A Holly Patterson Extended Care Facility

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

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.

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.

29.0% 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 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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.

Staffing

How full it usually is: this home is certified for 589 beds and averages 453.8 residents a day — about 77% occupied, or roughly 135 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.79 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.40 hrs/resident/day on weekends vs 2.95 on weekdays — 18% thinner on weekends. RN hours go from 0.70 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 16% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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

Inspection deficiencies

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

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

22 citations, most serious first. The 17 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · Jcited beforedisputed · IDR2026-06-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to provide adequate supervision and a safe environment for each resident. This was identified for one (Resident #3) of five residents reviewed for elopement. Specifically, Resident #3 who had severe cognitive impairment, exit seeking behaviors, and was at high risk for elopement, exited their fourth-floor room through a window and fell to a second-floor patio (awning roof) sustaining multiple fractures (broken bones) on 03/03/2026. Upon the resident's return from the hospital to the facility on [DATE], the resident was placed back onto the fourth floor and continued to have access to the windows in their room. The facility's Elopement Risk Assessment tool failed to evaluate residents for exit-seeking behaviors or the risk of elopement through windows. The Comprehensive Care Plan interventions were not updated to address window safety in Resident #3's room to prevent future elopements through the window. This resulted in the potential…

  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 no plan of correction
• Immediate jeopardy · Jcited before2025-05-23 · 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, record review, and staff interviews during an abbreviated survey (NY00380105), the facility failed to prevent and protect an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, Certified Nursing Assistant #1 was observed on facility surveillance video restraining both hands of Resident #1 and hitting them in the head two (2) times. Using the reasonable person concept, this resulted in actual psychosocial harm that was Immediate Jeopardy. The findings are: Resident #1 had a medical diagnosis including dementia, hyperlipidemia, and hypertension. Review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 99, Resident #1 is not understood and does not understand, indicating severe impairment for decision making. Review of the facility policy entitled, Abuse with a revision date of 03/2024, documented it is the policy of the facility…

  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 · J2025-05-23 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 staff interview during an abbreviated survey (NY00380105), the facility failed to implement Abuse/Neglect policies to prevent, protect and report an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, the facility failed to protect Resident #1 from Certified Nursing Assistant #1 who was observed restraining both hands of Resident #1 and hitting them in the head. This incident was observed by Certified Nursing Assistants #2 and #3 who were in the hallway at the time of the incident and did not identify, correct, intervene or report the occurrence of abuse. Additionally, the incident was reported by a visitor on 05/06/2025 to Unit Liaison #1 who did not report the incident to their supervisor (Unit Liaison #2) until 05/07/2025. This allowed Certified Nursing Assistants #1, #2, and #3 to have continued access to Resident #1 and the other 436 Residents in the facility. Using the reasonable…

  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 · Kcited before2022-03-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022 the facility failed to ensure that the resident's environment was free of accident hazards for one (Resident #220) of 4 residents reviewed for accidents. Specifically, Resident #220 with a known history of Polysubstance abuse, was not supervised to prevent the availability of non-prescribed illicit drug usage within the facility. Resident #220 was readmitted to the facility on [DATE]. A Psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The current facility did not develop care plan interventions to monitor and supervise the resident for substance abuse. On 12/13/2021 Resident #220 was found unresponsive and transferred to hospital for opioid drug overdose. The facility did not initiate an investigation after the 12/13/2021 incident. The hospital discharge recommendations were to provide supervised…

  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
• Immediate jeopardy · K2022-03-09 · tag F0740 — failed to provide behavioral / mental-health care — pattern
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, the facility failed to ensure each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. This was identified for one (Resident #220) of three residents reviewed for Behavioral health. Specifically, Resident #220 was admitted to the facility with a known history of illicit drug abuse. The admission psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The facility failed to develop and implement an effective…

  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
• Actual harm · Gcited before2025-09-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (#769417) initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (1) (Resident #314) of four (4) residents reviewed for accidents. Specifically, Resident #314 required two (2) staff persons for transfers as per the Physician's order and their plan of care. On 01/10/2025, Certified Nursing Assistant #8 transferred Resident #314 from the wheelchair to the bed without a second staff member. During the transfer, Resident #314 hit their left leg on the metal bed frame and sustained a fractured tibia and fibula (lower leg bones). This resulted in actual harm to Resident #314, that was not Immediate Jeopardy.The finding is:The facility's policy titled Activities of Daily Living, dated March 2023, documented to ensure residents receive appropriate assistance with Activities of Daily Living to maintain or improve their quality of life,…

  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
• Actual harm · Gcited before2024-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification and Abbreviated Survey (Complaint #NY00314085) initiated on 3/26/2024 and completed on 4/2/2024, the facility did not ensure that each resident's environment remains free of accident hazards as is possible. This was identified for two (Resident #42 and #159) of eight residents reviewed for accidents. Specifically, 1) on 4/4/2023 Resident #42 fell out of the mechanical lift when the mechanical lift sling pad loops got detached from the mechanical lift's sling bar hook. The mechanical lift used for the resident's transfer was missing the safety latches (clips), which were supposed to hold the mechanical lift sling pad loops in place, on the mechanical lift's sling bar hook. Certified Nursing Assistant #14, who was assisting with the resident's transfer, was aware of the missing safety latches and continued with transferring the resident from the bed to the wheelchair. Subsequently, the resident was transferred to the hospital and was diagnosed…

  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 · D2025-09-30 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews during the Recertification Survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (1) (Resident #94) of eleven residents reviewed for Accidents. Specifically, Resident #94 was self-administering their inhaler medications. The facility staff was aware of the resident's self-administration of the inhalers; however, there was no documented assessment to determine if the resident could safely self-administer their medication. Additionally, Resident #94 did not have a physician's order to self-administer their medications. :The finding isThe facility's policy titled Medication Administration, last reviewed on 03/2024, documented that Residents may self-administer their own medications only if the attending clinician, in conjunction with the Interdisciplinary Care…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-30 · 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 record reviews and interviews during the Recertification Survey and Abbreviated Surveys (Complaint #769423 and Complaint #2580693) initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure the residents had the right to be free from abuse. This was identified for four (4) (Resident #183, Resident #26, Resident # 184, and Resident #90) of five (5) residents reviewed for Abuse. Specifically, 1) on 02/24/2025, Resident #183, with intact cognition, while fighting over a privacy curtain, hit Resident #26, with severely impaired cognition, in the face, resulting in Resident #26 having a swollen lip, and 2) Resident #90 had a physical and verbal altercation with Resident #184 on 08/03/2025 at 01:25 PM. Resident #90 accused Resident #184 of stealing their money. Later, the same day at 08:45 PM, Resident #184 was found on the floor and reported that Resident #90 had hit them in the face with the television remote to retrieve their money.The findings are: The facility's policy titled…

  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 · D2025-09-30 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interviews and record review, the facility did not coordinate and refer all Level II residents and all residents with newly evident or possible mental disorder, intellectual disability, or a related condition for Level II resident review upon a significant change in status assessment. This was identified for one (1) (Resident #5) of 37 residents reviewed for Pre-admission Screening and Resident Review (PASARR). Specifically, there was no documented evidence that the facility referred Resident #5 for Level II resident review when the resident was newly diagnosed with Schizoaffective Disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder) during the course of their stay in the facility.The finding is:The facility's policy titled Pre-admission Screening and Resident Review, last revised June 2023, documented that in the event a resident is admitted with a level I screen, and further exploration reveals information indicating that there is a serious mental illness, 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 · D2025-09-30 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment was implemented for each resident. This was identified for one (1) (Resident #6) of three (3) residents reviewed for Position/Mobility and for one (1) (Resident #70) of three (3) residents reviewed for Position and Mobility Specifically, 1) Resident #6 was observed on three separate occasions without a right-hand splint as ordered by a Physician. 2) Resident #70 had a physician's orders to apply a gauze roll to the right anterior (in the front) elbow. Resident #70 was observed on multiple occasions without the gauze roll in place as ordered. The findings are: 1) The facility's undated policy titled Splinting/Bracing/Orthotic Devices documented…

  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 before2025-09-30 · 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 observations, record review, and interviews during a Recertification survey initiated on [DATE] and completed on [DATE], the facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team. This was identified for one (1) (Resident #70) of one (1) resident reviewed for Advanced Directives. Specifically, Resident #70 had a physician's order for Medical Orders for Life Sustaining Treatment (MOLST), which included a Do Not Resuscitate (DNR) order; however, the resident's advance directives care plan documented to provide cardiopulmonary resuscitation (CPR). The finding is: The facility policy titled 'Advance Directives: Ascertaining existence of' last revised 05/2021 documents, Advance Directives are expressions of the patient's wishes as to how future care should be delivered or declined, including decisions that must be made when the patient is not capable of expressing those wishes. When the resident is transferred into the facility, Social Work reviews with…

  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 · D2025-09-30 · tag F0761 — failed to label and store drugs safely — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure all drugs and biologicals were stored in a locked compartment and accurately labeled. This was identified for one (Unit 22 medication cart) of seven (7) medication carts, one (Unit 22 medication room) of six (6) medication rooms reviewed for the Medication Storage and Labeling task, and one (1) (Resident #94) of eleven residents reviewed for Accidents. Specifically, 1) the Unit 22 medication cart was noted to be unlocked in the hallway without any staff members present, 2) the Unit 22 medication room refrigerator contained an injectable medication (Ozempic-medication for Diabetes Mellitus) that was opened and was not dated. 3) Resident #94 was observed with an unlabeled Spiriva Handihaler (a medication used for relaxing and opening the airway) on their nightstand and an unlabeled Advair (medication to treat Asthma) inhaler on the bed. There was no…

  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 before2025-09-30 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and staff interviews during the Recertification Survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #314) of four (4) residents reviewed for Pressure Ulcers. Specifically, during the wound care observation of Resident #314's left heel pressure ulcer, Licensed Practical Nurse #4 allowed the cleansed heel wound to come in contact and rest on a dirty surface.The finding is:The facility's policy titled Wound Dressing, dated 12/2023, documented the nurse to bring a Certified Nursing Assistant for assistance; remove the old dressing, observe the area; wash hands, put on new gloves, and cleanse the wound as ordered, with circular motion, inside to outside.Resident #314 was admitted with diagnoses including Muscle Weakness, Lack of Coordination, and Osteoarthritis (a common joint disease that causes pain, stiffness, and loss 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-05-22 · 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 interviews and record review conducted during an abbreviated survey (Complaint # NY00340951) the facility failed to protect a resident from physical abuse by nursing home staff. This was evident for one of three residents reviewed for physical abuse (Resident #1). Specifically, on 5/2/24 at 6:30AM Certified Nurse Assistant #1 was observed by Registered Nurse #1 pushing Resident #1 to the floor. The findings were: Resident #1 was admitted to the facility with medical diagnosis including Non-Alzheimer's Dementia, Diabetes Mellitus, and coronary artery disease (heart disease). The Annual Minimum Data Set, dated [DATE] documented Resident #1 had a Brief Interview for Mental Status score of 9 indicating impaired cognition. The Minimum data set further documented no behaviors exhibited, and Resident #1 uses a manual wheelchair for ambulation. The facility policy and procedure titled Resident Abuse dated February 2024 documented it is the policy of the facility to ensure that every resident is free from abuse…

  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 · Ecited before2024-04-02 · 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 observations, record review, and interviews during the Recertification Survey initiated on 3/26/2024 and completed on 4/2/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified on three (Unit 21, Unit 22, and Unit 31) of 13 nursing units. Specifically, during the medication storage task observations on Unit 21, Unit 22, and Unit 31, the Controlled Substance Administration Record form was not reconciled to reflect the available controlled medications in the medication blister pack for Resident #35 (Unit 21), Resident #221 (Unit 22) and for Resident #7 (Unit 31). The finding is: The facility's policy titled, Medication: Controlled Substances, revised 3/2024, documented that immediately after a medication dose is administered the licensed nurse administering the drug enters all of the following information on the controlled substance administration record: date/time of administration, dose/amount administered, and the signature of the nurse administering the drug. 1) Resident #35 was admitted with diagnoses…

  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 · D2024-04-02 · 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, record review, and interviews during the Recertification Survey initiated on 3/26/2024 and completed on 4/2/2024 the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for two (Resident #134 and Resident#192) of three residents reviewed for dignity. Specifically, during a lunch meal observation on 3/26/2024 two staff members were observed standing over Resident #134 and Resident #192 while they assisted the residents with eating. The findings are: The facility's policy titled, Meal Pass documented to provide dignified care to residents during the meal pass. 1) Resident #134 was admitted with diagnoses that included Cerebral Vascular Accident (stroke), Dementia, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score was 11, which indicated the resident had moderately impaired…

  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

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$141,265 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $14,777 — penalty dated 2025-09-30
• $113,140 — penalty dated 2025-05-23
• $13,348 — penalty dated 2024-04-02
• Medicare payment denial — starting 2024-07-02 for 92 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in NY