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Eddy Heritage House Nursing And Rehabilitation Ctr

2920 Tibbits Avenue, Troy, NY 12180 · Non profit - Corporation · 120 certified beds · (518) 274-4125 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Special Focus candidate (CMS is watching this home)Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
  • 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
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2200 Burdett Ave · (518) 272-0122 · Call to confirm hours
Pharmacy
549 Hoosick St · (518) 274-5080 · Call to confirm hours
Grocery
ALDI0.3 mi
662 Hoosick Road
Park
Typically dawn to dusk
Place of worship
411 Hoosick St · (518) 272-6113

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 rating1★
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 increased12.3%14.1%15.4%better
Long-stay residents who lose too much weight5.1%5.8%5.4%typical
Long-stay residents with a catheter left in their bladder3.1%0.5%0.9%worse
Long-stay residents with a urinary tract infection1.8%1.3%2.0%typical
Long-stay residents with depressive symptoms0.0%19.5%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.6%3.1%3.3%better
Long-stay residents whose ability to walk worsened11.3%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.1%13.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers6.1%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control19.6%19.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table14.0%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.2%78.8%79.4%better
Short-stay residents rehospitalized after admission27.5%20.6%22.6%worse
Short-stay residents with an outpatient ER visit15.7%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.981.701.67worse
Long-stay outpatient ER visits per 1,000 resident days1.611.361.80better

* 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.

54.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 153 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.1%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
37.8%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 37.8% 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 98 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.1%CMS range 43.8–59.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.2–12.310.7%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 discharge37.8%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 discharge38.8%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 discharge34.7%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 identified100.0%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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 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 stay0.8%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 worsened3.8%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 hospitalization7.2%CMS range 4.2–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.70
RN hours/ resident / day
1.12
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.90
Total nurse hours/ resident / day
0.29
RN hoursweekends
53.0%
Total nursing turnover
51.9%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 108.5 residents a day — about 90% occupied, or roughly 12 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.40 hrs/resident/day on weekends vs 4.10 on weekdays — 17% thinner on weekends. RN hours go from 0.87 to 0.29 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

9
deficiencies at the latest standard inspection (2024-02-27)
2
at the previous standard inspection (2021-09-14)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · J2025-11-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 observations, interviews, and record reviews conducted during the abbreviated survey (#2665815), the facility failed to ensure residents' right to be free from neglect for one (1) of five (5) residents reviewed. (Resident #1). Specifically, on [DATE] at 2:00 PM, the facility identified that Resident #1 received four (4) incorrect doses of morphine sulfate (a strong opioid analgesic used to treat moderate to severe pain) totaling 80 milligrams over a 12-hour timeframe. This resulted in the resident becoming lethargic and unresponsive with unstable vital signs including blood pressure and oxygen saturation. The facility failed to provide interventions to reverse the effects of the medication despite the family inquiry to Narcan (also known as naloxone, a medication used to reverse or reduce the effects of opioids). The resident expired on [DATE] at 6:20 AM. This resulted in Substandard Quality of Care that was Immediate Jeopardy that resulted in the death of Resident #1, with the likelihood of serious…

    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
  • Immediate jeopardy · J2025-11-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews conducted during the abbreviated survey (#2665815), the facility failed to ensure residents were free from significant medication errors for one (1) of five (5) residents reviewed (Resident #1). Specifically, the facility administered four (4) incorrect doses of morphine sulfate (a strong opioid analgesic used to treat moderate to severe pain), totaling 80 milligrams over a 12-hour period. This resulted in Substandard Quality of Care that was Immediate Jeopardy and resulted in the death of Resident #1, with the likelihood of serious injury, harm, impairment, or death to all 108 residents in the facility.This is evidenced by:Cross reference to F-600: Free from Abuse and Neglect.The facility policy and procedure titled Medication Administration dated [DATE], documented that each resident would receive medications according to the provider orders and accepted professional standards. The nurse was responsible for having knowledge of the therapeutic effects, contraindications,…

    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 · Ecited before2025-11-26 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during an abbreviated survey (Case #2665815), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for four (4) (Resident #'s 10, 11, 12, and 13) of four (4) residents reviewed for medication administration. Specifically, the resident's medications were administered late across various units and their medical providers were not notified. This is evidenced by: The Facility Policy titled Medication Administration effective date 12/21/2025, documented it was the policy of the facility that each patient/resident/elder would receive medications according to provider orders and accepted professional standards. Times entered into the electronic medication administration record are used to organize the nursing workflow and do not reflect times ordered by the medical staff. Red alerts highlighted in the electronic medication administration record do not reflect late medications. The nurse…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-26 · 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 record reviews and interviews conducted during the abbreviated survey (Case #2665815), the facility did not ensure equal access to quality care regardless of diagnosis for (1) (Resident #1) of one (1) resident reviewed. Specifically, staff did not question, assess, or respond to a significant medication error because Resident #1 was receiving hospice services. Licensed Practical Nurse #2 stated they did not question medication that they dispensed to Resident #1 because the resident was on hospice. This compromised Resident #1's right to dignity, self-determination, and access to medically appropriate care. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The Policy and Procedure titled Resident Rights, dated 5/28/2024 documented that the facility would ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside…

    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 · D2025-11-26 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the abbreviated survey (Complaint #2665818), the facility did not ensure that hospice or the resident representative/emergency contact was notified of a significant medication error for 1 (one) (Resident #1) of 5 (five) residents reviewed. Specifically, Resident #1 experienced a significant medication error on 10/09/2025, and there was no documented evidence that hospice was notified, and the resident's representative was not made aware until 10/28/2025. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The document Service Agreement by and between [Hospice Vendor #1] and [Facility] dated 10/24/2027, documented promptly upon admission of a hospice patient, who has not been residing in a nursing home, to the Nursing Facility and consent of the Hospice Patient (or his/her Authorized Representative), Hospice would furnish nursing with a copy of the then-current…

    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 · Dcited before2025-11-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 and record review conducted during an abbreviated survey (Case #2665815), the facility did not ensure that all alleged violations involving neglect were reported immediately, but not later than 2 (two) hours after the allegation was made, if the event that caused the allegation resulted in serious bodily injury to the Administrator and to the State Survey Agency in accordance with State Law for one (1) (Resident #1) of 1 resident reviewed. Specifically, Resident #1 was involved in a serious adverse event / medication error that resulted in their death on [DATE]. The event was not reported to the New York State Department of Health. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The Facility Policy titled Medication Errors and Reporting effective [DATE], documented the facility maintained a nonpunitive reporting culture, which encouraged all staff to report medication events immediately. All…

    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 · D2025-11-26 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    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 abbreviated survey (Case # 2665815) from 11/17/2025 to 11/26/2025, for 1 (one) (Resident #1) of 3 (three) residents reviewed, the facility did not ensure that the Physician provided supervision of medical care. Specifically, Physician #1 signed 5 incorrect orders for morphine concentrate oral liquid resulting in Resident #1 receiving 80 milligrams of morphine over a 12-hour period. Additionally, there was no documented evidence that Physician #1 provided any follow up instructions or care to Resident #1 after the medication administration was discovered. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. Record review revealed Resident #1 was admitted to the facility on [DATE] for five (5) days of respite care (a short-term, substitute care for a person who requires assistance by a caregiver. Respite care provides temporary relief for primary…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the abbreviated survey (Case # 2668815), the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 (one) of 5 (five) residents reviewed (Resident #1). Specifically, the facility administered morphine sulfate (strong opioid used to treat moderate to severe pain) as a routine, standing medication despite no documented clinical evidence of pain or shortness or breath, exposing Resident #1 to unnecessary risk of adverse drug effects including over-sedation and respiratory depression. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The Policy and Procedure titled Medication Administration, dated 12/21/2023 stated each resident will receive medications according to the provider orders and accepted professional standards and the nurse is responsible for having knowledge of the therapeutic effects,…

    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 · D2025-11-26 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews conducted during the abbreviated survey (Case # 2665815), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ar resident (Resident #1). Specifically, the facility lacked oversight in place to use its resources (staff, policies, and communication systems) effectively and efficiently to protect Resident #1. This is evidenced by: Reference is made to deficiencies related to ineffective administration: Please refer to F600 as it pertains to the facility's failure to ensure freedom from neglect. Please refer to F760 as it pertains to the facility's failure to ensure freedom from significant medication errors. Please refer to F550 as it pertains to the facility's failure to ensure resident dignity. Please refer to F609 as it pertains to the facility's failure to ensure adverse events were reported to the State Survey Agency. Please refer to F684 as it pertains to the facility's failure to ensure…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-27 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews conducted during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure prompt efforts were made to respond to grievances and complaints from residents of the facility. Specifically, the facility did not ensure the facility's process for missing property and grievances was followed when the residents reported lost items or filed complaints. Additionally, the residents needed to be appropriately apprised of the progress toward any resolutions made for grievances or missing items. This is evidenced by: Policy and Procedure titled Complaints and Grievances, dated 1/2016, documented that the facility would promptly deal with complaints and recommendations made by residents and their designated representatives. The purpose of this policy was to promptly bring complaints or recommendations to the attention of one individual responsible for addressing and explaining to the resident when a complaint could not be fully resolved. During a record review, grievances provided by the facility from August 2023 through November…

    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 · E2024-02-27 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not provide pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals according to professional standards. Specifically, (a.) an administered controlled substance was not signed out on the control substance record when documented in the resident's medical record as administered; and (b.) nursing staff did not verify the correct resident prior to medication administration for 2 (Resident #'s 4 and 76) residents observed for medication administration. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 12/21/2023, under Procedure: documented the Registered Nurse/Licensed Practical Nurse will 3. Note carefully the name, dose, amount of administration and expiration date. 5. Use pill crusher to crush tablets (per order). 6. Identify the resident/elder by two identifiers (ex, checking the ID bracelet, ID photo in electronic 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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, record review, and interviews conducted during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) controlled substances were not kept secured in a double locked cabinet; (c.) expired medications were present; and (d.) an unlocked medication cart was left unattended. This was evident for 4 out of 6 medication carts reviewed, and for 1 out of 3 medication storage rooms reviewed. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 12/21/2023, documented the nurse was to carefully check the name, dose, amount of administration and expiration date, and to remain with the unlocked medication cart/cabinet. It further documented that if nurse needed to leave the cart, the cart was to be locked. The Facility's Pharmacy Services and Procedure Manual revised 8/7/2023 documented the facility was to store Schedule II - V…

    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
Show the remaining 17 citations
  • Potential for harm · Ecited before2024-02-27 · 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

    Based on observation, record review, and interviews during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not prepare and serve food in accordance with professional standards for food service safety in 3 (three) of 3 kitchenettes. Specifically, food was not stored to preclude contamination, the kitchenettes were not clean, and the cabinetry in the kitchenettes were not in good repair. This is evidenced by: During observations on 2/20/2024 at 10:44 AM, single-serving packets of beverage thickener were stored under the sink in the Second Floor Unit kitchenette. Cabinets, cupboards, drawers, microwave ovens, and the floor in corners and next to walls were soiled with food particles in the Second Floor Unit kitchenette and the Third Floor Unit kitchenette; the bottom of cabinet under the sink in the Fourth Floor Unit kitchenette was warped and soiled with black particles. In the Second Floor Unit kitchenette, 2 cabinet doors would not close and stay shut when tested, and in the Third Floor Unit kitchenette, one cupboard door was missing a handle. The undated…

    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 · Dcited before2024-02-27 · 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, interviews, and record review during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (Resident #'s 257 and 258) of 22 residents reviewed for privacy and dignity. Specifically, (a.) staff did not knock on Resident #257's door prior to entering and (b.) did not cover the urine collection bag for Resident #258 for treatment reflective of dignified care and respect for the privacy of the residents. This is evidenced by: A. Staff did not knock on resident doors prior to entering: Resident #257 Resident #257 was admitted to the facility on [DATE] with diagnoses including acute chronic systolic (congestive) heart failure (a disease of the heart caused by damage that has developed over time), acute respiratory failure with hypoxia (a condition where you do…

    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 · Dcited before2024-02-27 · 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

    Based on observations, record reviews and interviews conducted during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 (Resident #70) of 22 residents reviewed for comprehensive care plans. Specifically, for Resident #70, the facility did not ensure a comprehensive care plan was developed to address the medical order for supplemental oxygen use. This is evidenced by: The facility's policy and procedure titled Interdisciplinary Care Conference and Care Planning dated 6/27/2023 documented the facility would develop a comprehensive, resident-centered care plan for each resident based on the individual needs/problems of each resident. Resident #70 Resident #70 was admitted to the facility with the diagnoses of dementia (a general term for the impaired ability to remember, think, or make decisions that…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · 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 record review and interviews during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 2 (Resident #'s 47 and #257) of 18 residents reviewed. Specifically, for Resident #47, the comprehensive care plan for psychotropic medication was not reviewed/revised with medication changes. For Resident #257, the comprehensive care plan was not updated/revised after intervention for oxygen administration was discontinued. This is evidenced by: The Policy and Procedure titled, Interdisciplinary Care Conference and Care Planning, dated 6/27/2023, documented the facility would develop a comprehensive, resident-centered care plan for each resident based on the individual needs/problems of each resident. Resident #47 Resident #47 was admitted to the facility with the diagnoses of type 2 diabetes mellitus (a…

    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 · D2024-02-27 · 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 Resident #47 Resident #47 was admitted with the diagnoses of dementia, generalized anxiety disorder (ongoing anxiety that interferes with daily activities), and type 2 diabetes. The Minimum Data Set, dated [DATE] documented the resident was able to be understood, could understand others and had a moderate cognitive impairment. Review of Resident #47's medical record indicated a Physician's Order dated 12/15/2023 for quetiapine (psychotropic) 25 milligrams by mouth every 24 hours as needed for psychosis. Record review indicated this order was discontinued on 1/15/2024. Record review indicated Resident #47 had a Physician's Order dated 1/16/2024 for quetiapine 25 milligrams by mouth every 24 hours as needed for psychosis. Record review indicated this order did not include an end date. Record review indicated Resident #47 had a Physician's Order dated 2/8/2024 for lorazepam (anti-anxiety) 1 milligram tablet to be given 1 tablet by mouth every 12 hours as needed for anxiety. Review indicated no end date included…

    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 before2024-02-27 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interviews during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not dispose of garbage and refuse properly. Specifically, the exterior dumpster was not clean nor in good repair, and the grounds around the dumpster was littered. This is evidenced by: During observations on 2/20/2024 at 10:38 AM of the exterior grounds, the side door to the garbage dumpster had a 3-inch round hole, one side of the dumpster was soiled with black drip marks, and the ground around the dumpster was littered with food refuse. During an interview on 2/20/2024 at 10:41 AM, Food and Nutrition Director #1 stated that litter could have been there for 2 days and that they would ask the Manager of Facilities #1 to contact the dumpster vendor for dumpster cleaning and door repair. During an interview on 2/20/2024 at 1:27 PM, Administrator #2 stated that Manager of Facilities #1 cleaned the area on 2/20/2024 by 11:00 AM, and the dumpster vendor would be contacted. 10 New York Codes, Rules, and Regulations 415.14(h)

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review during the recertification and abbreviated survey (Case # NY00297663) from 2/20/2024 to 2/27/2024, the facility did not ensure that a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standard of quality care was developed within 48 hours of admission. This was identified for 1 (Resident #107) of 22 residents reviewed. Specifically, Resident #107 was admitted on [DATE] with history of falls and was assessed to be high risk for falls. A baseline care plan was not developed within 48 hours to include at risk for falls with interventions for safety. This is evidenced by: Cross-reference F-689. The facility's policy and procedure titled Falls Management Policy, effective 10/04/2021, documented Procedure: #2: Residents who were at risk for falls would have an individualized care plan developed which identified interventions to reduce fall risk. The facility's policy 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 · Dcited before2024-02-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 record review and interviews during an abbreviated survey (Case # NY00316856), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #1) of 5 residents reviewed. Specifically, an allegation of physical abuse reported by Resident #1 on 5/15/2023 was not reported to the New York State Department of Health after the allegation was made. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, squamous cell carcinoma (skin cancer), and anemia (condition of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue). The Minimum Data Set (an assessment tool) dated 5/18/2023, documented the resident could be understood, could understand others, and had intact cognition for decisions of daily living. The facility's Abuse, Prevention and Investigation Policy, dated…

    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 · D2024-02-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #'s NY00310829, NY00311751, NY00316856, and NY00319018), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were thoroughly investigated for 5 (Residents #1, 2, 3, 4, and 5) of 5 residents reviewed. Specifically, the facility did not conduct a thorough investigation when Resident #1 alleged abuse on 5/15/2023 by a Certified Nurse Aide. For Resident #2, the facility did not conduct a thorough investigation to determine the cause of a fracture (bone break) identified on 2/28/2023. For Resident #3, the facility investigation began 5 days after the resident's unwitnessed fall and did not identify the cause or corrective actions to prevent re-occurrence. For Residents #4 and 5, facility investigations did not identify non-adherence to the residents' care plans as contributing factors; additionally, the facility investigations did not include appropriate corrective actions…

    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 before2024-02-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #'s NY00311751 and NY00316856), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents # 1 and 2) of 5 residents reviewed. Specifically, for Resident #1, the facility did not ensure an immediate and thorough assessment of the resident's injury alleged to be caused by abuse. For Resident #2, the facility did not ensure an assessment of new onset pain resulting in delay of treatment for a fracture (bone break). This is evidenced by: The facility Policy titled Abuse Prevention and Investigation, effective 6/27/2023, documented, when abuse is suspected or alleged, resident safety must be a priority. All required documentation, assessments, treatments must be completed as appropriate by facility staff. The resident shall be assessed and any necessary care provided. The facility Policy…

    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 · Ecited before2021-09-14 · 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

    Based on observation and staff interview during the recertification survey, the facility did not maintain food preparation areas in accordance with professional standards for food service safety. Food preparation and serving areas and equipment are to be kept clean and in good repair. Specifically, equipment in the main kitchen and 2 of 2 unit kitchenettes were not clean or in good repair. This is evidenced as follows. The main kitchen and the kitchenettes were inspected on 09/08/2021 from 9:05 AM through 10:09 AM. In the main kitchen, shelving, the cleaning chemical storage area and door, and the floor under the cafe prep sink were soiled with food particles or dirt. The light shields over the dish washing machine and by the walk-in refrigerator were broken. In the unit kitchenettes, the cooking range and range hood, cupboards, cabinets & drawers including doors, refrigerator door gaskets, floor behind the cooking ranges, walls, and ceiling vent cover were soiled with food particles, dirt, or grime. The white cupboard bottom shelves were cracked, door handles were loose, and/or…

    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 · Dcited before2021-09-14 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, 3 of 3 dumpsters and the surrounding grounds were not maintained in a sanitary condition. This is evidenced as follows. The garbage dumpsters and surrounding area were inspected on 09/08/2021 at 11:01 AM. One of 3 dumpsters, the left most dumpster and outside the caged area for dumpsters, was found to have garbage waste stored within, and the drain hole did not have a plug to prevent pest entry. This dumpster was placed on the earthen ground, and the instructions on the dumpster state Notice, Container Must Be Placed on a Hard Level Surface, Load Uniformly. The concrete pad (pad) for the 2 dumpsters in the caged dumpster area was heavily soiled with a build-up of black grease that was draining directly onto the ground behind the pad through a hole in the pad and cage fencing. The area around and behind all dumpsters was littered with kitchen refuse and an old tire. The Administrator stated in an interview on 09/08/21 12:21 PM, that…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-08-01 · tag F0656 — failed to write and follow a full care plan — pattern
    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 observations, record review, and interviews during a recertification survey the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for five Residents (#s 9, 40, 57, 65, & 162) of 24 reviewed. Specifically; the facility did not ensure that Resident #9 had a care plan (CP) to address constipation, that Resident #162 had a CP that addressed diarrhea; that Resident #57's CP for pain and comfort included person-centered interventions for pain management; that Resident #40 had a CP to address communication issues, and that Resident #65 had a CP to address respiratory issues. This is evidenced by: Resident #162: The resident was admitted to the nursing home on 5/31/19 with diagnoses 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-08-01 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility did not ensure a policy regarding use and storage of foods brought to residents by family and other visitors was developed to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure facility staff would assist dependent residents in accessing and consuming food brought in by family or visitors. This is evidenced by: A Policy and Procedure titled Use and Storage of Food Brought to Residents From Home dated 1/17, did not include documentation regarding how the facility staff would assist dependent residents in accessing and consuming food brought in by family or visitors. During an interview on 8/01/19 at 7:36 AM, the Assistant Director of Dining Services stated he was not aware of policy requirement. 10NYCRR415.14 (h)

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-01 · 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 observation, record review, and interviews during the recertification survey, the facility did not ensure residents maintained acceptable parameters of nutritional status for 2 (Resident #'s 29 and 84) of 3 residents reviewed for nutrition. Specifically, for Resident #29, the facility did not ensure reweighs were obtained and care plan interventions were revised to address the resident's significant weight loss; and for Resident #84, the facility did not ensure a protein supplement was implemented in a timely manner for the resident's increased protein needs while on dialysis. Resident #29: The resident was admitted to the facility on [DATE], with diagnoses of dysphasia, major depressive disorder, and dementia with behavior disturbance. The Minimum Data Set (MDS - an assessment tool) dated 5/11/19, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The undated Policy and Procedure for Weight Monitoring documented that for a weight…

    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 · D2019-08-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (1) resident (Residents #73) of three (3) residents reviewed for respiratory care. Specifically, for Resident #73, the facility did not ensure the resident received the physician ordered liter flow of oxygen (O2) from 7/28/19-7/30/19, did not ensure the resident's change in respiratory status was assessed, and did not ensure the resident's record reflected notification of the practitioner of the need to revise or alter the respiratory care provided. This is evidenced by: The Policy and Procedure (P&P) titled Oxygen Administration, last revised 1/2019, documented for staff to check the physician's order, adjust flow meter to prescribed meter flow, and to document use of oxygen recording the date and time of administration, mode, and liters. The policy did not include a procedure 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 · Dcited before2019-08-01 · 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

    Based on observation and staff interview during the recertification survey, the facility did not maintain equipment in a clean and sanitary manner in accordance with professional standards for food service safety. Food preparation and serving areas are to be kept in good repair, and equipment is to be kept clean. Specially, food and non-food contract surfaces were not kept clean and in good repair; and facial hair was not properly restrained to prevent physical contamination of food. This is evidenced as follows: Finding #1: The main kitchen and kitchenettes were inspected on 07/29/2018 at 8:35 AM. In the main kitchen the meat slicer, can opener, cutting boards, shelves under the food service counters, knife holder by the stovetop, and the floor in the walk-in freezer were soiled with dust, grease, or food particles. In the second-floor kitchenette the gasket on the reach in refrigerator was covered in food particles, the underside of the juice machine was covered in syrup, and the exhaust fan was heavily soiled with grease and dust. In the third-floor kitchenette the cabinetry…

    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 TRINITY HEALTH — 19 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 1 of 53.3-2.3 vs chain
Health inspection 1 of 53.0-2.0 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 2 of 53.7-1.7 vs chain
The other 18 homes this chain runs (chain average 3.3★, 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
ST PETERS HEALTH PARTNERSOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 06/10/2025
BALA, GUHAIndividualCORPORATE DIRECTORsince 10/01/2022
HANKS, STEVENIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2023
ISACKSEN, DANIELIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 10/01/2022
LAPCZYNSKI, PATRICIAIndividualCORPORATE DIRECTORsince 04/01/2025
MCCORMICK, ROBERTIndividualCORPORATE DIRECTORsince 01/01/2021
MEATH, MICHAELIndividualCORPORATE DIRECTORsince 10/01/2022
MYERS, GINAIndividualCORPORATE DIRECTORsince 10/01/2022
POLLARD, MERRIETTEIndividualCORPORATE DIRECTORsince 10/01/2022
SULLIVAN, MARGUERITEIndividualCORPORATE DIRECTORsince 01/01/2025
SWEET ZAVAGLIA, KERRIIndividualCORPORATE DIRECTORsince 10/01/2022
TOFADE, OLUWATOYINIndividualCORPORATE DIRECTORsince 01/01/2024
FARRELL, ERICIndividualCORPORATE OFFICER; ADP OF THE SNFsince 07/01/2023
JIMINO, KATHLEENIndividualCORPORATE OFFICERsince 10/05/2022
MARSHALL, JOHNIndividualCORPORATE OFFICERsince 10/05/2022
SIGNOR, KRISTINIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
WILDRIDGE, WILLIAMIndividualCORPORATE OFFICERsince 10/01/2022
TRINITY HEALTH CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/16/2025
BURKE, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2020
MAZZACCO, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/22/2021
MIER, SHERRIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2023
SPENCER, YOLANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/18/2025
BAKAR, MELISSAIndividualADP OF THE SNFsince 01/01/2025
DUNNING, TODDIndividualADP OF THE SNFsince 02/18/2024
LASHWA, DEBRA JEANIndividualADP OF THE SNFsince 02/05/1996

CMS files one row per role, so the 37 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.6M
Net patient revenuemost recent cost report
-10.4%
Operating marginrevenue minus expenses
$993K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 7%Other / private 29%

This home reported $993K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$395per resident / day
operating cost
$12,023per month
≈ monthly operating cost
$358per 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 335760. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-27, 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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