Baptist Health Nursing And Rehabilitation Center
297 N Ballston Ave, Scotia, NY 12302 · Non profit - Corporation · 262 certified beds · (518) 370-4700 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 | 20.8% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.1% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.7% | 1.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.6% | 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 | 4.1% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.1% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.3% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.2% | 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 | 16.9% | 13.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 26.6% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.8% | 20.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.4% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.22 | 1.70 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.76 | 1.36 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.5% 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 80 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 46.4%CMS range 36.9–54.3 | 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 | 10.6%CMS range 7.3–14.2 | 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 | 42.5% | 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 | 46.2% | 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 | 42.5% | 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 | 73.5% | 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 | 94.6% | 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 | 96.7% | 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 | 0.8% | 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 | 1.7% | 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 | 8.6%CMS range 5.5–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 262 beds and averages 187.1 residents a day — about 71% occupied, or roughly 75 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.12 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.83 hrs/resident/day on weekends vs 3.23 on weekdays — 12% thinner on weekends. RN hours go from 0.42 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 53% 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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2026-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during survey, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible for five (Resident #s 17, 80, 151, 161, and 162) of 18 residents reviewed for accidents. Specifically, (1) on 08/17/2025, Resident #17 was provided with an alternate meal (egg salad sandwich) upon request, which was not according to the resident's prescribed diet order of puree texture (a cohesive, smooth texture free of lumps and coarse particles that does not require chewing) diet, thin consistency fluids. As a result, Resident #17 sustained a choking occurrence, their skin turned blue, and they required the Heimlich maneuver. (2) Medications were observed unattended at the residents' bedside for Resident #s 80, 151, 161, and 162, observations were made daily starting on the first day of survey 06/08/2026 through and including the last day of survey on 06/15/2026. This resulted in actual harm to Resident # 17 that was not Immediate…
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 · F2026-06-15 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews, observations, and interviews conducted during the survey, the facility failed to provide services by sufficient numbers of staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Specifically, one Certified Nurse Aid was alone on unit H1 during the day shift on 06/09/2026, and one Certified Nurse Aid was left alone on unit H2 during the day shift on 06/11/2026. Findings include: Observations: During an observation on 06/09/2026 of Unit H2, Resident #87 placed call bell at 11:04 AM, Licensed Practical Nurse #5 answered the call bell at 11:07 AM. They then looked for an available Certified Nurse Aide to assist the Resident. There were two Certified Nurse Aides and one Licensed Practical Nurse in the break room on unit, located across hall from the resident's room. During an observation on 06/11/2026 at 11:45 AM on unit H1, there were multiple residents in the common area, there were no staff observed on the unit until 11:52 AM. Interviews: During an interview on 06/09/20206 at 11:10 AM, Licensed Practical Nurse…
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 · Fcited before2026-06-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 interviews during the survey, the facility failed to prepare and serve food in accordance with professional standards for food service safety in the main kitchen and 6 of 6 nourishment stations. Specifically, food was not stored properly; the automatic dishwashing machine was not operating within the manufacturer specifications; the concentration of the chemical sanitizing rinse was less than that required by the manufacturer; and food preparation area equipment, floors, walls, and ceilings required cleaning & repair. The findings include:During observations on 06/08/2026 at 9:34 AM:Pureed breakfast muffins were stored below raw beef patties in walk-in refrigerator; Director of Dining Services #1 stated that the pureed muffins were fully cooked but would be reheated before being served; [NAME] #1 did not know the temperature to reheat food (pureed muffins). The automatic dishwashing machine final rinse temperature was 120 degrees Fahrenheit at zero pounds per square inch of water pressure; dishwashing machine data plate stated that the final…
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 · F2026-06-15 · 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
Based on observations, record reviews, and interviews during the survey, the facility failed to establish and maintain an infection prevention and control program in accordance with professional standards of practice. Specifically, a) hand hygiene between rooms was not performed; b) sanitary transport of dirty linens and garbage was not performed; c) dressing supplies that were to be used were placed on the floor; d) urinary catheter drainage bags were observed to be resting on the floor. Findings include: The policy and procedure titled Isolation Precautions System, dated 04/2025, stated a two-tiered system of isolation was used, including standard precautions and transmission-based precautions. Enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of targeted multidrug resistant organisms. Enhanced barrier precautions were to be used when a resident had an external medical device such as a urinary catheter, feeding tubes or drains, and also for wounds that typically required dressing changes (excluding small skin…
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 before2026-06-15 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 conducted during a survey, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life. Specifically, (a) during a dining observation on 06/08/2026, plastic utensils were provided to residents during the lunch meal. (b) Resident #65's urinary catheter drainage bag was observed to be not covered by a dignity bag. (c) Resident #201's urinary catheter drainage bag was observed to be not covered by a dignity bag. Findings include: Facility Policy titled Maintaining Resident Dignity effective 09/2024, documented the mission of the facility was to provide loving care to all residents in a timely manner that bespeaks dignity, respect, compassion, sensitivity and concern. The facility promotes care for residents in a manner and environment that maintains or enhances each resident's dignity and respect in full recognition of their…
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 · E2026-06-15 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews conducted during the survey, the facility failed to ensure residents were given the right to be informed in advance, of the risks and benefits of the proposed treatment, and the ability to choose the alternative or option they preferred by the physician or other practitioner for three of five residents reviewed. Specifically, Resident #s 12, 19, and 87, were prescribed psychotropic medications without consent obtained. Findings include: The facility policy titled Psychotropic Medications-Unnecessary Use revised 05/2026 documented, there was to be documentation of discussion with the resident and /or responsible party regarding the risk versus benefit of the use of the medication. Resident #12 : Resident #12 was admitted to the facility with diagnoses of bipolar disorder, in partial remission, (chronic mental health condition characterized by extreme mood fluctuations), anxiety disorder (common mental health condition that involves excessive fear, worry, or nervousness that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews conducted during the survey, the facility failed to provide effective housekeeping and maintenance services on six of 6 resident units and the service areas. Specifically, floors, walls, ceilings, and dining tables were not clean and/or maintained; plumbing was in disrepair. The findings include: During observations on 06/11/2026 at 10:40 AM through 12:17 PM and again on 06/12/2026 at 9:15 through 12:00 PM:The main kitchen had an open drain and standing water under pre-rinse sink; the pre-rinse sink was plumbed to a sump pump system in the Boiler Room.The S unit Boiler Room had leaking pipes with standing water on the floor, was littered with trash, and had a sump pump system with an open wastewater collection tub.The dietary employee locker room floors, walls, doors, and lockers were heavily soiled; the walls below the sinks in the men's room had unfinished & unsealed repair work.The following areas were soiled with dirt, grime, food particles, or a black build-up: service…
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 · E2026-06-15 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews during the survey, the facility failed to ensure drug records were in order. Specifically, narcotic shift to shift count sheets were not completed every shift for two of five narcotic shift to shift count books reviewed. The policy and procedure titled Controlled Substances, dated 12/2021, stated that each narcotic dose is removed from the package to be noted on the control record as follows: date, time, dose, balance of remaining, and name/title. The policy and procedure titled Controlled Medication Storage, effective 08/2025, stated, At the beginning and end of each shift, all controlled substances would be accounted for by having two nurses (one from the present and one from the oncoming shift) count and sign the appropriate accountability records. Review of the narcotic shift to shift count book on unit H-1 on 06/10/2026 at 10:16 AM documented multiple missing signatures. There were no signatures for any shift from 06/08/2026 to 06/10/2026 at the time of the observation and review. Review of the narcotic shift to shift count…
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 before2026-06-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews during the survey, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls. Specifically, treatment carts were left unlocked, a medication (pain-relieving cream) was left unattended on top of a cart, an inhaler was undated and unlabeled, and temperature logs were not completed on two of three medication refrigerators. Findings include: The policy and procedure titled Storage of Medications, dated 09/2024, stated drugs and biologicals used in the facility were to be stored in locked compartments under proper temperature, light, and humidity controls. Nurses were responsible for maintaining medication storage and preparation areas in a clean, safe, and solitary manner. During an observation on 06/10/2026 on a medication cart on H-1, a pain-relieving cream was on top of a medication cart unattended, insulin pens were not in bags, and five tablets were loose (out of package) inside the medication cart. During an observation on 06/10/2026 at 11:00 AM, the medication room on H1…
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 · E2026-06-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature. Specifically, (a.) five out of five residents during the resident council meeting on 06/09/2026 stated that the food was cold; (b.) Resident #80 stated that cold food was room temperature and hot food was cold; (c.) Resident #99 stated that sometimes the food was cold; and (d.) for Resident #110, food was not served at an appetizing temperature during a lunch meal on 06/11/2026 and stated that food was cold.Findings include: Facility policy titled Mealtime Management, General Principles Of revised 08/2025, documented the facility will provide nutritious, well-balanced meals to all residents/patients three times a day in a pleasant atmosphere. Under key points, it is documented to accommodate preferences as much as possible. During a surveyor-led resident council meeting on 06/09/2026 at 1:30 PM, five out of five residents stated and agreed that by the time food was served…
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 · E2026-06-15 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
During observations on 06/12/2026 at 11:35 AM, the facility grounds were overgrown with vegetation as follows:Weeds were growing in the gap between the asphalt and the building foundation.Weeds, grape vines, and tree saplings were growing in the landscape gardening found at the facility entrances and in the resident garden sanctuary courtyard.A large tree sapling was growing over the pad-mounted electrical transformer. During an interview on 06/12/2026 at 12:09 PM, Director of Facilities #1 stated that they would address the landscaping overgrowth. New York Codes, Rules, and Regulations Title 10 S415.5(h)(4)Based on observation and interviews conducted during the survey, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building and grounds were not maintained. The findings include:
Show the remaining 16 citations
- Potential for harm · D2026-06-15 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review conducted during a survey, the facility failed to promptly notify the resident and the resident representative when there was a change in room for one (Resident #138) of two residents reviewed. Specifically, Resident #138 had a room change and the residents' representative was not given prior notice. The facility policy titled Resident Rights effective 10/2017, documented it was the facility's policy to protect the rights of all residents which included, but was not limited to the right to a dignified existence and self-determination. All residents must be supported and promoted, their right to self-determination in order to assist them in achieving their highest, practicable well-being. The resident representative had the right to exercise the resident rights to the extent those rights are delegated to the representative. The facility would treat all decisions made by the designated representative as the decisions of the resident. In regard to medical care, the resident had the right to participate in the decisions that affected their care.…
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 · D2026-06-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a survey, the facility failed to ensure that all alleged violations involving abuse were reported immediately, or no later than two hours after the allegation was made for one out of four incidents reviewed for abuse. Specifically, the facility did not report an incident with the allegation of sexual abuse between Resident #131 and Resident #151 within the two-hour reporting timeframe. Findings include: (1) Resident #17: Resident #17 was admitted with diagnoses that included dysphagia (difficulty swallowing) and congestive heart failure (a long-term condition where the heart's main pumping chamber weakens and cannot squeeze properly). The Minimum Data Set (a resident assessment tool) dated 08/08/2025, documented the resident had moderate cognitive impairment, was on a mechanically altered diet and required supervision or touching assistance for eating. The At Risk for Potential Alteration in Nutrition Comprehensive Care Plan initiated on 09/28/2022,…
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 · D2026-06-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a survey, the facility failed to ensure that comprehensive care plans were developed and implemented for residents according to professional standards for three (Resident #'s 12, 15, and 87) of 41 residents reviewed. Specifically, (a.) Resident #87 did not have a care plan for their respiratory diagnosis or use of oxygen; (b.) Resident #15 had a 16.25% weight loss from 10/28/2025-04/15/2026 and there was no care plan for it; (c.) Resident #12 was care planned for super-pubic urinary catheter care including daily dressing changes; it was not implemented in 10/2025 when the dressing was not changed for multiple days.The findings include:The facility policy titled Interdisciplinary Care Plan reviewed 9/2025, documented that the objective was to provide a person-centered plan of care that would establish continuity between all departments and maintain objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that were…
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 before2026-06-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, during the survey, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary assistance with eating, maintaining personal hygiene, and adequate grooming, for two (Residents #77 and #188) of five residents reviewed. Specifically, Resident #77 was observed unkept with dirty fingernails; Resident # 188 was not offered or provided the opportunity to get out of bed until the surveyor pointed it out to the assigned Certified Nurse Aide at lunchtime, despite the resident being awake and wanting to eat breakfast. The resident was observed on 6/08/2026 throughout the morning to be pleasantly confused, awake, in bed and to have a breakfast tray that remained in the room, until lunchtime when staff replaced it with a lunch tray. Staff interview confirmed that Resident # 188 did not receive the required assistance to access and consume breakfast. Resident interview confirmed he would like to have eaten breakfast.…
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 · D2026-06-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews conducted during a survey, the facility failed to ensure residents were provided with treatment and care in accordance with professional standards of practice for two of 41 residents reviewed, Residents #12 and #208. Specifically, (a) Resident #208, the bowel protocol was not initiated per physician orders after more than three days of the resident not having a documented bowel movement and (b) Resident #12 had a super-pubic catheter placed with dressing changes ordered daily, the dressing change was not changed over a period of 10 days, and a culture was obtained as ordered labeled with the wrong location causing a delay in care and the resident to be prescribed broad spectrum antibiotics empirically. Findings include: Facility policy titled Resident/Patient Bowel Program for Constipation (undated) documented the purpose was to provide residents at the facility interventions for constipation prevention and to monitor resident's bowel habits. Nurses would…
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 · D2026-06-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure a medication error rate of less than 5 percent. Specifically, medication error rate was observed to be 12.5 percent. Findings include: The policy and procedure titled Administration of Medications - General, revised 09/2024, stated medications were to be administered within one hour before or after the prescribed time. Resident #116 was admitted to the facility with diagnoses of dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life), anemia (the lack of healthy red blood cells or hemoglobin to carry adequate oxygen to tissues), and essential hypertension (high blood pressure). During an observation on 06/10/2026 at 11:30 AM, Licensed Practical Nurse #3 was observed administering medications scheduled for 9:00 AM at 11:30 AM for Resident #116. The medications were Amlodipine oral tablet 10 milligrams give 1 tablet by mouth one time a day for hypertension at 9:00 AM Sertraline hydrochloride 25 milligrams give 12.5 milligrams…
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 before2023-10-24 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during the recertification survey and abbreviated surveys (NY00281127 and NY00322303) dated 10/16/2023 through 10/24/2023, the facility did not provide effective housekeeping services on five (5) of 5 resident units, the resident common areas, and nurse stations. Specifically, floors were soiled, 3 floor tiles had brown stains; a corridor wall fan was soiled; ceiling tiles were stained or soiled; walls were soiled with splatter marks, drip marks, and dirt; wall surfaces were chipped; a 5-inch diameter section of wall surface was ripped; drill holes were found in the corridor walls; the paint was chipped on the heater register; handrail surfaces were worn; and coving base was missing. This is evidenced as follows: During observations on 10/18/2023 from 11:15 AM through 12:39 PM: 1.) The floor was soiled in the H-1 Unit nurse station, H-2 Unit nurse station, and N-2 nurse station. 2.) Floors were soiled by the door frames in the room #s H-176 bathroom, H-1 quiet room, and H-258 bathroom. 3.) Floors were soiled in corners and long…
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 before2023-10-24 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews during the recertification survey from 10/16/2023 through 10/24/2023, the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards on 3 of 6 medication carts. Specifically, for the Homeward Bound (HB) Unit, the facility did not ensure medications on HB Medication Cart #2 (an opened, unlabeled insulin pen and an expired bottle of bisacodyl) were stored in accordance with facility policy and accepted professional principles, for the H2 unit, the facility did not ensure medications on H2 Medication Carts #1 (an opened, unlabeled insulin pen) and #2 (an opened, unlabeled insulin pen and an unrefrigerated bottle of cephalexin) were stored in accordance with facility policy and accepted professional standards. This is evidenced by: The policy and procedure (P&P) titled, Medication, General Principles of Administration and Storage, reviewed 10/2023, documented multi-dose vials which have been opened or accessed (e.g., needle-punctured) should be dated and discarded within 28 days unless 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 · Ecited before2023-10-24 · 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
Based on observation, record review, and interviews during the recertification survey dated 10/16/2023 through 10/24/2023, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for five (5) of 5 resident unit kitchenettes and the main kitchen. Specifically, a can of cherry pie filling with a dent with metal touching metal was found ready for use in the dry storage area speed rack. When checked, the concentration of quaternary ammonium compound (QAC) in use for sanitizing food contact surfaces was found to be 100 parts per million (ppm) when measured at 80 degrees Fahrenheit (F). The following areas in the main kitchen were soiled with food particles, food splatters, and/or grime: can opener and holder, walk-in refrigerator door around the handle, wall fan, tray rack dolly, ceiling by the labeling machine had food splatters. In the N-2 Unit nourishment station, the refrigerator door gasket, bottom of refrigerator, cabinet below the sink, and floor next to cabinets were soiled with food particles,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-24 · tag F0813 — patternHave 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 interviews during the recertification survey dated 09/16/2023 through 09/24/2023, the facility did not have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for five (5) of 5 resident units. Specifically, the facility did not have a policy regarding foods brought to residents that included a procedure to ensure all residents had the necessary assistance in accessing and consuming food, did not ensure that family and visitors that bring food to residents were provided with information to understand safe food handling practices (such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.). Additionally, the N-2 unit nourishment station refrigerator/freezer contained food items brought from home that were not consistently labeled with a resident name and were not consistently dated, the S-2 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 · D2023-10-24 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the recertification survey from 10/16/2023 to 10/24/2023, the facility did not ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the resident's status. This was evident for 2 (Resident #'s 15 and #102) of 34 residents reviewed. Specifically, the Discharge Tracking MDS was not completed for 2 residents within 7 days. This is evidenced by: The policy and procedure titled MDS Completion and Submission Timeframe's revised 9/2023 documented the following time frames will be observed by the facility, please refer to the RAI (Resident Assessment Instrument- tool used to assess clinical and functional characteristics of resident in long term care setting in order to measure and assess a resident's level of care needs) manual guidelines Chapter 2 time frames. A documented titled Chapter 2: The Assessment Schedule for the RAI revised December 2002 documented it presented instructions for the completion of the mandated clinical and Medicare…
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 · D2023-10-24 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews during the recertification survey dated 10/16/2023 through 10/24/2023, the facility did not dispose of garbage and refuse properly. Specifically, the side doors to the two outdoor garbage dumpsters were not closed, the sides of the dumpsters below the doors were soiled with food drips, and the grounds around dumpsters were littered with paper waste. This is evidenced as follows: During observations on 10/16/2023 at 11:26 AM, the trash compactor access door and portal to the compactor were heavily soiled with a caked-on build-up of black grime, and the grounds around dumpsters were littered with paper waste. During an interview on 10/16/2023 at 11:27 AM, the Director of Facilities stated that the facility was in the process of replacing the door as the warning labels were no longer readable. The document titled Weekly Task List (undated), a log for trash disposal, documented that the trash compactor would be cleaned every Monday, Wednesday, and Friday. During an interview on 10/19/2023 at 1:37 PM, the Director of Facilities stated that the door 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 · Dcited before2023-10-12 · 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 interview during an abbreviated survey (Case #NY00305238), the facility did not ensure that each resident was treated with respect and dignity for 3 (Resident #s 11, 12, and 16) of 5 residents reviewed. Specifically, during the survey, Resident #s 11, 12, and 16 on the N2 unit reported they were displeased that their meals were frequently served on paper plates or in disposable containers and that they had to use plastic cutlery. This is evidenced by: The Policy and Procedure titled Residents' Rights dated 1/28/2020, documented residents had the right to be treated with respect and dignity. Review of Resident Council Meeting Notes documented the following: -On 3/6/2023 at 3:00 PM, Dietary/Nutrition documented Paper and plastic starting to be used? What happened to regular plates and silverware? It documented Resident #s 11 and 12 attended the meeting. -On 4/10/2023 at 3:00 PM, Dietary/Nutrition documented Dietary should be moving away from paper/plastic soon. New plates…
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 before2023-10-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (Case #NY00305238), the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for 1 (Resident #14) of 6 residents reviewed. Specifically, the facility did not ensure Resident #14 on the N2 unit received their AM personal care on 9/21/2023. This is evidenced by: Resident #14: Resident #14 was admitted to the facility with diagnoses of urinary tract infection (UTI), hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebrovascular disease affecting left dominant side, and depression. The Minimum Data Set (MDS - an assessment tool) dated 6/29/2023, documented the resident was cognitively intact. The Policy and Procedure (P&P) titled AM Care revised 5/2023, documented residents at the facility would be provided with personal care every AM when not giving AM shower/tub bath/complete bed bath. The objective 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 · Ecited before2023-09-28 · 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
Based on observation and interviews during abbreviated survey (NY00324646) dated 09/26/2023, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety in the main kitchen. Specifically, the floor in the main kitchen was soiled with food particles and grime; the main kitchen was soiled with dirt under equipment; the adjoining stockroom was soiled with dirt under the shelving. This is evidenced as follows: During observations on 09/26/2023 at 9:46 AM, the floor in the main kitchen was soiled with food particles, grime, and dirt under equipment in the main kitchen and under the shelving in the adjoining stockroom. The undated document titled associate daily and weekly cleaning schedule listed floors were to be swept and mopped daily. During an interview on 09/26/2023 at 10:43 AM, the Executive Chef stated that the floors were cleaned daily in the general work areas. During an interview on 09/26/2023 at 10:45 AM, the General Manager of Food Service (GMFS) stated they were part of a contract company 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 before2021-08-10 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean on 4 of 5 resident units. This is evidenced as follows. The floors were spot checked on 08/09/2021 at 10:30 AM and again on 08/10/2021 at 9:30 AM, revealing that floors at the base of door frames in resident rooms H170, H175, H177, H255, S307, S308, S313, S335, N2254, and HB3341 were soiled with dirt and a brownish build-up. The Housekeeping Supervisor stated in an interview on 08/09/2021 at 11:30 AM, that the facility will make sure that the floors are cleaned in the resident doorways. The Administrator stated in an interview on 08/10/2021 at 11:21 AM, that the facility will audit the floors in resident rooms to ensure that they are clean. 483.10(i)(2)
“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 |
|---|---|---|---|
| BUSH, CLAUDIA | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| DELUKE, DEBRAH | Individual | CORPORATE DIRECTOR | since 01/01/2015 |
| KO, ELAINE | Individual | CORPORATE DIRECTOR | since 12/23/2014 |
| TRAUX, DARLENE | Individual | CORPORATE DIRECTOR | since 12/23/2014 |
| WHITBECK, KIM | Individual | CORPORATE DIRECTOR | since 01/01/2015 |
| BARTLEY, MARY | Individual | CORPORATE OFFICER | since 12/07/2015 |
| CHAPPELL, PAMELA | Individual | CORPORATE OFFICER | since 12/30/2019 |
| DUNHAM, JAMES | Individual | CORPORATE OFFICER | since 01/01/2017 |
| GOLDING, RICHARD | Individual | CORPORATE OFFICER | since 01/01/2017 |
| WOOD, HARRY | Individual | CORPORATE OFFICER | since 12/23/2014 |
| EDGAR, DAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/11/2026 |
| ODUWA, FELIX | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/04/2026 |
CMS files one row per role, so the 14 rows in the source record cover these 12 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.
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. This home reported $865K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 335612. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-15, 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 →
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