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Sodus Rehabilitation & Nursing Center

6884 Maple Avenue, Sodus, NY 14551 · For profit - Corporation · 130 certified beds · (315) 483-9118 Medicare & Medicaid certified

Call the home — (315) 483-9118 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Apr 2024Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6353 Ridge Rd · (315) 483-8300 · Call to confirm hours
Pharmacy
34 Main St W · (315) 483-2502 · Call to confirm hours
Grocery
36 W Main St · (315) 553-2430 · Call to confirm hours
Park
Lake Rd · (315) 947-5205 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.7%14.1%15.4%better
Long-stay residents who lose too much weight9.7%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection0.0%1.3%2.0%better
Long-stay residents with depressive symptoms1.1%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened5.2%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.4%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine97.9%95.3%95.3%typical
Long-stay residents with pressure ulcers5.9%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control15.7%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.7%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine69.2%78.8%79.4%worse
Short-stay residents rehospitalized after admission17.4%20.6%22.6%better
Short-stay residents with an outpatient ER visit10.8%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.601.701.67worse
Long-stay outpatient ER visits per 1,000 resident days2.131.361.80worse

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.

36.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.1%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
53.7%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy

Met the expected recovery: 53.7% 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 41 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 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.1%CMS range 26.0–47.151.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.8–13.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge53.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge36.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.6–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.46
RN hours/ resident / day
0.86
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.20
RN hoursweekends
52.6%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 115.2 residents a day — about 89% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 3.88 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.20 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

4
deficiencies at the latest standard inspection (2024-10-11)
10
at the previous standard inspection (2022-11-02)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2024-10-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review conducted during the Recertification Survey from 10/07/2024 to 10/11/2024, for one of one main kitchen and one (Cortland/[NAME]) of two satellite serveries, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically: there were dirty food and non-food contact surfaces, perishable food items were kept longer than 3-days per facility policies, and a sanitizer cleaning bucket with solution and a cleaning rag was dirty and not replaced between meals. The findings are: Record review of the undated facility policy Food and Supply Storage included: All perishable items will be disposed of 3 days after opening or on expiration date whichever is earlier. Observations during the initial tour of the main kitchen on 10/07/2024 from 7:45 AM to 8:35 AM included the following: 1. The following covered and labeled perishable food items were located in the walk-in cooler as follows: seafood…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the Recertification Survey from [DATE] to [DATE], for 54 of 102 residents, the facility did not ensure residents' right to privacy related to their medical records in that advanced directives wishes were not kept confidential. Specifically, there was a list of advanced directives information (such as wishes for cardiopulmonary resuscitation (CPR) in the event of an acute cardiac or respiratory event) that included the names of 44 residents with their wishes posted in plain sight in the facility library, which all residents and visitors have access to. In addition, there was a large picture frame hanging in the front lobby of the facility with 17 resident's pictures and names in view of the public; nine residents were listed in an elopement group (at risk for unsafe wandering outside the building) and eight residents an explorer group. This is evidenced by the following: During observations on [DATE] at 1:43 PM, [DATE] at 8:37 AM, [DATE] at 12:49 PM, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey from 10/07/2024 to 10/11/2024, for one (Resident #35) of three residents reviewed for food and nutrition, the facility did not ensure services were provided to maintain acceptable parameters of nutritional status. Specifically, Resident #35 was not consistently monitored for significant weight loss, and the facility could not provide documented evidence of consistent meal monitoring or interventions despite a significant weight loss. The finding is: The undated facility policy Weights documented each resident will be carefully monitored on a regular basis (monthly or weekly), or as otherwise specified by the provider, so that appropriate timely interventions may be initiated. Interventions will be initiated as needed to track unplanned significant weight variances of 5% weight loss/gain in 30 days, 7.5% weight loss/gain in 90 days, or 10% weight loss/gain in 180 days. The Dietitian/Designee will be responsible for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Sodus F760D Based on observations, interviews, and record reviews conducted during a Recertification Survey and complaint investigation (NY00338097) from 10/07/2024 to 10/11/2024, the facility did not ensure that two (Residents #43 and #66) of six residents reviewed were free of significant medication errors. Specifically, Resident #43 received several medications prescribed to treat Parkinson's disease and seizures one to three hours after scheduled times and a second medication to treat Parkinson's was administered too closely to the next dose. Resident #66 did not receive their insulin administration as ordered. This is evidenced by the following: The facility policy Administration of Medications, dated September 2020, included that medications will be administered to residents in a timely and accurate manner. Administer medications within one hour before or after prescribed time. Immediately chart medications administered in the proper time and date via initials by signature in designated space on the administration record. If resident refuses to take scheduled medication(s),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review completed during an Abbreviated Survey (#NY00337643), for one (Resident #1) of three residents reviewed, the facility did not ensure that an allegation of abuse was thoroughly investigated. Specifically, a staff member reported on 3/25/24 that they witnessed a potential abuse incident on 3/20/24 between another staff member and Resident #1. The facility's investigation to rule out any abuse, neglect or mistreatment concluded no abuse occurred but did not include any interviews with staff members who were working at the time of the alleged incident and witnessed the incident. Additionally, the facility did not report the alleged abuse until 13 days after it occurred. This was evidenced by the following: Resident #1 had diagnoses including dementia, depression, and diabetes. The Minimum Data Set Resident Assessment, dated 1/10/24, documented the resident was severely impaired cognitively. Review of a facility's Investigation Summary dated 3/25/24 and completed by the Director of Nursing, revealed that an incident occurred on 3/20/24…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-14 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during an Abbreviated Survey (#NY00320671) completed 10/12/23 to 10/13/23, it was determined that for one of one main kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food service operations were conducted in the area of an active wastewater backup and the incident was not reported to New York State Department of Health (NYSDOH). The findings are: During an interview on 10/12/23 at 8:47 AM, the [NAME] stated that there was a flood in the kitchen in July this year because the septic backed up. The [NAME] further stated that a vendor had to come in because the water from the septic came up to above their shoe line all along the cook line. During an interview on 10/12/23 at 8:56 AM, the Food Service Director (FSD) stated that they had a problem in July this year when there was a flood in the kitchen when the drains backed up, and they had to have…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (NY00304512) completed on 11/2/22, it was determined that for one (Empire) of three residential care units reviewed and one (Resident #27) of three residents reviewed for accidents, the facility did not ensure that the resident environment remained free of accident hazards. Specifically, hot water temperatures exceeding 120 degrees (°) Fahrenheit (F) were accessible to residents at point of use. Additionally, Resident #27 was observed with unlabeled and unsupervised medications at the resident's bedside. This is evidenced by the following: 1. Observations, interviews, and record reviews on 10/27/22 from 10:33 a.m. to 5:15 p.m. included the following: a. Water temperatures observed in the Empire Unit using a ThermoWorks Thermapen One digital thermometer: 129°F from the handwash sink in bathroom in resident room [ROOM NUMBER], 130°F from the handwash sink in the shower room next to room…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-02 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during the Recertification Survey, completed on 11/2/22, it was determined that for two (Resident #81 and #220) of two residents reviewed for tube feedings (TF), the facility did not provide appropriate treatment and services to prevent potential complications. Specifically, there was no process for tracking and monitoring the daily total intakes of TF for either resident to ensure the resident's nutritional needs were being met. This is evidenced by the following: The facility policy Gastrostomy Tube Feeding, dated April 2022 directed that when an intermittent feeding was completed to document administration in the Medication Administration Record (MAR). 1.Resident # 81 has diagnoses including a stroke with left side hemiparesis (weakness on one side of the body), dysphagia (difficulty swallowing) and malnutrition. The Minimum Data Set (MDS) Assessment, dated 9/22/22, revealed the resident was severely impaired cognitively and that a feeding tube…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-02 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews conducted during the Recertification Survey, completed on 11/2/22, it was determined that for one (Resident #54) of five residents reviewed the facility did not ensure that the attending physician documented that the Medication Regimen Review (MRR) that was completed by the pharmacist was reviewed for irregularities/recommendations and action taken if any and/or a rationale if no action taken. Specifically, the pharmacist had consistently noted irregularities on the MRR reports related to a Gradual Dose Reduction (GDR) of an antipsychotic medication and recommendations for other medications and there was no evidence that the irregularities were addressed by the by the physician or the Director of Nursing (DON) per the regulations. This is evidenced by the following: The facility policy, 'Medication Regimen Reviews', effective November 2021, documented that any recommendations are acted upon and documented by the facility staff and/or the prescriber. The Physician accepts…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the Recertification Survey completed on 11/2/22, it was determined that for two (Empire and [NAME]) of three resident units, one of one service wing, and one of one basement, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, exhaust ventilation was not working, a water softener tank and circulating pump was leaking, soiled towels were present on a windowsill, and there was a leak in a water hose behind a washer. The findings are: 1. Observations in the presence of the Assistant Director of Maintenance (ADM) on 11/1/22 from 1:46 p.m. to 1:55 p.m. revealed that the mechanical exhaust ventilation was not drawing air through the ventilation ducts in the following locations on the [NAME] Unit: both shower rooms, the shared bathroom between resident rooms #12 and #14, in the shared bathroom between resident rooms #29 and #31, and in the soiled work room. When…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2022-11-02 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 11/2/22, it was determined that for one (Resident #22) of one resident reviewed for restraints and one (Resident #117) of one resident reviewed for a discharge from the facility, the facility did not accurately code the Minimum Data Set (MDS) Assessment to reflect the resident's status. Specifically, for Resident #22, the MDS Assessment did not accurately reflect the use of a restraint, and that the resident was on an antipsychotic and antidepressant medication. For Resident #117, the MDS Assessment did not accurately reflect the resident's discharge disposition. This is evidenced by the following: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 3.0, and published by the Centers for Medicare & Medicaid Services (CMS) includes that its purpose is to provide guidance on gathering information about the resident to assess and develop individualized care plans 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during a Recertification Survey, completed on 11/2/22, it was determined that for one (Resdient #22) of five residents reviewed the facility did not review and revise the resident's care plan to reflect the resident's current status. Specifically, Resident #22's Comprehensive Care Plan (CCP) was not revised to reflect the discontinued use of an antipsychotic medications. This was evidenced by: The facility policy Comprehensive Care Planning, dated 12/5/21, included the interdisciplinary team will review and revise the care plan quarterly following MDS completion, with a significant change, return following hospital admission, annually, and as needed. The CCP will be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating their respective care plans on a continual basis. Resident #22 was admitted [DATE] with diagnoses that included schizoaffective disorder, cerebral infarct (stroke) with right hemiparesis (weakness on one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-02 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during a Recertification Survey completed 11/2/22 it was determined that for one (Resident #86) of one resident reviewed, the facility did not provide an ongoing program of activities based on the comprehensive assessment, the comprehensive care plan (CCP) and the preferences of each resident in order to support the resident in their choice of activities and to support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility could not provide evidence Resident #86 was provided activities based on their preferences and needs. This is evidenced by the following: The facility policy Activity Programs, dated 3/22/22, included activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Activities are offered based on the comprehensive resident-centered assessment of each resident, are offered seven days a week and are documented in the medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review conducted during a Recertification Survey, completed on 11/2/22, it was determined that for one (Resident #92) of two residents reviewed for pressure ulcers, the facility did not ensure that the resident received care consistent with professional standards of practice, and that the resident received the necessary treatment to promote healing of a pressure ulcer, prevent infection and prevent new ulcers from developing. Specifically, the facility did not administer treatments as ordered by the medical team. This was evidenced by the following: Review of the facility policy 'PRESSURE INJURY PREVENTION & MANAGEMENT WOUND ROUNDS' dated December 2021, revealed that the nurse is responsible for the following when a pressure ulcer is identified: To administer the treatment as ordered. Resident #92 had diagnoses including a compression fracture of the spine, diabetes, and epilepsy (nerve cell activity in the brain disturbance causing seizures). The Minimum Data Set Assessment, dated 9/3/22, documented that the resident was moderately…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-02 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY ased on observations, interviews, and record review conducted during the Recertification Survey completed on 11/2/22, it was determined that for one (Resident #220) of one resident reviewed for bowel and bladder incontinence, the facility did not ensure that the resident who required colostomy, urostomy, or ileostomy services, received such care consistent with professional standards of practice, the resident's comprehensive person-centered care plan and the resident's goals and preferences. Specifically, Resident #220's current physician orders and Treatment Administration Record (TAR) did not include instructions for a colostomy (an opening from the bowel diverting feces through the abdomen into a pouch) care, and the resident's Comprehensive Care Plan (CCP) did not include goals, person-centered approaches for the resident's colostomy care or include that Resident #220 had a colostomy. This is evidenced by the following: Review of the facility's Colostomy, Ileostomy, Urostomy Care, policy, dated March 2011…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews conducted during the Recertification Survey completed on 11/2/22, it was determined that for one (Resident #54) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free from unnecessary medications. Specifically, Resident #54 was prescribed an anti-psychotic medication without evidence of implementation of resident specific non-pharmacological interventions, and without evidence that a Gradual Dose Reduction (GDR) of the medication had been attempted or documentation of a clinical contraindication for a GDR. Additionally, current physician documentation did not accurately reflect the resident's currently prescribed medications. This is evidenced by the following: The facility policy, 'Psychotropic Medications, Unnecessary Use', dated 10/24/22, included orders for psychotropic medications are used only for the treatment of specific medical and /or psychiatric conditions or when the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2020-09-24 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three of three residential units, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, the facility was unable to provide evidence of a complete infection control program that consistently identified, tracked, investigated, monitored, and analyzed surveillance data to prevent infections in the facility. This is evidenced by the following : A review of the infection control program was conducted on 9/23/20 at 2:00 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). When asked for the facility infection control line listing, the DON provided an Antibiotic Tracking Form. The ADON said that the Antibiotic Tracking Form was used to track and trend all infections and antibiotic usage. Review of the form, from 1/1/20 to present, revealed inconsistent data…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-09-24 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of two residents reviewed the facility did not thoroughly investigate injuries of unknown origin to rule out abuse, neglect, or mistreatment. Specifically, Resident #92 had bruises of unknown origin that were not investigated. This is evidenced by the following: Resident #92 had diagnoses that included Alzheimer's, chronic obstructive pulmonary disease, and pneumonia. The Minimum Data Set Assessment, dated 9/5/20, revealed that the resident had severely impaired cognition. The nursing admission assessment, dated 9/10/20, included no skin issues. The weekly skin check form, dated 9/15/20, documented the resident's skin was intact. The Comprehensive Care Plan, dated 9/15/20, included the resident was at risk for impaired skin integrity. Interventions included to monitor and document skin injuries. A review of the progress notes, from 8/25/20 through 9/20/20, revealed no documented bruises or skin issues. Observations conducted on 9/17/20 at 10:09 a.m.,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-09-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of two residents the facility did not ensure a comprehensive person-centered care plan was developed that included measurable objectives and timeframes to meet the resident's medical and nursing needs that were identified in the comprehensive assessment. Specifically, Resident #49 did not have a care plan for an actual pressure ulcer and bone infection. This is evidenced by the following: The facility policy, Comprehensive Care Planning, dated April 2020, revealed that actual infections and pressure ulcers would be included in the Comprehensive Care Plan. Resident #49 had diagnoses including an unstageable pressure ulcer of the sacral region, fracture of the right femur, and sacral osteomyelitis (bone infection). The Minimum Data Set Assessment, dated 8/3/20, revealed the resident had severely impaired cognition, received antibiotics, and had one unstageable pressure ulcer. The care area assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-09-24 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not provide proper treatment and assistive devices to maintain vision for one of two residents reviewed. Specifically, the facility was unaware that Resident #11 lost their glasses and would like them replaced. This is evidenced by the following: The facility policy, Vision Services and Devices, dated October 2017, directs if a resident loses their devices, the nursing home will assist the resident or designated representative in locating resources including assistance in making appointments and transportation. Resident #11 has diagnoses including unspecified dementia with behavioral disturbance, schizophrenia, and nicotine dependence. The Minimum Data Set Assessment, dated 6/13/20, revealed the resident had moderately impaired cognition and adequate vision (able to see in adequate light with glasses or another visual appliance). The Visual/Bedside [NAME] which directs daily…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-09-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not provide necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers from developing for one of three residents reviewed. Specifically, Resident #6 was not wearing blue booties on both feet at all times and was not repositioned every two hours. This is evidenced by the following: Resident #6 had diagnoses including sacral osteomyelitis (bone infection) and a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum. The Minimum Data Set Assessment, dated 6/4/20, revealed the resident had moderately impaired cognition, was dependent on two staff members for bed mobility and transferring, and had a Stage IV pressure ulcer. The initial wound consultant notes, dated 6/4/20, revealed that the resident had a Stage IV pressure ulcer of the sacrum. Interventions in place included a low-air loss support surface,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-09-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #84) of two residents reviewed, the facility did not ensure that a resident with limited Range of Motion (ROM) received appropriate treatment and services to increase ROM or to prevent further decrease in ROM. Specifically, Resident #84 had contractures of the left upper extremity, and the facility did not implement interventions to prevent complications related to decreased ROM. This is evidenced by the following: Resident #84 had diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, amputation of the right leg below the knee, and amputation of the left leg above the knee. The Minimum Data Set Assessment, dated 8/24/20, revealed the resident had severely impaired cognition, required extensive assistance of two or more staff for personal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-09-24 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed, the facility did not ensure that residents received services consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, Resident #57's fluid restriction was not consistently monitored, assessed, and documented, there was a lack of consistent ongoing communication between the facility and dialysis, and the facility did not consistently document assessments before and after dialysis treatments. This is evidenced by the following: Resident #57 had diagnoses including diabetes, renal disease with hemodialysis, and cerebral vascular accident. The Minimum Data Set Assessment, dated 8/13/20, revealed the resident had moderately impaired cognition and received dialysis. The facility's April 2020 Hemodialysis Policy included the licensed nurse would complete pre and post dialysis progress notes on dialysis days including…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-09-24 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed, the facility did not ensure a resident was promptly referred to dental services for lost dentures. Specifically, the facility did not identify that Resident #57's dentures were missing or provide dental services to replace them. In addition, the Comprehensive Care Plan (CCP) did not address the resident's dental needs. This is evidenced by the following: Resident #57 had diagnoses that included diabetes, renal disease with hemodialysis, and cerebral vascular accident. The Minimum Data Set (MDS) Assessment, dated 8/13/20, revealed the resident had moderately impaired cognition and required the extensive assistance of one staff for personal hygiene (which included oral care). The admission MDS Assessment, dated 12/30/19, did not identify the resident as edentulous (no natural teeth). A dental evaluation, dated 12/17/19, revealed the resident had full upper…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-09-24 · tag F0801 — isolated
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review conducted during the Recertification Survey, it was determined that the facility did not ensure that a qualified dietician carried out the functions of the food and nutrition services. Specifically, the Registered Dietician had not been onsite since March 2020 and had not completed physical nutritional assessments or participated in interdisciplinary care plan meetings. This is evidenced by the following: When interviewed on 9/22/20 at 2:49 p.m., the Director of Nursing said visitors to the building were limited due to the COVID-19 pandemic. She said she considered the Registered Dieticians (RD) contractors and told them not to come onsite. She said that she did not realize that the RDs performed physical nutritional assessments. In an interview on 9/23/20 at 9:45 a.m. and 10:01 a.m., RD #1 said the last time an RD was in the building was in March 2020. She said the RDs have been working remotely with access to the medical record. She said the RDs did not have access to electronic devices to be able to physically see or interact with residents.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PERSONAL HEALTHCARE MANAGEMENT — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.9+0.1 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 4 of 53.0+1.0 vs chain
The other 20 homes this chain runs (chain average 2.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BARTH, ALEXANDERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF35%since 02/29/2016
WALDEN, YEHUDAHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 09/18/2014
ZAGELBAUM, EPHRAIMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 09/18/2014
ODUWA, FELIXIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
OLTON, SHAINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2023

CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$12.2M
Net patient revenuemost recent cost report
+1.3%
Operating marginrevenue minus expenses
$1.7M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 6%Other / private 17%

About 77% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$289per resident / day
operating cost
$8,777per month
≈ monthly operating cost
$293per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335378. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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