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Lutheran Center At Poughkeepsie Inc

965 Dutchess Turnpike, Poughkeepsie, NY 12603 · For profit - Individual · 160 certified beds · (845) 486-9494 Medicare & Medicaid certified

Call the home — (845) 486-9494 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 20252 actual-harm citations
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — 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
696 Dutchess Tpke · (845) 463-2896 · Call to confirm hours
Pharmacy
827 Dutchess Tpke · (845) 486-4041 · Call to confirm hours
Grocery
25 Eastdale Ave N · (845) 795-8099 · Call to confirm hours
Park
25 Caroline Ave · (845) 485-3628 · 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 5 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased19.1%14.1%15.4%worse
Long-stay residents who lose too much weight7.0%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.5%0.9%better
Long-stay residents with a urinary tract infection2.0%1.3%2.0%typical
Long-stay residents with depressive symptoms0.5%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.2%3.1%3.3%better
Long-stay residents whose ability to walk worsened23.9%12.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.1%13.2%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers4.1%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control27.8%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.6%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 vaccine98.5%78.8%79.4%better
Short-stay residents rehospitalized after admission23.4%20.6%22.6%typical
Short-stay residents with an outpatient ER visit4.7%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.111.701.67worse
Long-stay outpatient ER visits per 1,000 resident days0.781.361.80better

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.

62.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 557 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.0%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
60.3%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 60.3% 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 305 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 0.36 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF62.0%CMS range 57.8–65.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.8–14.410.7%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 discharge60.3%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 discharge59.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.3%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 identified99.5%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 setting92.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.0%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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%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 hospitalization7.1%CMS range 5.4–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 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

0.45
RN hours/ resident / day
1.25
LPN hours/ resident / day
2.36
Aide hours/ resident / day
4.06
Total nurse hours/ resident / day
0.33
RN hoursweekends
31.9%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 160 beds and averages 142.1 residents a day — about 89% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.68 hrs/resident/day on weekends vs 4.21 on weekdays — 12% thinner on weekends. RN hours go from 0.49 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2024-02-06)
4
at the previous standard inspection (2021-04-16)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited before2026-04-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during survey, the facility failed to ensure each resident received adequate supervision and consistent with resident needs to prevent accidents for two (2) of four (4) residents (Resident #9, Resident #8) reviewed for accidents. Specifically, on 03/25/2026, Resident #9 left the facility though an alarmed fire door, staff did not respond for over three (3) minutes to the alarm, and the resident fell in the parking lot and was found bleeding with abrasions to their forehead, nose and knees. 2) Resident #8 was at high risk for falls and care planned to be in the dining room in view of staff. On 04/07/2026, the resident fell in the dining room and sustained a large bump on the forehead while the certified nurse aide providing supervision was looking at their phone and out the window. This resulted in actual harm to Resident #8 and #9 that was not Immediate Jeopardy. Findings include: The facility policy Elopement / Wandering, last reviewed 12/2025,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-12-26 · 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 interviews, the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (1) out of three (3) residents (Resident #1) reviewed for pressure ulcers. Specifically, on 08/20/2025, Resident #1 was assessed as having a blanchable area of moisture associated skin damage to their coccyx/buttocks, was dependent for bed mobility, had no interventions implemented and was later diagnosed with an unstageable pressure ulcer. Additionally, Resident #1 had functional limitations with an order to have their feet offloaded while in bed, which was not consistently done resulting in a deep tissue injury to the resident's right heel. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are:The facility Pressure related Injury Prevention and Treatment and Wound Management…

    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 · E2026-04-14 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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, interviews, and record reviews during the survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of three (3) residents (Resident #147) reviewed for Urinary Tract Infection, one (1) of three (3) residents (Resident #13) reviewed for Position/Mobility, and one (1) of one (1) resident (Resident #12) reviewed for Anticoagulation. Specifically, 1) Resident #147 was exhibiting symptoms of a urinary tract infect, urine samples for testing were not collected as ordered and the antibiotic was started prior to the sample collection; 2) Resident #13 was evaluated and waiting for a fitting for new orthotics which was delayed due to untimely follow up by the facility; 3) Resident #12 refused to continue their anticoagulant. There was no documented evidence that education was provided on the possible effects of discontinuation, or that 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 · D2025-12-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (2625335), the facility did not ensure assessments accurately reflected the resident's status for 1 out of 3 residents (Resident #1) reviewed for assessments. Specifically, Resident #1 had a Physical Therapy evaluation in the facility on 08/22/2025 and was found to require maximum assistance for bed mobility. However, an admission Minimum Data Set, dated [DATE] documented Resident #1 as dependent for bed mobility on their functional assessment. The findings are: The facility did not have a policy related to the Minimum Data Set assessment.Resident #1 was admitted with diagnoses including but not limited to Dementia, Unspecified Intracapsular fracture of right femur and Type 2 Diabetes Mellitus. An Admission/Medicare 5 Day Minimum Data Set, dated [DATE] documented Resident #1 had severe cognitive impairment. The resident had impairment to the lower extremity on one side and required a walker or a wheelchair for locomotion. The resident required…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-26 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during an abbreviated survey (2625335), the facility administrator did not ensure they used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, during an abbreviated survey, the facility did not provide requested facility policies to the Surveyor on-site. The Director of Nursing stated there is no documented facility policy for the following: Braden scale assessments, skin observation, admission assessments or a Minimum Data Set Assessment policy.The findings are: During an interview on 10/9/2025 at 1:00 PM, the Director of Nursing stated they do not have a policy related to Braden scale assessments and it is a Corporate issue. The Director of Nursing stated they are doing their best and will try to address all these issues brought up during the onsite survey. The Director of Nursing stated the facility does not have a skin observation policy or an admission assessment policy. They were not sure if the facility has a minimum data set…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-23 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record reviews, and interviews during an abbreviated survey (NY00345910, NY00358013), the facility did not ensure the residents right to be free from abuse for 2 out of 3 residents (Residents #1 & #3) reviewed for abuse. Specifically, (1) on 6/19/2024, Certified Nurse Assistant #1 was observed on video surveillance engaging in a verbal altercation with Resident #1 and taunting them in the dining room. Certified Nurse Assistant #1 was also observed engaging in a shoving match at a table in the dining room with Resident #1. Resident #1 and Certified Nurse Assistant #1 later engaged in a physical altercation at the nurse's station where Resident #1 was seen grabbing Certified Nurse Assistant #1 by their shirt and Certified Nurse #1 and Resident #1began tussling; (2) on 10/4/2024, Resident #3 reported Physical Therapy Assistant #2 was verbally aggressive with them causing them to lose sleep and endure psychological distress requiring antianxiety medication intervention. The findings are: The facility Abuse Prohibition Protocol last revised 3/2024 documented each…

    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 · Ecited before2025-01-23 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during an abbreviated survey (NY00345910, NY00333580, NY00358013) the facility did not ensure the report of the results of an investigation to the New York State Department of Health in accordance with State law within 5 working days of the incident or report an allegation of abuse within the regulatory timeframe for 3 of 4 residents (Resident #1, #2, #3) reviewed for abuse. Specifically, (1) On 6/19/2024 Certified Nurse Assistant #1 was observed on video surveillance engaging in a verbal altercation and the pushing and pulling of a table back and forth with Resident #1. Review of the 5-day investigative conclusion submission revealed it was not submitted to the New York State Department of Health until 7/25/2024; (2) On 2/13/2024 Resident #2 reported alleged inappropriate contact by Certified Nurse Assistant #3. Review of the 5-day investigative conclusion submission revealed it was not submitted until 3/6/2024; (3) On 10/6/2024 Resident #3 reported to the social worker that Physical Therapy Assistant #2 spoke to them in a manner 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · 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 observations and interviews during an abbreviated survey (NY00333580), the facility did not ensure that each residents had the right to a dignified existence and each resident was cared for in a manner and environment that promoted maintenance or enhancement of their quality of life. This was evident for 1 of 3 residents (Resident #4) reviewed for dignity. Specifically, during an observation on Unit 1 South on 1/6/2025 Certified Nurse Assistant #2 was standing over Resident #4 while assisting them with their meal in the alcove in the hallway. The findings are: The facility Resident Rights policy last revised 9/2024 documented the facility strives to make sure that each resident is afforded a dignified existence, is treated with respect and dignity, and receives care in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life. Resident #4 admitted to the facility on [DATE] with diagnoses including but not limited to Schizoaffective Disorder, Unspecified…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during an abbreviated survey (NY00345910, NY00358013), the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 2 out of 3 residents (Resident #1, #3) reviewed for care planning. Specifically, (1) On 6/19/2024 Certified Nurse Assistant #1 was observed on surveillance footage engaging in a verbal altercation and taunting Resident #1. Certified Nurse Assistant #1 and Resident #1 then engaged in a physical tussle at the nurse's station. Review of Resident #1's care plans revealed they did not have an abuse, victim, or potential victim care plan initiated until after the incident on 6/19/2024; (2) Resident #3 reported that on 10/4/2024 they had a verbal altercation with Physical Therapy Assistant #2 which led them to become angry and suffer mental anguish. Review of Resident #3 care plans revealed they did not have a risk to be victimized care plan before and after the verbal…

    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 before2024-02-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity in an environment that promotes maintenance of their quality of life for 2 of 4 residents (Residents #49, and #116) reviewed for dignity. Specifically, 1. Resident #49 was observed on several occasions wearing a food-stained gown; 2. signs that were visible to staff and visitors detailing how to feed Resident #116 were placed above the bed. The findings are: The facility policy titled Resident Rights and revised 11/2023 documented the facility strives to make sure each resident is afforded a dignified existence, is treated with respect and dignity and receives care in a manner and environment that promotes maintenance or enhancement of his/her quality of life. 1. Resident #49 was admitted to the facility and had diagnoses including but not limited to multiple sclerosis, rheumatoid arthritis, and hypothyroidism. The 12/5/23 Minimum Data Set…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during the recertification survey process from 1/30/2024 through 2/6/2024, the facility did not ensure that all alleged violations involving abuse were reported no later than 24 hours even if the events did not result in serious bodily injury, to other officials (including to the State Survey Agency) in accordance with State law through established procedures. Specifically, the facility did not report 3 resident-to-resident altercations involving Resident #126 as the victim. Findings include: Resident #126 was admitted to facility with the following diagnoses and conditions: schizoaffective disorder, unspecified intellectual disability, and suspected adult neglect or abandonment. The 10/25/23 quarterly minimum data set (MDS, an assessment tool) documented Resident #126's cognitive skills for daily decision making were severely impaired and displayed other behaviors such as hitting/scratching self, pacing and disrobing in public. The accident/incident report dated 8/14/23 documented Resident #126 was in their wheelchair in the hallway…

    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 before2024-02-06 · 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 observations, interviews, and record reviews conducted during the recertification and abbreviated surveys (NY00326854), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two of three residents (Resident # 24 and #62) reviewed for accidents. Specifically, 1. staff did not ensure that Resident #24 received the correct meal texture based on physician order; and 2. the plan of care for Resident #62 was not implemented resulting in the resident sustaining a fall with major injury. The findings are: The revised 9/2023 policy entitled, Feeding-at Risk Residents, documented that assigned staff were to distribute trays and verify all food and liquids provided matched the meal ticket to ensure correct diet and food consistency. The education hand-out entitled, Proper distribution of Meal Trays and Set Up for Residents, directed nurse to check and compare consistency of meal to the meal ticket included before tray served. 1. Resident #24…

    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 11 citations
  • Potential for harm · Dcited before2024-02-06 · 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 observations, record review and interviews on a recertification survey 01/30/24-02/06/24 the facility did not ensure that drugs and biologicals were stored in locked compartments under temperature controls, and only permitted authorized personnel to have access to the keys. Specifically, 8 blister packs of medicines were left on a table in the manager's unlocked office on a unit with wandering residents. The findings are: The facility policy titled storage of medications dated 04/2023 documented medications are stored at proper temperatures and locked at all times, except when under direct supervision of staff. An observation was made on 02/1/24 in the Staff #27 (Registered Nurse Unit Manager), unit office located across from the nurses station which was accessed by Staff #27 without the use of keys or codes and found to be unlocked. On a small table in the room was a stack of 8 blister packs of pills. During an interview on 2/1/24 with Staff #27 they confirmed the office door was unlocked but stated they usually lock the door. Staff #27 stated the meds were from a 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview conducted during a recertification survey and abbreviated survey (NY00324752), the facility did not ensure that food contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with standards for food service safety. Specifically (1) dirty and dusty fan blowing on clean dishes that were drying, (2) ovens and stove had caked on particles and grease, (3) dirty and dusty ceiling tiles and vents with dark markings on them, and (3) kitchen had a foul odor. Chapter 1 Sub-Part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated; non-food contact surfaces are to be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris; and all equipment and utensils are to be air dried after sanitizing. The findings are: During tour of kitchen on 2/01/24 at 2:35 PM, the kitchen was noted to have a foul smell, a dirty/dusty fan was blowing on clean drying dishes, stove 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · 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 interviews during the recertification survey 1/30/24-2/6/24, the facility did not ensure that staff maintained 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. Specifically, staff were observed handling clean linen on a cart with dirty gloves in 2 of 3 rooms, clean PPE (personal protection equipment) carts were located on the inside of contact isolation rooms. The findings are: The facility policy titled Infection Prevention and Control Program revised 11/2023 documented the facility's primary goal is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of communicable diseases and infections. During observation on 02/02/24 at 01:18 PM Staff#22 (Certified Nurses Assistant) came out from room N 103 and with gloves on hands grabbed towels from the clean linen cart and brought…

    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 · D2024-02-06 · 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 01/30/24-2/6/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #49) reviewed. Specifically, there was no documented evidence Resident #49 was offered, declined, or educated on the pneumococcal immunization. Findings include: The facility policy titled Pneumococcal Vaccine last revised 11/11/2023, documented the facility will provide pneumococcal vaccination for all residents who are identified at risk for developing pneumococcal pneumonia and related complications. Resident #49 had a diagnoses history including hypothyroid, hemiparesis, and depression. The 12/05/2023 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, the pneumococcal vaccine was not up to date and not offered by the facility. There was no documented evidence that 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 · D2024-02-06 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview during the recertification survey and abbreviated survey (NY00324752) the facility did not ensure that essential equipment was maintained in safe operating condition. Specifically, there were missing floor tiles located in the kitchen on the floor by the 3-bay sink around the grease trap and water was noted pooling in this area that measured approximately 36 x 12. The findings are: During observation of the kitchen on 1/31/2024 at 11:00 AM, there were missing floor tiles located on the floor by the 3-bay sink around the grease trap and water was noted pooling in this area that measured approximately 36 x 12. This measurement was provided by the Food Service Director. Further observation revealed that the drain under the 3-compartment sink overflowed, and the water traveled from the crevice of a floor tiles to the larger area where the missing floor tiles were located above the grease trap. It was also noted that there was a missing floor tiles under the first sink compartment of the 3 bay sink and water was observed pooling in this area, and…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review conducted during a Recertification Survey, the facility did not ensure that investigation results of all alleged violations involving misappropriation of property are reported within a timely manner to the New York State Department of Health (NYSDOH). This was evident in 3 out of 5 residents reviewed for personal property (Residents #73, #83 and #286). Specifically, the facility failed to report to the NYSDOH a pattern of misplacing/theft upon discovery and/or after investigating 1) Resident #73's missing necklace, 2) Resident #83's missing rings and 3) Resident #286's missing Grand-Pad within 24 hours. The findings are: The facility Policy and Procedure titled, Abuse Prohibition Protocol with an effective date of [DATE] stated that each resident has a right to be free from misappropriation of property. Misappropriation of resident property was defined as the theft, unauthorized use or removal or embezzlement of a resident's personal property, including but not limited…

    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 before2021-04-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews during a Recertification Survey, the facility did not ensure that resident Comprehensive Care Plans (CCP) were reviewed and revised to meet resident needs consistent with their rights. This was evident in 2 of 5 residents reviewed for personal property (Resident #73 and Resident #83). Specifically, Residents #73 and #83 had no documented evidence of person-centered goals or appropriate interventions specific to missing personal property in the facility. Resident #73 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses including COVID-19, Cerebrovascular disease, and Dementia. The Minimum Data Set (MDS; a resident assessment tool) dated 3/1/2021 documented a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severely impaired cognition. Review of a CCP dated 1/29/2021 documented that Resident #73 had Cognitive Deficits related to Dementia Progression. There was no documented evidence of person-centered goals and an appropriate…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 that catheter care was provided in accordance with professional standards of care. This was evident for 1 of 1 residents (Resident #97) reviewed for urinary catheter. Specifically, Resident #97 had no order for foley catheter care after readmission on [DATE] which resulted in the treatment not being rendered for 3 days. The findings are: Resident #97 is a [AGE] year old, readmitted from the hospital on 4/5/2021 with diagnoses including Sepsis due to Urinary Tract Infection (UTI), Acute Kidney Failure, Chronic Kidney Disease, Retention of Urine and Calculus of Kidney. The admission MDS (Minimum Data Set; a resident assessment and screening tool) dated 3/16/2021 documented that Resident #97 had severely impaired cognition skills for daily decision making. Resident #97 also required extensive two-person assistance with bed mobility and toilet use. The resident was totally dependent on two-person assistance 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a Recertification Survey, the facility did not ensure that all medications were stored in accordance with manufacturer's specifications and standards of practice. Specifically, in 1 of 4 medication rooms reviewed for medication storage on [DATE] (2 South), a multiple dose vial of Lantus Insulin was observed to be dated as opened on [DATE]. The findings are: An observation of medication storage was conducted in the 2 South unit's medication room on [DATE] at 10:15AM. Inside the refrigerator was an opened, multiple-dose vial of Lantus Insulin marked house stock. The vial was dated as opened on [DATE]. The manufacturer's website recommends that once the Lantus Insulin is opened, the discard date is 28 days after it was opened when stored refrigerated or at room temperature. The Facility policy and procedure on Injectable Medications, revised on [DATE] documented that medication in multidose vials may be used (until the manufacturer's expiration date…

    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 before2020-02-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview conducted during the recertification survey, the facility did not ensure that 3 of 3 residents reviewed for dignity were provided care in a manner that promoted each resident's dignity. Specifically, urinary drainage bags were not concealed to prevent direct observation by visitors, staff and other residents. (Residents #37, 82, and 125.) The findings are: Resident #37 was admitted with diagnoses including Urinary Tract Infections, Diabetes Mellitus and Heart Failure. During resident screening at 10:00 AM on 2/3/2020 Resident #37 was observed in her room in bed with her urinary drainage bag attached to the bedside, uncovered and visible to all who passed the room. Resident # 125 was admitted with diagnoses including Hypertension, Neurogenic Bladder and Diabetes Mellitus. The resident was observed multiple times in bed during the survey with an uncovered urinary bag, attached to the rail of the bed, facing the door. The urinary drainage bag was hanging from the bed facing the door filled halfway with urine. In an interview with the Licensed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2020-02-07 · tag F0623 — pattern
    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 conducted during the recertification survey, the facility did not ensure that written notices were sent to families or their representatives regarding transfer/discharge to the hospital or the reasons for the transfer/discharge. This was evident for 3 of 3 residents reviewed for hospitalization (Residents #66, #82, #62). The findings include but are not limited to the following: 1. Resident #66 was admitted on [DATE] with diagnoses including Alzheimer's disease, unspecified dementia and chronic kidney disease. Review of the resident's medical record revealed on 01/15/20, the resident was transferred to the the hospital emergency room due to a change in mental status, in addition to symptoms of fever, nausea and vomiting. The resident's family was informed via telephone by nursing staff that the resident was being transferred to the hospital. There was no documentation that a written notice or the reasons for the resident's transfer was sent to the family. 2. Resident #82 was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
EISGRUBER, JOHNAIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 01/01/2017
FELLEGARA, LARAINEIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 02/01/2018
LUDINGTON, PATRICIAIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 02/01/2018

CMS files one row per role, so the 6 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$20.8M
Net patient revenuemost recent cost report
-5.6%
Operating marginrevenue minus expenses
$858K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 17%Other / private 27%

This home reported $858K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$412per resident / day
operating cost
$12,537per month
≈ monthly operating cost
$391per 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 335810. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-06, 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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