Pine Valley Center For Rehabilitation And Nursing
661 N Main St, Spring Valley, NY 10977 · For profit - Limited Liability company · 160 certified beds · (845) 356-0567 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 fell from 3 to 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 | 12.1% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.1% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 19.5% | 6.5% | check this* — see note marked star 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 | 1.3% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.4% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.7% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.3% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.7% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.1% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 67.9% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.3% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.1% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.60 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.91 | 1.36 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
41.2% 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 255 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 36.5% 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 104 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 41.2%CMS range 35.4–46.7 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.8–12.9 | 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 | 36.5% | 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 | 41.4% | 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 | 18.3% | 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 | 99.2% | 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 | 100.0% | 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 | 100.0% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 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 | 7.2%CMS range 4.8–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 160 beds and averages 154.9 residents a day — about 97% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 3.99 on weekdays — 15% thinner on weekends. RN hours go from 0.66 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2025-12-22 · 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 and interview the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, twenty-five (25) food items were not properly identified and dated in the kitchen refrigerators, freezers, and food storage areas.Findings include:The facility policy titled Food Storage last revised May 2025, documented all containers must be legible and accurately labeled and dated. Food must be dated as it is placed on the shelves and left over food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before it is refrigerated. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates. On 12/15/2025 at 9:40 AM, the initial inspection of the kitchen was conducted with the Food Service Director, and the following were observed:In the Meat Refrigerator: a five (5) lb. container of peeled garlic with no opened date, one (1) tray of cabbage-open to air in a container…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 observation, record review, and interview the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent and/or treat pressure ulcers for three (3) of eight (8) residents (Residents #59, #91 and #100) reviewed for Pressure Ulcers. Specifically, 1) heel offloading was not implemented as per physician order for Resident #59 who was assessed at risk for pressure ulcers 2) heel offloading was not implemented as per comprehensive care plan and physician order for Resident #91 who was assessed at risk for pressure ulcers and 3) heel offloading was not implemented as per physician order for Resident #100 who was assessed at risk for pressure ulcers.The findings include:A policy titled Pressure Ulcer Prevention and Intervention Program, updated 06/2025, documented residents of this facility will have a pressure sore prevention and intervention program to identify risk factors, prevent pressure sore and ulcer formation when avoidable and promote skin integrity, as well as interventions to heal existing pressure sores and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-22 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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 observation, interview, and record review the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for four (4) of six (6) residents (Residents #50, #34, #59, and #91) reviewed for Positioning and Mobility. Specifically, 1) the use of carrot splints was not implemented as per physician order and care plan for Resident #50 with contractures (fingers bent into the palms) of both hands, 2) the use of a left- hand roll brace was not implemented as per physician order for Resident #34, and 3) the use of a right resting hand splint was not implemented as per physician order for Resident #59. Additionally, the use of a left-hand carrot was not implemented as per physician order for Resident #91. The findings include: The policy and procedure titled Contracture Management revised 09/21/2025 documented prevent the decrease in range of motion, maintain skin and joint integrity, 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 · D2025-12-22 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review the facility did not ensure the residents' Minimum Data Set assessments were completed not less frequently than once every three (3) months for one (1) of two (2) residents (Resident #44) reviewed for Resident Assessment. Specifically, a quarterly Minimum Data Set assessment was not completed three (3) months after the completion of the 06/28/2025 annual Minimum Data Set for Resident #44.The findings includeAn undated facility policy titled Comprehensive Assessment documented the Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments at least quarterly.Resident #44's diagnoses included obstructive uropathy, unstageable pressure ulcer of sacral region and adult failure to thrive. An annual Minimum Data Set (a resident assessment tool) dated 06/28/2025 documented Resident #44 had severe cognitive impairment, was dependent for activities of daily living, and had one pressure ulcer. There was no documented evidence of a September/October 2025 quarterly Minimum Data Set.During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview conducted during the recertification survey from 12/15/2025 to 12/22/2024, the facility did not ensure that Minimum Data Set 3.0 Assessments accurately reflected the residents' status for one (1) of seven (7) residents reviewed for Accidents. Specifically, the Minimum Data Set 3.0 annual comprehensive assessment did not identify Resident #9 as an active smoker.The findings included:An undated facility policy titled Comprehensive Assessment documented information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. Resident #9's diagnoses included nicotine dependence, unspecified paraplegia and bipolar disorder. The Resident Smoking Contract was signed and dated on 12/05/2024.The care plan updated 08/24/2025 documented monitor compliance with smoking contract, resident would be directed to designated smoking area and smoking screen to determine safety.The Annual Comprehensive Minimum Data Set (a resident assessment tool) dated 10/22/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-22 · 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 observation, Interview, and record review the facility did not ensure they developed and/or implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's needs for one (1) of five (5) residents (Resident #13) reviewed for Environment. Specifically, a care plan was not developed and/or implemented to address Resident #13's known hoarding behavior.The findings include:Resident #13 had diagnoses of chronic kidney disease and malignant neoplasm of the cervix.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #13 was cognitively intact and did not display any inappropriate behavior.The Comprehensive Care Plan related to behavior initiated 10/15/2025 documented Resident #13 had episodes of refusing to go for dialysis treatment.There was no documented evidence a behavior care plan was developed to address Resident #13's hoarding behavior.On 12/16/2025 at 11:57 AM 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 · D2025-12-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure the resident plan of care was reviewed and revised for one (1) of three (3) residents (Resident #13) reviewed for Rehabilitation Services. Specifically, Resident #13 had a care plan intervention for bilateral siderail enablers and was observed without enablers in place. Resident #13 had diagnoses of chronic kidney disease and malignant neoplasm of the cervix.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #13 was cognitively intact and was independent in rolling to the left and right in bed.The Comprehensive Care Plan related to activities of daily living performance and physical mobility dated 08/28/2025 and last reviewed 09/10/2025 documented Resident #13 used top bilateral bed rails for rolling to the left and right in bed, bed mobility, and transfers from bed. The Comprehensive Care Plan related to impaired mobility dated 08/28/2025 documented Resident #13 was provided with bilateral 1/2 siderails to promote…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for storage. Specifically, the Three East High Side medication cart was found unattended in the unit corridor near the nursing station unlocked with one (1) drawer left open.The findings are:The policy titled Medication Storage dated May 2025, documented nursing staff shall be responsible for maintaining medication storage, and compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use.During an observation on 12/18/2025 at 4:00 PM, the Three East High Side medication cart was found unattended in the unit corridor near the nursing station unlocked with one (1) drawer left open. The medication carts assigned nurse, Licensed Practical Nurse #20 was not near the cart, not within eyesight of the cart and was in the unit's medication room behind a closed door. During an interview on 12/18/2025 at 4:09 PM, Licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-06 · 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
Based on interview and record review conducted during the abbreviated survey (2626453), the facility did not ensure all alleged violations of abuse were reported immediately, but not later than two (2) hours to the New York State Department of Health for one (1) of three (3) residents reviewed for abuse (Resident #1). Specifically, on 9/23/2025 at approximately 2:00 PM Resident #1's family member reported that Resident #1 alleged sexual abuse, and the allegation was not reported to the New York State Department of Health until 9/24/2025 at 11:18 AM. The 10/10/2024 facility policy titled Abuse Prevention Policy and Procedure, documented it is the responsibility of all facility employees, consultants, visitors, family members and physicians to immediately report any incident or suspected incident of resident abuse, neglect, mistreatment, exploitation, misappropriation of resident property or any resident injury of unknown origin. All alleged violations involving abuse neglect exploitation or mistreatment including injuries of unknown origin and misappropriation of resident property…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, interviews, and observations conducted during an abbreviated (NY00361070, NY00351353) survey, the facility did not ensure that a resident was free from abuse. This was evident for 1 (Resident #1) of 3 residents sampled for abuse. Specifically, Certified Nursing Assistant #1, Certified Nursing Assistant #4, Resident Assistant #2 and Resident Assistant #3 are seen in video footage using more force than necessary to provide care to Resident #1. As evidenced by: The facility policy for abuse has no date created no indication of ever having been reviewed/revised, and it is not printed on official letterhead. The Policy documents, The Purpose of the Abuse Prevention Program is to ensure a safe, respectful, and dignified environment for all residents. The Policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Resident #1 was re-admitted [DATE] with diagnoses which included Cerebral vascular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2024-12-02 · 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 interviews, observations and record review conducted during an abbreviated (NY00361070) survey, the facility did not report incidents of staff to resident abuse to local law enforcement. This was evident for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, Certified Nursing Assistant #1, Certified Nursing Assistant #4, Resident Assistant #2, and Resident Assistant #3 are seen in video footage using more force than necessary to provide care to Resident #1, and those incidents were not reported to local law enforcement. As evidenced by: The facility Policy for abuse has no date, as well as no indication of ever having any updates or reviews it is also noted to not be on any official letterhead. The Policy is written as follows, The Purpose of the Abuse Prevention Program is to ensure a safe, respectful, and dignified environment for all residents. The Policy defines abuse and lists various types of abuse, Abuse is defined as the willful infliction of injury, unreasonable confinement,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-02 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and review of facility documentation conducted during an abbreviated (NY00361070, NY00351353) survey, it was determined that the facility did not ensure that a performance review of every nurse aide was completed at least once every 12 months, and that each nurse aide, based on the outcome of the performance reviews, received no less than twelve hours of in-service education per year. This was evident for 2 of 2 Certified Nursing Assistants (nurse aides) reviewed for completion of performance review and in-service education. Specifically, the facility did not ensure that Certified Nursing Assistant #1 & Certified Nursing Assistant #4 had a performance review at least once every 12 months and based on their individual performance review receive no less than twelve hours of in-service education per year. Findings Surveyor requested the facility administrator to provide the 2 Certified Nursing Assistant files including their performance reviews and their in-service education. Review of the documents revealed the following: Certified Nursing Assistant #1 had an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and staff interviews conducted during an abbreviated (NY00351353, NY00361070) survey the facility did not ensure infection control practices to prevent the development and transmission of communicable disease and infection were maintained for 2(Resident #1, Resident #6) of 3 residents reviewed. Specifically,1) Resident #1 was on enhanced precautions, Certified Nursing Assistant #7 and Licensed Practical Nurse #9 were not wearing gowns when they transferred Resident #1 from the bed-chair via Hoyer-lift and Licensed Practical Nurse #9 was not wearing a gown when they stopped Resident #1's G-Tube feeding, clamped the tubing and closed the feeding tube cap. Additionally, during a review of videos Certified Nursing Assistant #1 and #4 and Resident Assistant #2 and #3 were not wearing a gown while assisting Resident # 1 with a bed bath, changing clothes and emptying Resident #1's Foley catheter. 2) for Resident # 6 on enhanced barrier precautions Certified Nursing Assistant #6 and #8 and Resident Assistant # 15 were observed not wearing a gown while…
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 · D2023-07-14 · 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 conducted during a recertification survey (7/10/23-7/14/23) the facility did not ensure that care was provided in a manner that maintained dignity for 3 of 3 residents (#34, #21, #6). Specifically, Residents #34, #21, and #6's urinary catheter drainage bags were not concealed to prevent direct observation of urine by others. The findings are: Resident # 34 had diagnoses that included cerebral infarction, dysphagia and obstructive and reflux uropathy. The resident's 5/20/23 quarterly Minimum Data Set (MDS) documented the resident had an indwelling catheter. The resident's Urinary Catheter care plan dated 6/21/22 included an intervention to cover the drainage bag with dignity cover. An observation was made on 7/10/23 at 6:55 AM of Resident #34 lying in bed with their Foley bag hanging from their bed facing the hallway. There was urine in tubing and bag, which was visible from the hallway. Resident #21 had diagnoses that included acute kidney failure, Type 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review conducted during a recertification survey, it could not be ensured that the facility thoroughly investigated an injury of unknown origin for 1 (Resident #118) of 5 residents reviewed for accidents. Specifically, Resident #118 stated they had a burn to their right upper thigh on 6/24/2023 from hot water that was served to them in their own lidded mug, when the nurse who served the hot water did not screw on the top of the mug. The findings are: The facility policy and procedure (P/P) dated 11/2022 and titled Accidents/Incidents (A/I) documented examples of accidents included second- and third- degree burns. Procedures for the Charge Nurse/Licensed Nurse included completion of sections 1 through 17 on the A/I form and give to Registered Nurse Supervisor. Registered Nurse Supervisor procedures included review of section 1 through 17 of the A/I form, determines if an accident or incident, and completes sections 18 and 20. The A/I P/P documented in bold type: In the event an A/I occurs that is either unwitnessed or involves questionable factors the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-14 · 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
Based on observation, record review and interview during the recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure that 1 (Resident #118) of 5 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. Specifically, on 6/24/2023 Resident #118 reported they had sustained a right thigh burn after staff provided heated water from the microwave and the facility did not implement interventions for the treatment a skin impairment on the thigh until 6/26/2023. Additionally, the medical provider was unaware the resident had spilled hot water and the blister on the resident's thigh was not identified as a burn, and treated with Silvadene until 6/28/2023 when the nurse practitioner (NP) assessed. The findings are: Resident #118 had diagnoses including hypertension, renal insufficiency, and malnutrition. The 6/22/2023 Minimum Data Set (MDS: an assessment tool) documented Resident #118 was cognitively intact for decision making, received assistance with set up and supervision for eating, had limited range…
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 before2023-07-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the 7/10/23 to 7/14/23 recertification survey it was determined for 1 of 4 residents (Resident #75) reviewed for Activities of Daily Living (ADL) Decline, the facility did not ensure all residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent a further decrease in range of motion. Specifically, Resident #75 had a Physical Therapy/Occupational Therapy screen on 5/13/23 that recommended restorative nursing that was not ordered until 7/12/23. The findings are: The Policy and Procedure titled Restorative Nursing last revised 2/2019 documented the following as the purpose: range of motion is the movement of a joint though its full range in all appropriate planes. It may be passive, active or active assistive. The objective is to maintain function and prevent deterioration and to maintain motion of the joint. Additionally documented procedure can be done by licensed practical…
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 · D2023-07-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review conducted during the recertification survey from 7/10/23 to 7/14/23, it was determined for 1 of 3 residents (Resident # 48) reviewed for Nutrition and Hydration, the facility did not ensure the resident was provided the necessary care to maintain an acceptable body weight. Specifically, when Resident #48 lost 19 pounds the significant weight loss was not addressed by the dietitian for over one month. The findings are: The facility undated policy for weights documented that weights would be monitored regularly to evaluate potentially undesirable weight changes. The nurse on the unit and the registered dietitian (RD) would review weights for discrepancies from prior weights. Resident #48 had diagnoses including cerebral infarct, dysphagia (difficulty swallowing), and gastro-esophageal reflux. The admission Minimum Data Set (MDS, a resident assessment tool) completed on 6/11/23 documented the resident's cognition was intact and the resident ate with supervision and tray set up. A physician order dated 3/9/23 documented monthly weights.…
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 before2023-07-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews conducted during the recertification survey from 7/10/23 to 7/14/23, the facility did not ensure food was prepared, stored, and served in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, 1. a food service worker was observed preparing food without a proper hair restraint, 2. the freezer and refrigerator logs in the meat kitchen were forged and, 3. a large pan of raw chicken was improperly stored. The findings are: A facility policy and procedure last revised in January 2022 titled 'Food Storage' stated all foods should be covered, labeled, and dated. The policy additionally stated refrigerator/freezer temperatures should be checked at least 2 times a day and documented on the refrigerator temperature sample form. 1. On 7/10/2023 at 6:26 AM, Food service worker (FSW) #1 was observed cutting onions in the meat kitchen without proper a proper hair covering. During an interview on 7/10/23 at 6:26 AM, FSW #1 stated, as they were cutting onions, they had just arrived…
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 before2023-07-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey (7/10/23-7/14/23), the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) During a meal observation two certified nurse aides (CNA) buttered toast using their bare hands before handing the toast to Residents #124 and #26. 2) Housekeeping staff was observed pushing clean linen on an uncovered cart down a hallway. 3) A CNA was observed not using Personal Protective Equipment (PPE) and removed dishes from a resident's room that was on contact precaution, placed the dishes on a food truck, and continued to stack more dishes from the dining room on the food truck without performing hand hygiene. The findings are: 1) Resident #124 had diagnoses including dementia, chronic obstructive pulmonary disease (COPD) and need for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-14 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Revised 9/26/2023 IDR Based on observations, interviews and record review conducted during a recertification survey from 7/10/23 to 7/14/23, it could not be ensured that the facility maintained all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the walk-in freezer door was broken causing excessive frost on equipment, and the ice machine in the dairy kitchen was not maintained in a sanitary manner. Findings include: During an initial tour of the kitchen on 7/10/23 between 6:15 AM and 7:20 AM and the following was observed: -The walk-in freezer in the meat kitchen had a broken cord dangling from the inside of the freezer door and excessive frost/freezer burn was observed on more than 10 boxes of frozen meat, there was also ice buildup on the floor and the walls. -An ice machine in the dairy kitchen was visibly soiled with a black/brown grimy substance in the drip tray, multiple dirty towels bunched-up underneath the machine, a metal tray to collect dripping water underneath, and excessive corrosion on the back of the machine. A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review conducted during the most recent recertification survey, it could not be ensured that the facility provided appropriate care and services for the use of an indwelling catheter (a tube inserted into the bladder to drain urine) for 1 of 4 residents reviewed (Resident # 91). Specifically, the catheter leg bag (to be used when the resident is out of bed) was attached to the resident above the knee while he was lying flat in bed. The findings are: Resident #91 was admitted to the facility 10/7/19 with diagnoses including Renal Insufficiency, and Obstructive Uropathy (a condition in which the flow of urine is blocked). Review of the Minimum Data Set (MDS - resident assessment tool) dated 10/12/19 revealed that Resident #91 was admitted with an indwelling catheter. Review of the Physician's Orders revealed that the resident was to have a urinary catheter to gravity for drainage. On 11/22/19 at 12:35 PM the resident was observed to be in bed, lying flat. A bedside drainage bag was not observed. The resident agreed to allow the surveyor to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that staff followed proper hand hygiene and gloving technique to prevent cross contamination and the spread of infection. Specifically, (1) cross contamination of a wound and wound supplies was observed and proper hand hygiene were not observed during a wound care observation for 1 of 7 residents (Resident #348) (2) soiled linens and diapers were observed in plastic bags on the floor in an occupied resident room on the second floor - [NAME] Side Unit. The findings are: A random observation was conducted on the second floor, [NAME] Side Unit on 11/19/19 at 11:04 AM and the following was observed: Soiled linens and diapers in plastic bags were observed on the floor in an occupied resident room. A Certified Nursing Assistant (CNA) was interviewed at that time and stated that she had no explanation and that she should have placed them in the soiled linen receptacle. Resident # 348 has diagnoses and conditions including Brain Injury, Seizure and Unstageable Pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- 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.
Part of a chain
This home belongs to UPSTATE SERVICES GROUP — 17 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 4 of 5 | 2.6 | +1.4 vs chain |
| Quality measures | 4 of 5 | 2.8 | +1.2 vs chain |
The other 16 homes this chain runs (chain average 2.0★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KOENIG, LAWRENCE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 17% | since 12/22/2010 |
| KOENIG, URI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 22% | since 12/22/2010 |
| STEIF, EFRAIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 50% | since 08/15/2017 |
| AUGENSTEIN, JACK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/15/2015 |
| WUERTZER, AMY | Individual | CORPORATE OFFICER | — | since 09/14/2017 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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 $1.7M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335285. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-22, 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.