Wesley Health Care Center INC
131 Lawrence Street, Saratoga Springs, NY 12866 · Non profit - Corporation · 356 certified beds · (518) 587-3600 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 20.6% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.9% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.8% | 1.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.5% | 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 | 7.0% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.9% | 12.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 19.2% | 13.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 94.4% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.2% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.8% | 13.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.1% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.5% | 20.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.9% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.36 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.34 | 1.36 | 1.80 | better |
‡ 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.
56.6% 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 330 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 49.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 146 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 56.6%CMS range 49.6–61.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.1–13.6 | 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 | 49.3% | 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 | 43.1% | 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 | 48.0% | 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 | 93.8% | 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 | 95.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.7% | 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 | 6.2% | 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 | 5.5%CMS range 3.6–8.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 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 356 beds and averages 276.4 residents a day — about 78% occupied, or roughly 80 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 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 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 3.34 hrs/resident/day on weekends vs 4.27 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.66 to 0.17 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%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · Fcited before2024-11-19 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, record review, and interviews during the Recertification Survey, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Specifically, (a) the facility had an outbreak of COVID 19 that started 7/11/2024 and continued through the survey with 174 (6 admitted w/Covid) resident positives and 100 staff positives and positive residents located in all units throughout the facility; during this time the facility kept COVID negative roommates in the same room with COVID positive roommates, specifically Resident #627 was left in the room with Resident #266 when they were COVID positive, Resident #73 was left in the room with Resident #66 when they were COVID positive, and Resident #55 was left in the room with Resident #265 when they were COVID positive. Resident #627, Resident #73, and Resident #55 all became COVID positive after being left in the room with positive…
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 before2024-11-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 8 of 8 resident unit kitchenettes. Specifically, the area of the resident kitchenettes was not clean, and open containers were not appropriately labeled when they were opened. This is evidenced by: The facility policy titled Area and Equipment Cleaning revised January 2024 documented that the kitchen staff have procedures in place for daily and weekly cleaning of all areas and equipment and documenting on the equipment cleaning log and master cleaning schedule. During an observation on 11/15/2024 at 10:15 AM, the [NAME] 3 unit resident kitchenette toaster had food particles on the catch tray, the counters had food particles on them, the sink area had substance in the basin of the sink, and the microwave shelving unit had food particles on them. None of the areas were appropriately cleaned.…
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 · D2024-11-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification survey and abbreviated survey (NY00356338), the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (Resident #s 6 and 33) of 7 residents reviewed for dignity. Specifically, for (a.) Resident #6 was left to soil themselves because staff did not attend to the resident in a timely fashion, leaving the resident feeling humiliated on more than one occasion. Resident #33 was not assisted with the consumption of their observed meal in a dignified manner. This is evidenced by: A facility policy titled Promoting Dignity and a Safe Environment Guidelines, dated 03/12/2024 documented it was designed to provide a safe, respectful, and dignified environment for all residents. A facility policy titled Feeding a Resident, dated 11/12/2024 documented under section 2.…
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 · D2024-11-19 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 1 (Resident #243) of 35 residents reviewed. Specifically, there was no documentation that a Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was completed for Resident #243 by a qualified screener prior to admission to the facility. This is evidenced by: Resident #243 was admitted to the facility with diagnoses of malignant neoplasm of prostate (prostate cancer that spread to other parts of the body), secondary malignant neoplasm of bone (cancer that spread to the bone from the prostate), and difficulty walking. The Minimum Data Set (an assessment tool) dated 8/29/2024 documented that the resident was able to be understood, understand others, and was somewhat cognitively impaired. There was no documented evidence that Residents #243 had a Preadmission Screening and Resident Review completed prior to admission to the facility as…
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 · D2024-11-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #68) of 39 residents reviewed. Specifically, for Resident #68, the Comprehensive Care Plan for Respiratory Therapy was not reviewed and revised to include changes in the resident's respiratory status when resident was not using oxygen. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order has been written. Resident #68 was admitted to the facility with diagnoses of sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection that may lead to organ failure or death),…
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 · D2024-11-19 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that it provided an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 (Resident # 80) of 2 residents reviewed for activities. Specifically, Resident #80 was not provided with activities that met the residents' preferences and cognitive abilities. This is evidenced by: The Policy titled General Activity/Life Enrichment Program Guidelines dated 03/01/2024 document the facility would provide activities, social events, and schedules that were compatible with the resident's interests, physical and mental assessment, and overall plan of care. The Policy documented activities were offered 7 days a week and should provide ongoing supportive program of the resident's psychosocial needs. Resident #80…
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 · D2024-11-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were following professional standards of practice, for 3 (Residents #'s 49, 53, and 68) of 6 residents reviewed for oxygen administration. Specifically, (a) for Residents #49, 53, and 68, their supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b) supplemental oxygen was not provided as ordered by the physician for Resident #68. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order had been written. Resident #49 was admitted to the facility with diagnoses of chronic respiratory failure (a condition where you do not have enough 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.
- Potential for harm · D2024-11-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 1 (Resident #68) of 39 residents reviewed. Specifically, for Resident #68 staff was observing and verifying every four hours that the resident's oxygen nasal canula was in place and the resident was using the oxygen as prescribed by the physician. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order has been written. Resident #68 was admitted to the facility with diagnoses of sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection that may lead to organ failure or death), rhabdomyolysis (a serious condition when muscle fibers die and release…
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 · D2023-08-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #NY00241321), the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice for 1 (Resident #1) of 3 residents reviewed. Specifically, for Resident #1, who was assessed with open areas on the right and left coccyx/inner buttock upon admission on [DATE], the facility did not implement their policy and procedure for the prevention and treatment of skin issues that included weekly pressure injury assessment and tracking for a stage 2 pressure ulcer on the residents coccyx/buttocks, as documented on the 48 Baseline Care Plan dated 5/2/2019. The electronic medical record (EMR) did not include documentation of weekly assessments and monitoring the characteristics and measurements of the wound(s) and did not ensure a care plan was developed that included intervention and treatment strategies for the healing of and prevention of infection in 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.
- Potential for harm · D2023-08-11 · tag F0777 — isolatedProvide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews during an abbreviated survey (Case # NY00241321), the facility did not ensure it promptly notified the ordering physician of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for 1 (Resident #1) of 5 residents reviewed. Specifically, for Resident #1 who was admitted for rehabilitation following a fall with a right hip fracture, the facility did not promptly notify the physician (MD) #1 of x-ray results dated 5/21/2019, that documented the possibility of interval development of fracture until 6/6/2019. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of routine healing of a closed fracture of unspecified part of neck of right femur (hip), chronic lymphocytic leukemia (CLL; cancer of the blood and bone marrow) not in remission, and diabetes with diabetic neuropathy (nerve damage caused by diabetes). The Minimum Data Set (MDS - an assessment tool) dated 5/9/2019, documented the resident was cognitively intact. 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.
Show the remaining 9 citations
- Potential for harm · Dcited before2021-10-05 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process when an irregularity that requires urgent action to protect the resident is identified. This is evidenced by: On 9/29/2021, the facility Administrator provided a policy titled; Medication Regimen Review, revised on 5/2019 and reviewed on 6/2021. The policy documented; If in the professional judgment of the Pharmacist, there is an irregularity that requires immediate action, the Pharmacist will report the irregularity to the Unit Charge Nurse and Attending Physician immediately. The policy did not include the steps to be taken or timeframes for the Unit Charge Nurse and Attending Physician's response to the reported irregularity requiring immediate action. During an interview on 10/05/21 at 1:59 PM, the Facility Administrator was asked to review the policy for the steps and timeframes. The Administrator was unable to find the information and stated, I…
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 before2021-10-05 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. A test kit is to be provided that accurately measures the parts per million (ppm) concentration of the chemical solution used to sanitize equipment, and dishwashing machines are to be operated in accordance with the manufactures' instructions. Specifically, an accurate test kit was not provided, and the automatic dishwashing machine was not operating according to the manufacturer's instructions. This is evidenced as follows. The main kitchen was inspected on 09/29/2021 at 9:57 AM. The bottle label of chemical concentrate used to sanitize food equipment in the 3-compartment sink stated the dilution is to be between 200 ppm and 400 ppm; the test kit used to measure the sanitizer did not provide color graduations to indicate if the solution is too concentrated. The automatic dishwashing machine final rinse water pressure was 12 pounds per square inch (psi); 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.
- Potential for harm · Dcited before2021-10-05 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview during the recertification survey, the facility did not ensure foods brought to residents is in accordance with adopted regulations. Specifically, the facility did not adhere to its established policy on food brought to residents and did not provide information for family and other visitors on safe food handling practices of food that they bring to residents. This is evidenced is as follows. The nursing unit kitchenette refrigerators were inspected for food brought in by or to residents on 09/29/2021 at 11:22 AM. On the 2 [NAME] Unit, food for Resident #220 was not dated. On the 3 [NAME] Unit, food had the name of Resident #6 and was dated; and a serving of turkey and rice was not dated and did not have a resident name. On the 4 [NAME] Unit, food for Residents #'s 50 and #156 were not dated. The facility policy Foods from Outside: Dining Services Responsibility was reviewed on 09/29/2021. This policy states that prepackaged foods requiring refrigeration…
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 · D2021-10-05 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain a pest-free environment and an effective pest control program. Specifically, the facility did not maintain an adequate pest control program as evidenced by sightings of flying insects in the main kitchen. This is evidenced as follows. Observations on 09/29/2021 at 9:57 AM, revealed tiny flies surrounding the ice machine located in the main kitchen. Additionally, the drain servicing the ice machine was soiled with grime. The Dining Services Director stated in an interview on 09/29/2021 at 9:57 AM, that the flies may be coming from the floor drain by the ice machine. Record review of the pest-control service reports on 09/29/2021, revealed that fruit fly activity was noted on 08/24/2021, 09/07/2021, 09/14/2021, and 09/21/2021. The Director of Environmental Services stated in an interview on 09/30/2021 at 1:32 PM, that the Environmental Services Department was not aware there was a fly problem in the kitchen but will make sure the issue is resolved. The Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-17 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during a recertification survey, the facility did not provide the resident and their representative with a written summary of the baseline care plan for 4 (Resident #'s 42, 65, 132 and #316) of 20 residents reviewed. Specifically, for Resident #'s 42, 65, 132 and #316, the facility did not ensure written summaries of the baseline care plans were provided to the resident and the resident's representative. This is evidenced by: Resident #42: The resident was admitted on [DATE], with the diagnoses of hypertension, arthritis, dementia, and alcohol dependence. The Minimum Data Set (MDS) dated [DATE], assessed that the resident understands, was understood and had a slight cognitive impairment. Review of the resident's medical record did not include documentation that a written summary of the resident's baseline care plan was provided to the resident and their representative. During interview on 4/17/19 at 12:19 PM, the Director of Nursing stated she spoke to the unit…
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 before2019-04-17 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for the steps in the MRR process. This is evidenced by: The Policy for Medication Regimen Review (undated) documented: 1. Results of Pharmacy Review findings (which require Physician response) are written on Pharmacy Review Sheet. 2. Physician indicates response to Pharmacist findings then signs and dates the form. 3. If, in the professional judgment of the Pharmacist, there is an irregularity that requires immediate action, the Pharmacist will report the irregularity to the Unit Charge Nurse and Attending Physician. 4. The Pharmacist will not dispense the medication identified in the irregularity until the Attending Physician issues a resolution to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-17 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This was evidenced as follows: Review of the facility's Policy on Food Brought in from the Outside on 5/15/19 documented that the facility was responsible for providing residents, family, and friends with guidelines for promoting safe food-handling practices for foods brought in from the outside. The resident handbook stated that nonperishable food was allowed in residents' rooms if it was put in a sealed container and labeled with name and date, and that nursing staff was notified. A letter addressed to residents and family members provided the same information. There was no documentation regarding providing instructions for safe food handling and preparation practices for food brought in by family 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 · D2019-04-17 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not clean and the area around the trash compactor was littered with refuse. This is evidenced as follows. The trash compactor area was inspected on 04/10/2019 at 9:15 AM. The trash compactor area was littered with refuse, and the compactor door portal and the trash compactor shuttle room were soiled with a black build-up. The Director of Environmental Services stated in an interview on 04/10/2019 at 9:15 AM, that she will clean the compactor, compactor area, and compactor shuttle room. 10 NYCRR 415.14(h)
- Potential for harm · Dcited before2019-04-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program (IPCP) to prevent the development and transmission of disease and infection. Specifically, the facility did not insure the IPCP policies were reviewed annually. This is evidenced by: The following facility Infection Control Policies did not include documentation of an annual review: The Infection Prevention & Control Program Policy documented a review date of 10/18/17; The Antibiotic Stewardship Policy documented a review date of 10/18/17, 10/16/17; The facility Electronic Health Record (EMR) Nursing Guidelines Immunizations Policy did not include a date initiated or a date of review or revision. During an interview on 04/17/19 at 02:17 PM, the Infection Control Preventionist (ICP) stated they have recently reviewed the policies and the dates were not updated to reflect this. 10 NYCRR 415.19
“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.
- 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 |
|---|---|---|---|
| BOUCHER, JESSE | Individual | CORPORATE DIRECTOR | since 12/23/2024 |
| MARTIN, RAYMOND | Individual | CORPORATE DIRECTOR | since 12/23/2024 |
| O'BRIEN, DEBORAH | Individual | CORPORATE DIRECTOR | since 12/24/2024 |
| PANCOE, BROOKE | Individual | CORPORATE DIRECTOR | since 12/24/2024 |
| TULLY, KEVIN | Individual | CORPORATE DIRECTOR | since 04/28/2025 |
| AMATO, SHELLY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 02/03/2003 |
| LAHOFF, KATHERINE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/11/2006 |
| NEALON, BRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2003 |
| JLR PHYSICAL,OCCUPATIONAL AND SPEECH THERAPY | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/30/2024 |
| UNITED METHODIST HEALTH AND HOUSING INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/28/1998 |
| WESLEY HEALTH CARE CENTER, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/20/2025 |
| MIRZA, ALI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2018 |
| WALKER, MARC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/07/2024 |
| FREED MAXICK CPAS PC | Organization | ADP OF THE SNF | since 01/20/2014 |
| NOTT STREET MEDICAL PLLC | Organization | ADP OF THE SNF | since 01/01/2019 |
CMS files one row per role, so the 25 rows in the source record cover these 15 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.
5 organizational owners 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.
About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 335394. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-19, 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.