The Friendly Home
3156 East Avenue, Rochester, NY 14618 · Non profit - Corporation · 200 certified beds · (585) 381-1600 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.5% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.1% | 1.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.3% | 19.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.2% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.9% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.6% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.9% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 6.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.8% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.0% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.2% | 20.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 0.0% | 9.6% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 0.53 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.24 | 1.36 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
38.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 100 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.5% 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 40 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.0%CMS range 28.9–46.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.5–14.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 52.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 47.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 45.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 3.1–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.65 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 200 beds and averages 169.1 residents a day — about 85% occupied, or roughly 31 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 4.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above 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 3.75 hrs/resident/day on weekends vs 4.58 on weekdays — 18% thinner on weekends. RN hours go from 0.63 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% 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
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.
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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · E2025-12-19 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 12/11/2025 to 12/19/2025, it was determined that for one (Resident #61) of five residents reviewed, the facility did not ensure that PRN (as needed) orders for anti-psychotic drugs (medications used to treat symptoms of psychosis) were limited to 14 days. Specifically, there were several instances in which Resident #61 had as needed (PRN) Haldol (an antipsychotic medication) orders that exceeded the 14 day timeframe. Additionally, over several months, Pharmacist #1 identified through monthly Medication Regimen Reviews the Haldol orders and recommended they be reordered every 14 days. This is evidenced by the following: Resident #61 had diagnoses including dementia, depression, and anxiety. The Minimum Data Set (a resident assessment tool) dated 10/13/2025 revealed Resident #61 was severely impaired cognitively, was on hospice (specialized medical care for people nearing end of life), and received antipsychotic medications. The current Comprehensive Care Plan revealed Resident #61 was nearing end…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-19 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during a recertification survey from 12/11/2025 to 12/19/2025, for two (2) (Resident #33 and #140) of three (3) residents reviewed for respiratory care, and two (2) (Resident #6 and #88) of five (5) residents reviewed for drugs and medications, the facility did not provide services to meet professional standards of quality. Specifically, Resident #6 had physician's orders for blood pressure to be obtained prior to receiving blood pressure medication, and the facility could not provide documentation the blood pressure was consistently obtained prior to the administration of the medication per the medical order. Resident #33 and Resident #140 had reportable instances of high blood glucose, and the facility could not provide documentation a medical provider was notified per the medical order. Resident #88 had physician's orders for measuring blood glucose levels and obtaining blood pressure and pulse before administering blood pressure medication, 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.
- Potential for harm · Ecited before2025-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 review conducted during recertification and complaint (#2619460) surveys from 12/11/2025 to 12/19/2025, for three (3) (Resident's #85, #125, and #126) of ten (10) residents reviewed, the facility did not ensure the resident's environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, Resident #85 was observed over several days to have unopened wine bottles unsecured at their bedside, Resident #85 was not care planned for personal alcohol possession or consumption and there were other residents with wandering tendencies residing on that unit. In addition, Resident #125 had a right-sided transfer bar attached to their bed and a gap of approximately four (4) inches was observed between the transfer bar and mattress, concerning of a potential area of entrapment (where an individual can be caught between components of a bed). The facility could not provide…
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.
- Potential for harm · D2025-12-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 and interviews, for one (1) of one (1) resident reviewed (Resident #138), the facility failed to ensure the resident was treated with respect and dignity and cared for in a manner and environment that promotes the maintenance or enhancement of the resident's quality of life. Specifically, staff entered the resident's room without knocking or announcing their presence, failed to communicate with the resident during care interactions, and moved the resident's personal items without discussing the action with the resident.The findings include:The facility policy Resident Rights/Facility Responsibilities revised 05/30/2024 included, but was not limited to, the facility will treat each resident with respect and dignity, recognize each resident's individuality, and protect and promote the rights of the resident, including the right to participate in his or her treatment. Resident #138 had diagnoses that included Parkinson's disease, right femur fracture, and dysarthria (a motor speech disorder making it difficult to speak clearly) following a stroke. The Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 observations, interviews, and record review, review conducted during recertification and complaint (#2691821) surveys from 12/11/2025 to 12/19/2025, the facility failed to ensure residents were free of significant medication errors for three (3) of six (6) residents reviewed (Residents #33, #88, #154). Specifically, Resident #33 received insulin outside of administration parameters included in the medical order. Resident #88 received insulin outside of administration parameters included in the medical order and received insulin without documented evidence a blood glucose measurement was obtained prior to administration. Resident #154 did not receive medications and treatments in accordance with physician orders for multiple days after returning to the facility following a hospitalization. The findings include:The facility policy Medication Administration, Documentation, and Premedication revised August 2024 included, but was not limited to, licensed nursing staff were to check for hold parameters 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.
- Potential for harm · Dcited before2025-12-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, the facility failed to ensure medications were stored securely and accessible only to authorized personnel, in accordance with professional standards of practice and State and Federal regulations, for two (2) of four (4) residential units reviewed ([NAME] Place and [NAME] Place). Specifically, multiple loose pills (unsecured medications that were not contained in labeled packaging) were observed in medication carts, and a medication cart was observed unlocked and unattended.The findings include:Review of facility policy Medication Storage revised [DATE] included, but was not limited to, all medications stored and used within the facility shall be properly labeled and securely stored. Licensed nursing staff ensure expired, discontinued, or contaminated medications are removed promptly and disposed of according to facility policy and applicable regulations. Review of facility policy Medication Administration, Documentation, and Premedication revised [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.
- Potential for harm · Dcited before2025-12-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey from 12/11/2025 through 12/19/2025, the facility did not ensure they established and 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 for three (3) (Residents #11, #69, and #184) of six (6) residents reviewed. Specifically, Resident #11 had catheter care performed, the new drainage bag was observed on the floor uncovered and a nurse stepped on it. Resident #69 was on transmission based precautions (an infection control strategy used to control the spread of air-borne infections) and staff were observed going into the resident's room without wearing personal protective equipment (such as mask, gown, and gloves, worn to protect individuals and staff and reduce the risks of exposure to and spread of infections). Resident #184 was on enhanced barrier…
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.
- Potential for harm · E2023-12-26 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview conducted during the Recertification Survey, it was determined that for four (Employees #1, #3, #4, and #5) of five newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, the results of a nurse aide registry abuse screening were not documented for newly hired employees prior to starting work. The findings are: A review of facility policy, Administrative Policy #20A Abuse Prohibition, last reviewed November 22, 2022, included that it is the responsibility of Human Resources to screen all potential employees for a history of abuse, neglect or mistreatment of residents. On 12/20/23 from 9:03 AM to 9:47 AM, newly hired employee files were provided to the surveyor for review and included the following: 1) Employee #1 was hired on 10/2/23 as a Dining Services Associate and the results for a nurse aide registry screen for prior abuse findings were dated 10/19/23. 2) Employee #3 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.
- Potential for harm · Ecited before2023-12-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews conducted during a Recertification Survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and an antibiotic stewardship program (processes to ensure that individuals are receiving appropriate antibiotics, at the correct dose, and for the proper length of time) that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide evidence of on-going surveillance and tracking of infections since June 2023 and there was no evidence that the facility had been maintaining an antibiotic stewardship program. This is evidenced by the following: The Facility Assessment, dated October 2023, documented that the facility's infection prevention and control program included surveillance and tracking of infections to monitor for trends and clusters, investigate contributing factors, provide staff education, and monitoring…
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.
- Potential for harm · D2023-12-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #53) of six residents reviewed for Activities of Daily Living, the facility did not ensure that a resident with limited range of motion received the appropriate treatment and services to prevent further decline. Specifically, Resident #53 had contractures (deformities that result when muscles, joints, tendons, or other tissues tighten or shorten) to both hands and was not provided the hand devices (hand rolls) per their plan of care to prevent a decline. Additionally, the facility could not provide documented evidence that Resident #53 received range of motion per their plan of care. This is evidenced by the following: Resident #53 had diagnoses including central nervous system lymphoma (malignant cancer cells that affect the brain and/or spinal cord), brain tumor (swelling caused by an abnormal growth of tissue), and encephalopathy (a disease that affects brain function).…
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.
Show the remaining 8 citations
- Potential for harm · D2023-12-26 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #53) of one resident reviewed for tube feedings (nutrition administered via a tube inserted directly into the stomach via the abdomen due to the residents' inability to consume food and drink by mouth), the facility did not provide appropriate treatment and services to prevent potential complications for a resident who receives enteral feedings (tube feedings), as outlined by the resident's person-centered comprehensive care plan and physician orders. Specifically, the facility was unable to provide documented evidence that the resident had received the correct tube feeding and water intakes as ordered by the physician to ensure the necessary nutrition and prevent complications. This is evidenced by the following: The January 2023 facility policy, Gastrostomy (feeding) Tube Feeding, included that all patients with Gastrostomy tubes will have their intake and output measured each shift. The amount of tube feeding, and water administered should 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.
- Potential for harm · Dcited before2023-12-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, it was determined that for two of five medication carts reviewed for medication storage, the facility did not ensure that all drugs and biological were properly stored in accordance with State and Federal Laws. Specifically, two expired medications were stored in medication cart #1on [NAME] Place resident care unit and a medication cart on [NAME] Place had multiple loose unlabeled pills. In addition, one of the medication drawers in the cart on [NAME] Place contained a large amount of debris at the bottom of the drawer. This is evidenced by the following: During an observation on 12/21/23 at 12:03 PM on [NAME] Place, medication cart #1 had a bottle, approximately one-quarter filled, of bisacodyl (laxative) tablets with an expiration date of September 2023 and a full bottle of sorbitol solution (laxative) with an expiration date of August 2023 were stored in the cart. During an observation and interview on 12/21/23…
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.
- Potential for harm · Ddisputed · IDR2023-12-26 · tag F0882 — isolatedDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews conducted during a Recertification Survey, the facility did not ensure that the individual designated as the facility's current Infection Preventionist (individual responsible for the facility's Infection Prevention and Control Program) had completed specialized training in infection prevention and control. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. This is evidenced by the following: The facility policy, Infection Control Program, dated 12/13/23, defined the Infection Preventionist as a person whose primary training was either in nursing, medical technology, microbiology, or epidemiology and who had acquired additional training in infection control. The policy revealed the Infection Preventionist was responsible for monitoring the rate of infections, maintaining records of all communicable diseases and nosocomial (infections that developed during the process of receiving health care) infections, and defining, analyzing, 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.
- Potential for harm · D2023-12-26 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey, it was determined that for one of one main kitchen the facility did not properly maintain essential equipment. Specifically, a high-temperature mechanical dish machine did not reach the required final rinse temperature to properly sanitize dishes. The findings are: Observations on 12/19/23 at 9:27 AM included facility staff starting breakfast dishes by running them through the [NAME]-brand mechanical dish washing machine in the main kitchen. Further observations included that after several racks of dishes were run through the machine, the final rinse temperature displayed on the temperature screen after each of four runs was: 140 degrees Fahrenheit, 141 degrees Fahrenheit, 146 degrees Fahrenheit, and 144 degrees Fahrenheit, respectively. Additional observations included dietary staff removing dishes that had come out of the machine onto the clean side drainboard and place them away, even though the dish machine had…
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.
- Potential for harm · Ecited before2022-03-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 and interview conducted during the Recertification Survey completed on 3/2/22, it was determined that for four ([NAME], Porter, [NAME], and [NAME]) of six resident units and one of one main lobby, the facility did not ensure that the resident's environment remained free of accident hazards. Specifically, hot liquids were accessible to residents and a heating surface exceeding 125°F was not adequately protected from accidental contact. The findings are: The facility policy, Dining Services Policy #49 Coffee on the Neighborhoods, effective July 2017 with a revision date of July 2019, included: Coffee will be available on the neighborhoods for Members, Families, and Staff. The temperature of the coffee will be monitored regularly to ensure safety of the Members. The coffee machines are set to dispense coffee at 155-160°F. The policy also included that dining services associates are responsible for the following procedure: Check the temperature of the coffee from the machine daily by dispensing…
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.
- Potential for harm · D2022-03-02 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
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 a Recertification and complaint investigation (#NY00270684) Survey, completed on 3/2/22, it was determined that for one (Resident #346) of three residents reviewed, the facility did not permit a resident to return to the facility following an acute transfer to the hospital. Specifically, the resident was transferred to the hospital and upon receiving a referral from the hospital for a readmission, the facility determined they could not meet the resident's needs without proper notification per the regulation. This is evidenced by the following: Resident # 346 was admitted to the facility on [DATE] and had diagnoses including leukocytosis (acute elevation of white blood cell count) and heart failure. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. A discharge MDS assessment dated [DATE] was coded as discharge, return not anticipated. A medical provider note, dated 1/14/21, documented an evaluation of 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.
- Potential for harm · D2022-03-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review conducted during a Recertification Survey, completed on 3/2/22, it was determined that for 2 Residents (#22 and #106) of 26 residents reviewed for care planning, the facility did not develop and implement a comprehensive person- centered care plan that included measurable objectives to meet the resident's medical, nursing, mental and psychological needs as identified in the comprehensive assessments. Specifically, Resident #22's Comprehensive Care Plan (CCP) did not include the resident's suprapubic (SP) urinary catheter or congestive heart failure with edema (excess fluid), and Resident #106 CCP did not include the use of a psychotropic (medications that affect mental function and behavior) medication. This was evidenced by: 1.Resident #22 had diagnoses that included Parkinson's disease, urinary retention, and heart failure. The Minimum Data Set (MDS) Assessment, dated 11/11/21, revealed the resident was moderately impaired cognitively, had an indwelling urinary catheter and had recevied a daily diuretic (medication to reduce…
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.
- No harm found · B2022-03-02 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review during a Recertification Survey, and complaint investigation (#NY00270684), completed on 3/2/22, it was determined that for two (Residents #146 and #346) of three residents reviewed, the facility did not provide evidence that a valid written notification of transfer or discharge was sent to the residents or resident representatives in a timely manner. Specifically, Resident #146 was not provided a notice of transfer or discharge following a hospital admission and Resident #346 was not provided a valid notice of discharge that included the reason for the discharge, complete and correct appeal information and did not supply evidence of a reason for inabilty to return as per the regulations. This is evidenced by the following: 1.Resident #346 had diagnoses included leukocytosis (acute elevatation of white blood cell count), dysphagia (difficulty swallowing) and heart failure. The Minimum Data Set (MDS) Assessment, dated 12/7/20, revealed the resident was cognitively intact.…
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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BROWN, AMANDA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 12/06/2022 |
| JOHNSON, CHRISTINE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | since 09/02/2015 |
| BAIER, DANIEL | Individual | CORPORATE OFFICER | since 01/01/2014 |
| COOPER, GLEN | Individual | CORPORATE OFFICER | since 08/17/2015 |
| WILBORN, KIMBERLY | Individual | CORPORATE OFFICER | since 01/01/2014 |
CMS files one row per role, so the 7 rows in the source record cover these 5 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.
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
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
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.
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 335476. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, 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.