weekends vs 3.62 on weekdays — 18% thinner on weekends. RN hours go from 0.84 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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

14
deficiencies at the latest standard inspection (2024-10-25)
0
at the previous standard inspection (2021-07-30)

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2024-10-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review conducted during recertification and abbreviated survey (NY00329299), the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for 5 (Residents #76, 104, 119, 139, and 177) of 44 residents reviewed for comprehensive care plans. Specifically, (a.) Resident #76 care plan interventions were not implemented based on recommendations from the interdisciplinary team to reduce falls and injuries after a fall and the resident had subsequent falls, (b.) Resident #104 care plan did not include interventions and goals for dementia care, (c.) Resident #119 had fallen several times and the care plan was not developed for falls, (d) a Certified Nurse Aide did not follow care plan and transferred Resident #139 alone that caused injury, and (e) Resident #177 fell when staff did not follow resident care plan 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-25 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey, the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions for 4 (Resident #'s 50, 53, 76, and #177) of 44 residents reviewed. Specifically, (a.) for Resident #53, the comprehensive care plan for Clotridoides or Clostridium difficile infection (a bacterium that causes diarrhea and inflammation of the colon) was not updated when the infection had resolved; (b.) for Resident #76, the fall care plan was not revised after the most recent Minimum Data Set Assessment; the comprehensive care plan for behaviors did not include a psychiatric consult or on-going psychiatric services; the comprehensive care plan for altercations was not updated after visiting restrictions were lifted for spouse; and the comprehensive care plan for wandering/elopement was not updated to reflect removal of 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 · E2024-10-25 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification and abbreviated survey (Case #s NY00326260, NY00329259, NY00334623, and NY340304), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels of Certified Nurse Aides were not met every day on multiple shifts and multiple units, from 10/05/2024 to 10/20/2024. This is evidenced by: The Facility assessment dated [DATE], documented budget and minimum nursing staffing levels needed for each unit during the 7-3 shift (day), 3-11 shift (evening), and 11-7 shift (night), when the resident census was 233: Certified Nurse Aide Shift Unit Beds Budget Minimum 7-3 Shift The Orchards - LTC 38 5 4 Oak Woods - LTC 39 5 4 Chestnut Grove - LTC 38 5 4 Aspen View - LTC 41 5 4 Pine Ridge - LTC 40 5 4 Sub-Acute 37 5 4 3- 11 Shift The…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-25 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 3 (Resident #s68, 182 and 199) of 6 residents observed during a medication pass for a total of 34 observations. This resulted in a medication error rate of 38.24%. This is evidenced by: The facility's Policy and Procedure titled Medication Administration reviewed 2/2020 documented Nurses were required to adhere to the following: Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified by the physician. Nurses must take every safety precaution when administering medications. The Five Rights are safety rules to be implemented each time a drug is administered: o Right Medication o Right Patient/Resident o Right Time o Right Route o Right Dose. Resident #68 was admitted to the facility with diagnoses of bacterial Infection, limited mobility and depression. The Minimum Data Set, dated 8/2024, documented resident was cognitively intact, could be understood, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-25 · tag F0761 — failed to label and store drugs safely — pattern
    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, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates, and (b) a medication cart was left unattended and unlocked. This was evident for 3 (Aspen, Subacute, and Orchard Units medication carts) out of 3 medication carts reviewed. This was evidenced by: The facility's Policy and Procedure titled Medication Administration reviewed 2/2020 documented Nurses were required to adhere to the following: The expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened should be recorded on the container. During administration of medications, the medication cart would be kept closed and locked when out of sight of the medication nurse. The cart must remain clearly visible to the nurse administering medications. and all outward sides must be inaccessible to others passing by. 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 · E2024-10-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 6 of 6 resident unit kitchenettes and main kitchen. Specifically, area of the main kitchen and resident kitchenettes were not clean. This is evidenced by: During observations in the main kitchen on 10/20/2024 at 5:45 PM, the rolling toaster appliance had a large amount of buildup and debris on the device. In a follow up observation on 10/22/2024 at 9:34 AM the rolling toaster was not cleaned and still had a large buildup of debris on the device. During observations on the Orchards 1st Floor Unit on 10/22/2024 at 10:34 AM, the resident kitchenette microwave had food particles along the door and on the interior of the appliance. Door, shelving units, and the bottom of the unit refrigerator was soiled with food and liquid particles. During observations on the Orchards 2nd Floor Unit on 10/22/2024 at 10:46 AM, the resident kitchenette microwave had food particles…

    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 before2024-10-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infection for all residents and staff in facility reviewed for infection control. Specifically, facility staff did not properly use personal protective equipment on units with COVID. This is evidenced by: The Infectious Disease Outbreak Control policy, revised 07/19/2024, all employees would maintain transmission-based precautions as indicated During an observation on 10/22/2024 at 10:34 AM on the subacute unit, a nurse exited a resident room wearing a cloth gown. The nurse removed the gown in the hallway outside of the resident's room. The resident in the room (room [ROOM NUMBER]) was on transmission-based precautions for COVID. During an interview on 10/24/2024 at 10:46 AM, Director of Nursing #1 stated personal protective equipment was located on each unit 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during a recertification survey, the facility did not ensure the resident representative and the physician was notified when there was a change in condition that required a change in the residents' plan of care, medication, or treatment regimen for 3 (Resident #s 7, 58, and 198) of 3 residents reviewed for resident notification issues. Specifically, (a.) for Resident #7, provider was not notified when resident had a fall with a fracture on 8/20/2024 until the next day. For (b.) Resident #58, representative was not notified of a fall on 8/29/2024 and the need for x-rays for 9 hours; (c.), for Resident #198, representative was not notified when Haldol Lactate Solution 5 MG/ML, give 0.5 mg intramuscularly was ordered and given 4 times on 6/26/2024, 7/12/2024, 7/28/2024 (1 mg), and 7/29/2024. This was evidenced by: The facility policy and procedure titled, Notification of Change in Condition, dated 1/2022 documented, in accordance with State and Federal Regulations, the 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 a recertification survey, the facility did not ensure the resident had a right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 (Resident #198) of 2 residents reviewed for restraints. Specifically, Resident #198 had a chair alarm (a pad placed on a chair) hooked to a sensor box that alarmed if a wheelchair resident attempted to stand, and had a seat belt around their lap that the resident was not able to remove when asked and that prohibited the resident from rising independently. This is evidenced by: The policy titled Restraints, dated 01/2020, documented that the facility would consider physical restraint after all other interventions were exhausted; it further documented that the nurse would document each time the restraint was applied and/or removed and the restraint would be discontinued as soon as possible. Resident #198 was admitted to the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-25 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 residents (Resident #104 and 119) of 2 residents reviewed. Specifically, Residents #104 and 119 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure titled Activities Department, undated, documented its policy was to provide meaningful activities to residents with various cognitive, physical, and social abilities on a regular basis to enhance their quality of life. Include resident in a variety of programming and adapt the event/activity to assist resident in participating within their ability and comfort zone. Resident #104 was admitted to the facility with diagnoses of Polymyalgia Rheumatica (an inflammatory disorder that causes muscle pain…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2024-10-25 · 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 record review and interview during a recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent further pressure ulcer for 1 (Resident #50) of 44 residents reviewed. Specifically, for Resident #50, the facility did not (1.) complete an accurate assessments and documentation of an unstageable pressure ulcer on the right great toe identified on 9/23/2024 and a wound on the second toe on the left foot identified on 10/14/2024: (2.) physician ordered treatments for the wounds were not administered as ordered: (3.) the resident's care plan did not include measurable objectives and timeframes to promote healing of the wounds. This is evidence by: Resident #50 was admitted to the facility with diagnoses of cerebral infarction (stroke), diabetes, and acute on chronic diastolic (congestive) heart failure). The Minimum Data Set (an assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice for 2 (Resident #'s 9 and 122) of 5 residents reviewed for oxygen administration. Specifically, (a) Resident #9, there was no physician's order for Resident #9's oxygen, and (b) for Resident #122 oxygen delivery was not provided by unlicensed personnel. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Administration, dated 02/2020, documented that a physician's order was required for oxygen use and that oxygen would be initiated per the?Medical Directors order or by a?nurse in an acute situation. Resident #9 was admitted to the facility with diagnoses of asthma (chronic inflammation of the airways), chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · 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, record review, and interview during the recertification survey, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services, received such services consistent with professional standards of practice for 1 resident (Resident #150) of 1 resident reviewed for Dialysis. Specifically, Resident #150 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments. This is evidenced by: The facility's Policy and Procedure titled Hemodialysis, reviewed 4/2020, documented: Patients/residents requiring hemodialysis therapy would be transported to the local Renal Center for hemodialysis therapy. A Dialysis Communication Book shall be established for each patient/resident receiving hemodialysis. A pre and post dialysis assessment would be completed and documented in the electronic medical record. Resident #150 was admitted to the facility with diagnoses of end…

    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 before2019-02-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for nine (Resident #'s 15, 110, 132, 165, 177, 189, 190, 220, and 246) of 16 residents reviewed. Specifically, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed for Resident #15's diagnosis of Respiratory syncytial virus (RSV- a common respiratory virus) and for droplet precautions to aide in the spread of infection, that Resident #110 had a CCP to address lower extremity edema, that Resident # 132's &165's Comprehensive Care Plans (CCP) addressed the use of psychotropic medications, Gradual Dose Reductions (GDR) attempt, and monitoring for side effects of psychotropic medications, that Resident #132 & 190 had CCPs for activities, and that Resident #220 had a nutrition care plan.…

    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 · E2019-02-28 · 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 record review and interview during the recertification survey, the facility did not ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, the facility did not ensure that a resident group agreed to the 14 1/2 hour or more time span between the facility's scheduled times for the evening and breakfast meals. This was evidenced by: Review of listed meal times on 2/26/2019 at 10:17 AM showed that dinner was served between 4:40 PM and 5:00 PM. Breakfast was served between 7:30 AM and 7:45 AM, a lapse of 14 1/2 to 14 5/6 hours between the two meals. During an interview on 2/27/2019 at 11:13 AM, the Activities Director was unable to locate Resident Council notes in the last 7 months stating the group agreed to the greater-than-14-hour meal span. At 2:45 PM, the Activities Director stated she looked through 12 months 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 · E2019-02-28 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced as follows: Review of the facility's policy on Food Brought to Residents from the Outside on 02/26/19 at 10:00 AM, revealed the policy did not include procedures for families and visitors to be educated on the safe preparation, handling, or storage of foods brought in for residents. During an interview with Dietitians #4 and #5 on 2/26/19 at 11:40 AM, the Dieticiians stated they did not provide any instruction to families regarding the safe and sanitary home preparation, handling and storage of food to be brought in for residents. They thought the Food Service Manager might provide instructions. During an interview with the Food Service Manager (FSM) at 11:49 AM on 2/26/19, 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 · E2019-02-28 · tag F0836 — pattern
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 02/27/2019 12:00 PM, revealed that carbon monoxide (CO) detection was not provided near fuel burning appliances in the main kitchen (stoves). The Director of Engineering stated in an interview on 02/29/2019 at 1:50 PM, that a CO detector was added to the kitchen today, but no CO detectors are monitored by the fire panel, and staff has not received training on how to respond to the CO alarms. 483.70 (b); 2015 International Fire Code, Section 915

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-02-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during a recertification survey, the facility did not 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 (Resident #15) of one resident's reviewed for isolation precautions. Specifically, for Resident #15, on the Aspen Unit, the facility did not ensure droplet precautions were implemented and maintained to prevent the spread of the Respiratory syncytial virus (RSV) and on the Oakwood Unit the facility did not ensure that infection control standards were maintained during a dressing change. This is evidenced by: Resident #15: The resident was admitted to the facility on [DATE] with diagnoses of heart failure and chronic kidney disease. The Minimum Data Set (MDS) dated [DATE], documented the resident had moderately impaired cognition, and was understood and usually understood verbal content. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-28 · 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 interviews during the recertification survey the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for residents on 3 of 7 units. Specifically, for Unit's 1, 2, and 4, the facility did not ensure that residents were not moved during their meal to accommodate for residents who were entering or exiting the dining room, did not ensure that resident's meals were not interrupted by the need for other resident's to enter or exit the dining room, did not ensure that medications were not administered while residents were eating, and did not ensure that residents' seated at the same table received their meals at the same time. This was evidenced by: Unit 1: Finding #1 The facility did not ensure that residents were not moved during their meal to accommodate for residents who were entering or exiting the dining room. During an observation 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-28 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review during the recertification survey, the facility did not ensure 4 (Resident #'s 190, 191,197 and #220) of 5 residents reviewed for hospitalization received written notice of transfer/discharge and the reasons for the transfer in a language and manner they understand. Specifically, the facility did not ensure that there was documented evidence that written notification of transfer/discharge was provided to the resident and/or the resident's representative(s). This was evidenced by: Review of the policy titled Emergency Transfer dated 7/2018, did not include documentation regarding notice of transfer/discharge to the resident and/or resident's representative. Review of the policy titled Discharge Planning dated 12/2015, did not include documentation for notification of hospital transfer/discharge. Review of the facility letter used for transfer/discharge to the hospital by the social worker is labeled Bed Hold. The letter includes bed hold information along with a sentence that…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-28 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review during the recertification survey, the facility did not ensure written notice was provided to the resident and/or the resident's representative of the bed hold and return policy for 4 (Resident #'s 190, 191,197 and #220) of 5 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This evidenced by: Review of the policy titled Bed Hold Policy dated 6/2018, documented that each resident be given a notice of this policy upon each leave of absence from the facility. It did not include documentation that it must be given in writing. Review of the facility letter used for Bed hold and for hospital transfer/discharge by the social worker is labeled Bed Hold. The letter includes bed hold information along with an attachment of the Bed Reservation Policy Notice that is provided upon…

    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 before2019-02-28 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (Resident #'s 132 and 228) of 4 residents reviewed for activities. Specifically, the facility did not ensure that Resident #'s 132 & 228 were provided with activities on an ongoing basis according to the residents' Comprehensive Care Plans and that activities provided met the residents' preferences. This is evidenced by: The Monthly Event Calendar for February 2019 documented for each of the four: Sundays: Communion at 8:30 AM on 3 Sundays, Activity visits 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey the facility did not provide proper treatment and assistive devices to maintain vision for 1 (Resident #177) of 5 residents reviewed for visual impairment. Specifically, the facility did not ensure that Resident #177 was provided assistance locating her glasses and that the resident's plan of care included a plan for vision and devices. This is evidenced by: Resident #177: The resident was admitted to the facility on [DATE], with diagnoses of Cerebrovascular Accident, dementia, and diabetes. The Minimum Data Set (MDS) dated [DATE], documented the resident used corrective lenses and had adequate vision. The resident had the ability to be understood and usually understood others. The MDS dated [DATE] & 1/30/19, documented the resident did not use corrective lenses, had impaired vision with the ability to see large print, was understood and understands and continued mild cognitive impairment. During an interview on 02/25/19 at 2:09 PM,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY00233249) the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 (Resident #13) of 5 residents reviewed. Specifically, for Resident #13, the facility did not ensure medications were not left unsecured and unattended at the resident's bedside. This was evidenced by. The Policy and Procedure (P&P) titled Medication Administration dated 6/13/16, documented the facility shall administer medications in a safe and timely manner in accordance with current standards of nursing practice. Never leave medications unattended or unsecured. Resident #130: The resident was admitted to the facility on [DATE], with the diagnosis of Schizophrenia, depression and hypertension. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, and was able to make herself understood and was usually able to understand others. An observation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-10-25 · tag F0755 — failed to provide safe pharmacy services — widespread
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during a recertification survey and abbreviated survey (NY00326260), the facility did not ensure procedures that assured the accurate acquiring, receiving, dispensing, reconciliation, and storage of medications. Specifically, the facility did not ensure that narcotic medications received at the facility were properly destroyed. This is evidenced by: On October 13, 2023, Director of Nursing #1 sent a notification to the New York State Department of Health Bureau of Narcotics advising them of the destruction of controlled substances. A follow-up notification from the manager of the Bureau of Narcotics Enforcement on 10/17/2024 advising the facility that their destruction notification was denied as they did not submit a narcotics license renewal. The manager from the Bureau of Narcotics also issued two statements of deficiencies to the facility for operating without a license and destruction of controlled substances without approval from the New York State Department of Health Bureau of Narcotics. During an interview on 10/24/2024 at…

    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 · Past Non-Compliance

“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 / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$33.7M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$5.6M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 46%Medicare 33%Other / private 21%

This home reported $5.6M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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

$436per resident / day
operating cost
$13,267per month
≈ monthly operating cost
$434per 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 335438. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-25, 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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