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St. John's Health Care Corporation

150 Highland Avenue, Rochester, NY 14620 · For profit - Corporation · 455 certified beds · (585) 760-1300 Medicare & Medicaid certified

Call the home — (585) 760-1300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 2025Resident-funds citation (F0565)3 actual-harm citations$141,034 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $141,034 in federal fines (most recent 2025-06-09)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 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
1732 South Ave · (585) 461-0410 · Call to confirm hours
Pharmacy
Grocery
249 Highland Ave
Park
1320 South Ave · Typically dawn to dusk
Place of worship
65 Highland Ave · (585) 473-6893

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 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 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased30.7%14.1%15.4%worse
Long-stay residents who lose too much weight8.7%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.5%0.9%better
Long-stay residents with a urinary tract infection2.6%1.3%2.0%worse
Long-stay residents with depressive symptoms4.7%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.2%0.2%0.1%worse
Long-stay residents with falls causing major injury4.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened28.7%12.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication7.1%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine92.5%95.3%95.3%typical
Long-stay residents with pressure ulcers7.0%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control32.6%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.8%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine48.5%78.8%79.4%worse
Short-stay residents rehospitalized after admission16.6%20.6%22.6%better
Short-stay residents with an outpatient ER visit5.7%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.011.701.67better
Long-stay outpatient ER visits per 1,000 resident days0.841.361.80better

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.

56.4% 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 200 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.4%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
54.0%U.S. median 56.6%
Met the expected recovery
0.09U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 54.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 148 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% 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 SNF56.4%CMS range 49.3–63.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 8.5–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge48.0%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 discharge60.1%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 identified79.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.7%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 worsened6.9%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 hospitalization7.7%CMS range 5.3–12.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.611.02Oct 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

0.65
RN hours/ resident / day
1.31
LPN hours/ resident / day
2.28
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.42
RN hoursweekends
46.8%
Total nursing turnover
46.9%
RN turnover

How full it usually is: this home is certified for 455 beds and averages 337.7 residents a day — about 74% occupied, or roughly 117 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.83 hrs/resident/day on weekends vs 4.41 on weekdays — 13% thinner on weekends. RN hours go from 0.75 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% 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 (2025-06-09)
11
at the previous standard inspection (2023-12-13)

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.

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-06-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (3) (Residents #120, #213 and #222) of seven (7) residents reviewed. Specifically, Resident #120 was observed with debris underneath multiple fingernails and eating food items with their hands. Resident #213 was observed over several days with greasy hair and the facility was unable to provide evidence of the resident getting their hair washed for the prior month. Resident #222 was observed with untrimmed overgrown mustache hair going into their mouth which they reported made them feel shameful about themselves and did not want visitors to see them in that state. This resulted in actual psychosocial harm to Resident #222 that was not immediate jeopardy. The findings include: The facility policy…

    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 · G2025-06-09 · 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 observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure residents with indwelling urinary catheters (a tube inserted into the bladder to drain urine) received the care and services to manage the urinary catheter for two (2) (Resident #112 and #222) of four (4) residents reviewed. Specifically, Resident #112 had a urinary catheter that was not consistently secured to prevent tension resulting in a genital injury. Additionally, Resident #112's Comprehensive Care Plan did not include the presence of a urinary catheter or interventions for appropriate care of the urinary catheter to prevent complications. Resident #222 had a urinary catheter that was observed not secured appropriately to prevent complications. Additionally, the urinary catheter drainage bag (a collection bag attached to the catheter that the urine drains into) was observed on multiple occasions lying on the floor without a barrier. This resulted in…

    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 · G2023-12-13 · 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 observations, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00300345) from 12/6/23 to 12/13/23, for three (Residents #90, #108 and #183,) of six residents reviewed for pressure ulcers, the facility failed to ensure the residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, the facility did not consistently provide Residents #90, #108 and #183 with physician-ordered treatments for skin impairments and/or care plan interventions. This resulted in actual harm to Resident #90 that is not Immediate Jeopardy. This is evidenced by the following: The facility policy Wounds: Pressure Ulcer Care, dated August 2023, documented that all residents admitted without a pressure ulcer will receive preventative care according to their documented Braden Scale (an…

    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 · E2025-06-09 · tag F0554 — pattern
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, for one (1) (Resident #28) of one (1) resident reviewed, the facility did not ensure the interdisciplinary team determined the resident's right to self-administer medications was clinically appropriate. Specifically, there were multiple observations of unsecured medications left at Resident #28's bedside and the resident had not been assessed for their ability to self-administer medications. Additionally, there was no medical order or comprehensive care plan in place to address the self-administration of medications. The finding is: The facility policy Self-Administration of Medications, last reviewed 10/07/2008, included residents may self-administer medication when it has been determined by the interdisciplinary care team that the practice is safe. The interdisciplinary team will meet to determine the safety and appropriateness of the resident to self-administer medication. The physician writes an order for self-administration. The nurse will take 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification Survey and complaint investigations (NY00352162 and NY00356860) from 06/02/2025 to 06/09/2025 for 6 (Residents #23, #27, #93, #210, #313, #721) of 14 residents reviewed, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, Resident #23 and #721 both had multiple unwitnessed falls including one with a major injury. Resident #27 had multiple bruises on their face of unknown origin. Resident #210 was observed by staff engaging in potential sexual abuse towards Resident #93. Resident #313 had an unwitnessed fall with a major injury and subsequently passed away within two (2) days. None of the identified incidents had been reported to the New York State Department of Health. The findings include but not limited to: The facility policy Abuse Prevention and Incident Investigation, dated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-09 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification Survey and complaint investigations (NY00352162 and NY00356860) from 06/02/2025 to 06/09/2025 for 4 (Residents #23, #27, #313, #721) of 14 residents reviewed, the facility did not ensure that incidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, the facility was unable to provide documented evidence (including statements from all involved staff members or potential witnesses) that the following incidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. Residents #23 and #721 had multiple unwitnessed falls with one fall resulting in a major injury for each resident. Resident #27 had multiple bruises to their face of unknown origin. Resident #313 had an unwitnessed fall with a hematoma (bleeding and swelling under the skin) to their forehead and subsequently passed away within two (2) days. The findings include: The facility policy Abuse Prevention and Incident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-09 · 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 observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure that person-centered comprehensive care plans were developed and/or implemented to address the resident's medical, physical, mental, and psychosocial needs for 7 (Residents #10, #110, #112, #122, #127, #199, and #236) of 40 residents reviewed. Specifically, Resident #10 had a diagnosis of diabetes and the comprehensive care plan did not include measurable goals or interventions related to diabetes. Resident #110 had a history of post-traumatic stress disorder, a history of suicide attempts, and a history of falls with injuries. The comprehensive care plan did not include measurable goals and interventions related to post-traumatic stress disorder, a history of suicide attempts, or falls. Resident's #112 had current pressure ulcers, a seizure disorder, a diagnoses of deep vein thrombosis (blood clot) requiring injectable anticoagulant (blood thinner)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure that all drugs and biologicals were stored and/or labeled in accordance with currently accepted professional principles and regulations for six (6) of nine (9) medication carts and two (2) of six (6) medication rooms reviewed. Specifically, on Reservoir Three residential unit, there were pre-poured unlabeled medications for multiple residents and multiple unlabeled loose pills inside several medication carts, multiple medication cups containing several pills and medication creams left on top of the unsupervised medication cart, and the medication cart keys were left on top of the cart unattended. Additionally, there were expired medicated dressings in the Reservoir Three medication storage room. On Reservoir Five Unit, there was a narcotic medication stored in the top drawer of the medication cart (under one lock versus two). On [NAME] Two Unit, there was a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025 for 8 (Reservoir 3rd, 5th, and 6th floors, [NAME] 1st floor, and South 2nd, 3rd, 5th, and 6th floors) of 20 resident use floors, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were dirty microwaves, a dirty refrigerator, outdated milk cartons, and a potentially hazardous food was not held at proper temperatures. The findings are: During an observation on 06/02/2025 at 9:20 AM, the interior of the microwave in the Reservoir 6th floor dining room was heavily soiled with food debris, crumbs, and splatter. During an immediate interview the Facilities Director stated that they think environmental services were supposed to clean them (the microwave). During an observation on 06/02/2025 at 10:00 AM, the interior of the microwave in the Reservoir 5th floor dining room was heavily soiled with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025 for one (1) (Resident #61) of 32 residents reviewed for dining, the facility did not ensure residents were treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life. Specifically, Resident #61 was observed having their blood sugar (measuring the amount of sugar in a blood sample from a finger-prick) tested and received an insulin injection and medications in the dining room with several residents, staff, and visitors present. The finding is: Resident #61 had diagnoses including diabetes, end stage renal (kidney) disease, and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Minimum Data Set (a resident assessment tool), dated 05/23/2025, documented the resident was cognitively intact and received daily insulin injections. During an observation and interview on 06/04/2025 at 11:57 AM, Registered Nurse #6 entered…

    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 · D2025-06-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, it was determined for 1 (Resident #120) of 32 residents reviewed for dining and 1 (Resident #222) of 2 residents reviewed for call bell accessibility, the facility did not ensure that a resident received services with reasonable accommodation of the resident's needs and preferences. Specifically, Resident #120 who was visually impaired reported to facility staff they needed assistance during meals. The resident was observed eating independently and there was no documented evidence the facility followed-up with the resident's request. Resident #222 was observed on several occasions without their call device within reach. The finding is: 1. Resident #120 had diagnoses including glaucoma (disease of the eye that can cause blindness), dysphagia (difficulty swallowing), and disorientation. The Minimum Data Set (a resident assessment tool), dated 04/21/2025, revealed Resident #120 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
  • Potential for harm · D2025-06-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #24) of four (4) residents reviewed for catheters. Specifically, there was no documented evidence that care of Resident #24's nephrostomy tube (tube inserted directly into the kidney through the skin to drain urine) was completed as ordered by the medical team. The findings include: The facility policy Nephrostomy Tube Care dated 06/09/2023, included irrigation of a nephrostomy tube could only be performed by a registered nurse, and to document the amount and type of liquid used and whether or not a complete return (of instilled fluid) was obtained. Resident #24 had diagnoses including chronic kidney disease, aphasia (a communication disorder that affects a person's ability to speak, understand, read, and write), and renal calculus (kidney stones). The Minimum Data Set (a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, for one (1) (Residents #2) of one (1) resident reviewed, the facility did not provide special eating equipment for a resident who required it to maintain or improve the resident's ability to drink independently. Specifically, Resident #28 was observed on multiple occasions without their two-handled cup as recommended by Occupational Therapy. The resident said it was difficult for them to consume beverages without it. The finding includes: An undated facility policy, Tray Line Procedure documented in part meal service will be changing to a tray line system. All food will be prepared and plated in the main kitchen, then sent up on trays to be distributed to the residents. It will be the responsibility of nursing staff to pass the meal trays and help with meal set up, including opening containers for drinks and pouring into cups as needed. If adaptive equipment is missing, call the kitchen to ask for the missing piece of equipment. If the kitchen does not have…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-06-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) (Residents #112) of four (4) residents reviewed. Specifically, Resident #112 did not have Enhanced Barrier Precautions (EBP, techniques used to prevent transmission of infectious diseases utilizing gloves and gowns with all high contact care) signage outside their room and staff were observed providing hands on care without the appropriate personal protective equipment (gowns). Additionally, several infection prevention and control related policies, including the enhanced barrier precautions and Infection Control Surveillance plan were not reviewed annually per the regulation. The finding includes: The undated facility policy Enhanced Barrier Precautions (Currently Under Review) documented enhanced…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey from 12/6/23 to 12/13/23, it was determined that for eight of nine medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws. Specifically, multiple loose unlabeled pills were observed in the drawers of several medication carts ([NAME] 1, [NAME] 2, [NAME] 3 and Reservoir 6 cart 1) and medications were observed unlabeled and/or expired ([NAME] 1, Reservoir 4, Reservoir 5 and Reservoir 6 cart 2). The evidence included but not limited to the following: The facility Policy Medication Administration, dated reviewed 6/1/23, documented that the medication pouches will include the name and description of each medication included in that pouch, along with the full directions for use and the expiration date, do not use medication from an unmarked or poorly labeled bottle or container, the nurse is to check the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey completed 12/6/23 to 12/13/23, it was determined that for one of one main kitchen, and five (Reservoir fifth and sixth floors, [NAME] first and second floors, and South third floor) of twenty resident use floors, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, potentially hazardous foods were not cold held at or below 45 degrees Fahrenheit (°F), potentially hazardous foods were not properly cooled, there were undated and unlabeled food items, and a freezer had a significant buildup of ice. The findings are: The undated facility policy titled 'Resource: Food Safety for Your Loved One' included the following: If you plan to bring food into the facility for your loved one, please be sure that the food is handled safely. Food or beverages should be labeled and dated to monitor for food safety. Food or beverage items without…

    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 · E2023-12-13 · 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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey completed 12/6/23 to 12/13/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide (CO) detection in a building that has fuel-burning appliances. The findings are: Record review on 12/8/23 at 11:35 AM revealed a list of facility carbon monoxide detectors within the facility was provided to the surveyor by the Director of Facilities (DF). The list of the locations of the carbon monoxide detectors were as follows: 1) [NAME] basement hallway by laundry, 2) [NAME] basement hallway between parts room doors, 3) Reservoir basement between two boiler room doors, 4) Reservoir first floor cafeteria by emergency exit, 5) East end hallway of second floor Reservoir building, 6) Ground floor South…

    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 · D2023-12-13 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during a Recertification and complaint investigation (#NY00305787) completed 12/6/23 to 12/13/23, it was determined that for two (Residents #62 and #235) of five residents reviewed for dignity, the facility did not ensure that the residents were treated in a respectful and dignified manner. Specifically, Resident #62 was observed walking on the unit completely naked from the waist down with several other residents and multiple staff members in the vicinity and Resident #235 was observed to have multiple different pureed foods mixed together for their meal and fed to them by staff. This is evidenced by the following: 1.Resident #62 had diagnoses including dementia with behavioral disturbances a history of falls, anxiety, and depression. The Minimum Data Set (MDS) Assessment, dated 11/7/23, documented the resident had severe impairment of cognitive skills and required partial assistance with dressing. Review of the current Comprehensive Care Plan (CCP)…

    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 · D2023-12-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey 12/6/23 to 12/13/23, it was determined that for 4 (South 3, South 4, Reservoir 4, Reservoir 6) of 11 resident care units reviewed, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, multiple resident wheelchairs, sit-to-stand lifts (assistive standing device), a shower mat, a resident reclining chair, and a dining room floor were observed soiled. This is evidenced by the following: During multiple observations on South 4 day shift on 12/6/23, 12/7/23, 12/8/23, 12/11/23 and 12/12/23 four wheelchairs, all occupied by residents had multiple dried food debris visible on them over three and four days. During observations on 12/6/23 at 9:40 AM on Reservoir 6, a shower mat on top of a wheeled stretcher located in the shower room near resident room [ROOM NUMBER] was soiled. The underside of the mat had a brown smear…

    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 · D2023-12-13 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews conducted during the Recertification Survey 12/6/23 to 12/13/23, it was determined that for two (Residents #99 and #182) of five residents reviewed for Minimum Data Set (MDS) Assessments (a mandated resident assessment tool) the facility did not assess the residents, using the Centers for Medicare and Medicaid Services (CMS) specified quarterly review assessment, no less than once every three months, between comprehensive assessments. Specifically, quarterly MDS Assessments were not completed within 92 calendar days from the prior MDS Assessment for both residents. Additionally, Resident #99's comprehensive MDS Assessment was also not completed in the required time frame. This is evidenced by the following: The Long-Term Care Facility Resident Assessment Instrument 3.0 Version 1.18.11 dated October 2023 included that a facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than every 3 months. 1.Resident #99 had diagnoses including diabetes, cerebral vascular accident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · 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 observations, interviews, and record review conducted during a Recertification Survey from 12/6/23 to 12/13/23, it was determined for two (Residents #48 and #52) of four residents reviewed for care planning related to respiratory care, the facility did not develop and/or implement a comprehensive, person-centered care plan for each resident that included services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as related to the need for respiratory care. Specifically Resident #48's Comprehensive Care Plan (CCP) did not include measurable goals, outcomes, and interventions for management of a tracheostomy (a surgically created hole in the windpipe that provided an alternative airway for breathing). Resident #52's CCP did not include measurable goals, outcomes, and interventions for use of oxygen (O2). This is evidenced by the following: 1.Resident #48 had diagnoses that included chronic respiratory failure (a long-term condition when the body does…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigations (#NY00300019 and #NY305787) 12/6/23 to 12/13/23, it was determined that for three (Resident #84, Resident #90 and Resident #183) of nine residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary services to maintain grooming/personal hygiene, toileting and repositioning. Specifically, Resident # 84 did not receive assistance with removing facial and ear hair. Resident # 90 did not receive timely incontinence care, turning and positioning, and Resident #183 did not receive nail care. This is evidenced by the following: The facility policy Care: Standards of Care, dated last revised 8/22/23, included to shave men during morning care as per resident choice. Make a significant position change every two to four hours as per resident choice. Follow range of motion, position goals, and toileting times per care plan and Key to Care of our Elders, nail…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · 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, interviews, and record reviews conducted during a Recertification Survey from 12/6/23 to 12/13/23 it was determined for two (Resident #52 and #152) of four residents reviewed for respiratory care, the facility did not ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, goals and preferences. Specifically, Residents #52 and #152 were observed with dirty oxygen (O2) tubing and/or humidification bottles (water bottles attached to the concentrator to provide moistened oxygen) not changed according to the physician's orders, and multiple missing documentation that the oxygen was being administered and/or equipment changed as ordered. This is evidenced by the following: The facility policy, Oxygen: Oxygen Administration via O2 Cylinder or Concentrator (a medical device that delivers oxygen), last reviewed June 2022 included to ensure there was an order from the medical provider for O2 therapy, that masks and nasal…

    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 · D2023-12-13 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00300019) 12/6/23 to 12/13/23, it was determined that for one (Resident #83) of one resident reviewed, the facility did not ensure that the resident was free from significant medication errors. Specifically, the resident did not receive multiple medications on 12/10/23, which included (but not limited to) an anticoagulant or blood thinner used to prevent strokes, an antidepression medication used to treat insomnia or depression, a medication used to treat dementia or Alzheimer's disease and multiple prescription eye drops for glaucoma. This is evidenced by the following: The facility policy Medication Administration, dated last reviewed on 6/1/23, included that the nurse who prepares the medications is responsible for administering it to the resident, and that medications are to be administered within one hour before or after the scheduled administration time. Resident #83 had diagnoses…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-08 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record reviews conducted during the Recertification Survey and Complaint survey #NY00272037, completed on 11/8/21, it was determined that for one (Resident #155) of one resident reviewed for choices, the facility did not allow each resident the right to make choices about aspects of life that were significant to them. Specifically, the resident did not receive showers twice weekly per their plan of care and stated preference. This is evidenced by the following: Resident #155 had diagnoses including dementia without behavioral disturbance, intracranial injury, and overactive bladder. The Minimum Data Set Assessment, dated 9/2/21, revealed the resident was cognitively intact, required assistance with personal hygiene and bathing, was occasionally incontinent of bowel and bladder and had stated that type of bathing was very important to them. Review of the facility policy, Showers or Bath and Resident Choice, dated April 2021 directed staff that residents will be offered a choice of how many times per week, actual day, and type of bathing. The schedule will be…

    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 · D2021-11-08 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews conducted during the Recertification Survey completed on 11/8/21, it was determined that for one of one resident groups and one of one residents (Resident # 112) reviewed, the facility did not ensure that concerns and recommendations of the residents group relating to resident care and life in the facility were acted on promptly. Specifically, residents' voiced concerns in the Residents Council meeting and a formal written grievance submitted by Resident #112, included long call bell wait times, not being provided personal care, and not being gotten up in a timely manner were not investigated and/or addressed in a timely manner. This is evidenced by the following: The facility policy, Grievances: Complaints/Grievances, last revised July 2020, included: The Social Worker will complete the Social Work Report of the Resident Concern form. Once the form is completed, the Social Worker will notify the Neighborhood Administrator or Designee, Clinical Coordinator or Nurse Leader. Resolution will be sought with the neighborhood team and documented 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 · Dcited before2021-11-08 · 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 interviews, and record review conducted during the Recertification Survey completed on 11/8/21, it was determined that for one (Resident #55) of six residents reviewed the facility did not report incidents of resident-to-resident abuse to the State Agency per the regulations. Specifically, Resident # 55 was involved in multiple incidents of resident-to-resident altercations that were not reported to the New York State Department of Health (NYSDOH). This is evidenced by the following: The facility policy Abuse Prohibition, last revised March 2021, included that if after review of the information gathered during the in-house investigation the Director of Nursing (DON) and/or the Assistant DON (ADON) have reason to believe abuse, neglect or mistreatment had occurred then the DON or the ADON should submit an online report to the NYSDOH within two hours of making the determination. Resident to resident abuse must be reported according to the New York State Operations Manual. Resident #55 had diagnoses that included vascular dementia with behavioral disturbance, hypertension, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-08 · 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 observations, interviews and record review conducted during a Recertification Survey, completed on 11/8/21, it was determined for one (Resident #288) of two residents reviewed, the facility did not provide a program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of the resident. Specifically, there was no evidence of activities or psychosocial support for Resident #288 who was on isolation for COVID-19 infection. This is evidenced by the following: Resident #288 had diagnoses that included dementia, failure to thrive and COVID-19. The Minimum Data Set Assessment, dated 10/13/21, revealed the resident had severely impaired cognition, and activities of interest included music, going outdoors and being with groups of people. Review of the current Comprehensive Care Plan revealed approaches for activities that included the following: a. To inform the resident of activities of interest b. That faith is important to them c. Walking around the neighborhood and talking to others d.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY00277696), completed on 11/8/21, it was determined for two of six residents the facility did not ensure that the resident's environment was free from accident hazards and each resident received adequate supervision to prevent accidents. Specifically, Resident #55 eloped due to inadequate staff response and a system failure, and Resident #276's multiple falls were not thoroughly investigated in order to make appropriate interventions to prevent accidents. This was evidenced by the following: 1.Resident #55 had diagnoses that included vascular dementia with behavioral disturbance, repeated falls and a history of wandering. The Minimum Data Set (MDS) Assessment, dated 5/25/21, revealed Resident #55 had severely impaired cognition and that the resident wandered daily at that time but that the wandering did not place the resident at risk of getting into a potentially dangerous place (e.g., stairs, outside the facility.) The Comprehensive Care Plan (CCP), dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-06-09 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review conducted during the Recertification Survey from 06/02/2024 to 06/09/2025, the facility did not ensure that a representative of the Office of the State Long-Term Care Ombudsman (an official patient advocate not hired by the facility) was notified of resident transfers or discharges including the reasons for the move in writing and in a language and manner they understand for three (3) (Residents #112, #217, and #314) of four (4) residents reviewed for discharges. Specifically, the facility did not notify the Office of the State Long-Term Care Ombudsman of Residents #112 and #117's transfers/discharges to the hospital and Resident #314's discharge to the community. The findings are: The facility policy Admissions: Referral Evaluation, admission Process, Bed Holds and Re-Admissions, dated 03/19/2025, documented a Notice of Transfer/Discharge, Bed Hold Letter & Discharge Rights are all completed by Social Work and sent to the resident's financial representative, and a copy is placed in the resident chart. The policy did not include any notification…

    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

$141,034 in federal fines across 2 penalties.

  • $77,168 — penalty dated 2025-06-09
  • $63,866 — penalty dated 2023-12-13

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

Who owns this facility

Owner / managerTypeRoleSince
RUNYON, CHARLESIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 02/01/1993
BOEHNER, ROBERTIndividualCORPORATE DIRECTORsince 09/25/2007
DUMYATI, GHINWAIndividualCORPORATE DIRECTORsince 06/30/2021
HALEWSKI, HELENIndividualCORPORATE DIRECTORsince 06/30/2021
PETTINE, RAYIndividualCORPORATE DIRECTORsince 06/30/2021
SHUMWAY, BRIDGETIndividualCORPORATE DIRECTORsince 09/25/2007
WALLACE, WILLIAMIndividualCORPORATE DIRECTORsince 06/30/2021
ST JOHNS HEALTH CARE CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/02/2007

CMS files one row per role, so the 9 rows in the source record cover these 8 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$35.5M
Net patient revenuemost recent cost report
-14.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 67%Medicare 2%Other / private 30%

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

$382per resident / day
operating cost
$11,621per month
≈ monthly operating cost
$333per 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 335008. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-09, 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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