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Masonic Care Community Of New York

2150 Bleecker Street, Utica, NY 13501 · Non profit - Corporation · 320 certified beds · (315) 798-4800 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$88,433 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $88,433 in federal fines (most recent 2025-11-12)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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

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

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 3 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1256 Culver Ave · (315) 738-7186 · Call to confirm hours
Pharmacy
1256 Albany St · (315) 735-3525 · Call to confirm hours
Grocery
600 Culver Ave · (315) 724-2041 · Call to confirm hours
Park
(315) 738-0172 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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 increased14.6%14.1%15.4%typical
Long-stay residents who lose too much weight4.1%5.8%5.4%better
Long-stay residents with a catheter left in their bladder1.4%0.5%0.9%worse
Long-stay residents with a urinary tract infection2.8%1.3%2.0%worse
Long-stay residents with depressive symptoms0.1%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury7.8%3.1%3.3%worse
Long-stay residents whose ability to walk worsened8.5%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.8%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers3.5%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control35.3%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.9%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine98.6%78.8%79.4%better
Short-stay residents rehospitalized after admission31.9%20.6%22.6%worse
Short-stay residents with an outpatient ER visit16.5%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.111.701.67worse
Long-stay outpatient ER visits per 1,000 resident days1.611.361.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.5% 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 187 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.5%U.S. median 51.5%
Got home and stayed home
8.6%U.S. median 10.7%
Went back to hospital
58.4%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 58.4% 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 89 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% 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.

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 SNF52.5%CMS range 46.1–58.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.6%CMS range 6.3–12.510.7%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 discharge58.4%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 discharge50.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified81.6%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 setting91.7%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.5%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 hospitalization5.7%CMS range 3.2–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 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

0.42
RN hours/ resident / day
0.98
LPN hours/ resident / day
2.54
Aide hours/ resident / day
3.94
Total nurse hours/ resident / day
0.26
RN hoursweekends
30.7%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 320 beds and averages 297.6 residents a day — about 93% occupied, or roughly 22 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above 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 3.58 hrs/resident/day on weekends vs 4.08 on weekdays — 12% thinner on weekends. RN hours go from 0.49 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% 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

12
deficiencies at the latest standard inspection (2026-04-06)
7
at the previous standard inspection (2024-05-17)

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.

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2025-11-12 · 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

    Based on observations, record review, and interviews conducted during the abbreviated (iQIES incident #2607732) survey, the facility failed to ensure residents received adequate supervision to prevent accidents for two (2) of five (5,) residents (Residents #1 and #3) reviewed for accidents. Specifically, Resident #1 was at risk for elopement and exited the facility undetected on 09/03/2025 and 10/25/2025; and Resident #3 left the facility grounds on 07/25/2025, undetected, on their motorized scooter and was found two (2) hours later at a fast-food restaurant approximately four (4) miles away. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #1 and #3 and placed all 59 residents with exit-seeking behaviors at risk for serious harm, serious injury, serious impairment, or death. The facility policy Elopement Risk Screen, revised 07/2011, documented staff would monitor a resident's whereabouts to ensure they remained within the facility. In the event of an elopement or elopement attempt, staff notified the Nurse Manager or supervisor. The policy did not…

    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 · F2026-04-06 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure each resident had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States to include sending and receiving mail and to receive letters, packages, and other materials delivered to the facility for all 296 of 296 residents residing in the facility. Specifically, mail was not delivered to residents promptly to include Saturdays.Findings include: The facility policy Resident Mail, last reviewed 9/2025, documented incoming mail would be sorted and distributed daily. The mail was to be given to the resident or placed in a secure location and not opened by staff unless requested or authorized to do so.The facility policy Resident [NAME] of Rights, last reviewed 05/2020, documented residents had the right to send and receive mail promptly and unopened.During an anonymous resident meeting on 03/31/2026 at 3:07 PM, 13 out of 13 anonymous residents stated they only received mail Monday through Friday, and never on Saturdays.During an interview on 04/03/2026 at 10:44…

    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 · F2026-04-06 · tag F0755 — failed to provide safe pharmacy services — widespread
    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 (iQIES Intake 2722137) the facility failed to ensure routine and emergency drugs and biologicals were provided to two (2) of two (2) residents (Residents #14 and #247) reviewed. Specifically, three (3) doses of Resident #14's alprazolam (used to treat anxiety) were not administered due to the medication not being available from pharmacy; and Resident #247 was not administered five different medications (diltiazem, methimazole, nadolol, hydralazine, and lisinopril) between February 2026 and March 2026 due to the medications not being available from pharmacy. Findings include:The facility policy Medication Administration, revised 10/2025, documented if a medication was not available at the time it was to be administered, the nurse was to notify the neighborhood manager or supervisor. The neighborhood manager or supervisor would explore alternate methods for obtaining the medication such as the emergency medication supply, contacting the pharmacy, or contacting medical for alternate medication. The facility policy Medication…

    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 · E2026-04-06 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care and the right to participate in social and community activities for two (2) of two (2) residents (Residents #133 and #281) reviewed and for 13 of 13 anonymous residents present at the resident group meeting. Specifically, Residents #133 and #281 and 13 anonymous residents present at the resident group meeting expressed their displeasure with not being able to go outside on facility grounds without supervision.Findings include: The facility policy Resident [NAME] of Rights, last reviewed 05/2020, documented residents had the right to make choices about aspects of their life that were significant to them. The facility would meet their individual needs and preferences to the extent possible, except where health and safety of the residents would be endangered. Residents had the right to participate in the development of their person-centered plan of care. During a resident meeting…

    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 · Ecited before2026-04-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for five (5) of eleven (11) medication carts ([NAME], [NAME], Westchester, Manhattan, and Placid Neighborhoods) reviewed. Specifically, the Placid Neighborhood narcotic box contained 30 morphine (opiate) syringes and 57 lorazepam (anti-anxiety) syringes belonging to a deceased resident; the Manhattan Neighborhood medication cart contained one (1) morphine syringe without a resident's name on the label; the Westchester Neighborhood medication cart contained three (3) pre-poured medication cups; the [NAME] Neighborhood medication cart contained expired eye drops and a nasal spray that was not labeled with an open date; and the [NAME] Neighborhood medication cart had expired and undated nasal sprays.Findings included: The facility policy Medication Administration, revised 10/2025, documented controlled medications were placed in the double…

    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 · E2026-04-06 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) test trays (the 03/30/2026 lunch meal and the 04/01/2026 lunch meal), 13 of 13 anonymous residents during a resident meeting, and one (1) resident (Resident #11) reviewed. Specifically, food was not served at palatable and appetizing temperatures during lunch meals on 03/30/2026 and 04/01/2026; 13 anonymous residents during a resident council and Resident #11 stated the food was cold. Additionally, multiple meal trays were observed sitting for 30-60 minutes prior to resident consumption; and the facility did not have a procedure in place to ensure food was properly re-heated on the resident units to the required temperatures. Findings include: The facility policy Taste and Temperature Control, revised 05/2023, documented cold food such as milk, juice, and ice cream, should be refrigerated or on ice during meal service to maintain proper temperature. There was no documentation…

    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 before2026-04-06 · 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 observations and interviews, the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one (1) of one (1) main kitchen. Specifically, the main kitchen had unlabeled/undated prepared and leftover food; and dishwashing machine temperatures were not monitored routinely. Findings include:The facility policy Mechanical Wear (ware) washing, revised 05/2023, documented warewashing temperatures would be taken and recorded in the supervisor monitoring log during each meal period. Food Storage During an observation and interview on 03/30/2026 at 9:56 AM, the following was observed in the main kitchen:-two pans of prepared and cooked food in the reach-in cooler, identified by Food Service Director #6 as leftover hashbrowns and ground chicken, were not labeled or dated; -one pan of prepared and cooked food in the walk-in cooler, identified by Food Service Director #6 as leftover kielbasa, was not covered, labeled, or dated; -three pans of prepared and cooked food in the walk-in cooler, identified by Food Service Director…

    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 · D2026-04-06 · 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

    Based on observations, record review, and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life for three (3) of three (3) residents (Residents #30, #190, and #288) reviewed. Specifically, staff stood over Residents #30, #190, and #288 while assisting them with feeding.Findings include:The facility policy Resident Dignity, revised 09/2025, documented the facility ensured all residents were treated with dignity and provided residents with a dignified dining experience. 1) Resident #30 had diagnoses including Alzheimer disease and dysphagia (difficulty swallowing). The 12/31/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, required substantial/ maximum assistance with eating, and received a mechanically altered diet. The Comprehensive Care Plan, initiated 08/13/2024 and revised 03/31/2026, documented the resident required substantial/ maximum assistance with eating.The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-06 · 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

    Based on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #299) reviewed. Specifically, Resident #299 had a large bottle of acetaminophen (pain reliever), a tube of Neosporin (antibiotic ointment), a bottle of antacids, loperamide gel capsule (antidiarrhea medication), and a medication cup with several different pills in their room. There was no documented evidence of assessments and/or physician orders for the resident to safely self-administer medications. Findings included:The facility policy Medication Administration, revised 10/2025, documented nurses were to remain with the resident until medications were swallowed. They were not to leave medication with the resident to be taken later unless it was ordered by medical and care planned. The facility policy Self-Administration of Medication Program, last reviewed 12/2025, documented if a resident requested to self-administer medications…

    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 before2026-04-06 · 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 review, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for two (2) of two (2) residents (Residents #77 and #16) reviewed. Specifically, Resident #77's person-centered comprehensive care plan did not include the use of oxygen; and Resident #16's person-centered comprehensive care plan did not include the use of psychotropic (used to treat mood/ behaviors) medications.Findings include:The facility policy Interdisciplinary Comprehensive Care Plans, revised 09/2025, documented a person-centered care plan would be developed by the interdisciplinary care team to ensure services were being provided to assist the resident in achieving/maintaining their highest practicable physical, mental, and psychosocial wellbeing. The person-centered Interdisciplinary care plan would be completed in conjunction with the medical data set assessment by day fourteen from admission and would be reviewed 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 before2026-04-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and promote healing of pressure ulcers for two (2) of five (5) residents (Residents #16 and #304) reviewed. Specifically, Resident #16's and Resident #304's pressure relieving interventions were not implemented as planned; and Resident #16 had conflicting wound care orders signed off as completed and wound care recommendations by the wound care provider were not implemented. Findings include: The facility policy Skin and Wound Care Policy and Procedure, reviewed 8/2025, documented the facility established a comprehensive, interdisciplinary approach for prevention, assessment, treatment, and monitoring of all wound types. Certified Nurse Aides were responsible for floating heels and managing offloading devices per the resident's care plan. The licensed practical nurses were responsible for implementing wound and prevention orders, performing ordered dressing changes within scope, and documenting wound…

    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
Show the remaining 17 citations
  • Potential for harm · D2026-04-06 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #4) reviewed. Specifically, Resident #4's hung tube feeding was not dated during multiple observations.Findings include: The facility policy Gravity, Tube Feeding, Enteral, Gastrostomy, or Jejunostomy, revised 06/2023 did not document dating and timing of tube feedings when administered. The manufacturer details for Nepro tube feeding formula, last updated 2025, documented unless a shorter hang time is specified by the set manufacturer, hang product for up to 48 hours after initial connection when clean techniques and only one new set are used. Otherwise hang for no more than 24 hours. Resident #4 had diagnoses including dysphagia (difficulty swallowing), chronic kidney disease, and cerebral infarction (stroke). The 02/27/2026, Minimum Data Set (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-06 · 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 observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #312) reviewed. Specifically, Food Service Worker #2 entered Resident #312's room, who was on enteric precautions (measures to prevent the spread of pathogens transmitted through feces), without donning personal protective equipment or performing hand hygiene upon exit. Findings included:The facility policy Transmission Based Precautions, last reviewed 11/2025, documented it was the responsibility of all personnel who had direct contact with residents to follow transmission-based precautions. Enteric precautions were contact precautions specifically for difficult to treat infections such as clostridium difficile, enterohemorrhagic Escherichia coli (severe intestinal infection), shigella (contagious intestinal infection), hepatitis A, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · 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 record review and interviews during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 6 of 8 anonymous residents. Specifically, 6 anonymous residents present at the Resident Council meeting stated they did not know how to file a grievance. Additionally, the facility did not have a process for residents to file a grievance anonymously. Findings include: The facility policy Resident Grievances, dated 11/2016, documented every resident of the facility and/or their resident representative had the right to voice grievances to the facility without fear of reprisal or discrimination. Grievances included those with respect to care and treatment which had been provided as well as those which had not been provided, the behavior of staff and of other residents, and other concerns regarding their stay at the facility. The facility would make prompt efforts to resolve a grievance. All complaints and/or grievances presented by a resident and/or the resident…

    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 before2024-05-17 · 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

    Based on observation, record review, and interview during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 2 of 6 residents (Residents #96 and #155) reviewed. Specifically, Resident #96 was observed with prescribed eye drops and nasal sprays at their bedside and there was no documented evidence the resident had an assessment or order to self-administer the medications. Additionally, Resident #155 was observed with prescribed eye drops at their bedside and did not have an assessment or order to self-administer the medications. Findings include: The facility policy Self-Administration of Medication Program reviewed 11/2016 documented the interdisciplinary team would determine if a resident was clinically appropriate for self-administration of medications, and reviewed on a quarterly and significant change basis. That decision would be documented in the resident's record. A physician order was needed prior to initiation of the program specifying the specific…

    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 before2024-05-17 · 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 record review and interview during the recertification survey conducted 5/13/2024 - 5/17/2024, the facility did not ensure a comprehensive, person-centered care plan was developed and implemented to meet a resident's medical and nursing needs for 1 of 5 residents (Resident #170) reviewed. Specifically, Resident #170 did not have a comprehensive, person-centered care plan that included anticoagulant (blood thinner) therapy. Findings include: The facility policy Interdisciplinary Comprehensive Care Plans (IDCP), reviewed 2/2022, documented a person-centered interdisciplinary care plan would be developed by the Interdisciplinary Care Team to identify a resident's problems, strengths and needs, and incorporate their personal and cultural preferences. The interdisciplinary care plan would be used to ensure services were provided to assist the resident achieve or maintain their highest practicable physical, mental, and psychosocial well-being. Resident #170 had diagnoses that included long-term use of anticoagulants, personal history of other venous thrombosis (blood clot) 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 before2024-05-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted 5/13/2024-5/17/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #106) reviewed. Specifically, Resident #106 was ordered to have bilateral heel float boots on 4/29/2024 and did not receive the left boot until 5/12/2024. The undated facility policy Skin Assessment for Admissions or Change of Condition: Skin Prevention Protocol documented there were three categories for a resident's skin that required physician orders and care plan interventions: high risk, moderate risk, and a skin tear. High risk included orders for a pressure guard mattress, specialty cushion, heel float boots (brand name Skil-Care) to bilateral feet when in bed, skin prep to heels, and an occupational therapy referral to recommend positioning aides. Interventions geared towards skin and skin protocol…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, or obtain informed consent prior to the installation of bed rails for 1 of 1 residents (Resident #40) reviewed. Specifically, for Resident #40, there was no documented evidence of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. Findings include: The undated facility policy Bed Rail Policy documented the facility would utilize approaches to identify and reduce safety risks and hazards commonly associated with bed rail use, including individual bed rail evaluations. Residents would be screened upon admission, readmission or change of condition. Prior to the installation of bed rails the following would be done:…

    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 before2024-05-17 · 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

    Based on record review and interviews during the recertification survey conducted 5/13/2024 - 5/17/2024 the facility did not ensure that residents were free of any significant medication errors for 1 of 1 residents (Resident #28) reviewed. Specifically, Resident #28 did not receive four consecutive doses of carbidopa - levodopa (brand name Rytary, used to treat Parkinson's Disease) on 5/11/2024 -5/12/2024 as physician ordered. Findings include: The 5/2024 revised Medication Administration policy documented if medication was not available at the time it was to be administered, the nurse was to notify the Nurse Manager/Supervisor. The Nurse Manager/Supervisor would explore alternative methods for obtaining medication such as the backup medication storage (Omnicell), contacting the pharmacy or contacting medical for an alternate medication. Resident #28 was admitted to the facility with diagnoses including Parkinson's Disease. The 4/10/2024 Minimum Data Set assessment documented the resident was cognitively intact, used a walker and wheelchair for mobility, and required partial to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · 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 and interview during the recertification surveys conducted 5/13/2024-5/17/2024 the facility did not ensure an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment was established and maintained to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #15) reviewed. Specifically, Resident #15 had a urinary catheter bag resting on the floor without a barrier for multiple days of survey. Findings include: The undated facility policy Catheter Care - Nurses Aides Role documented the external catheter tube needed to be kept as clean as possible. The drainage bag should never touch the floor. Resident #15 had diagnoses including urinary retention and a history of urinary tract infections. The 4/27/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent with toilet hygiene, was dependent with transfers, and had an indwelling urinary catheter (a tube inserted into the bladder to collect urine). The…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-12-07 · tag F0807 — failed to offer suitable drinks — pattern
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview during the recertification survey conducted 12/1/21-12/7/21, the facility failed to ensure each resident received drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 7 of 16 residents reviewed. Specifically, Residents #3, 53, 91, 92, 185, 232, and 258 on the Saranac Unit were not offered hot beverages or an equivalent substitution. This is evidenced by: The facility policy Diet and Menus Food Preferences dated 10/1/2017, documented providing preferred food and fluids enhanced and maintained the resident's quality of life and nutritional status. The Residence Aide (RA) job description revised 3/2008 documented the RA preformed a variety of activities and services necessary to meet the needs and comforts of the residents including meal service. The RA observes the residents at meal times and reports any needs or concerns. The RA reads and follows the resident's meal tickets and notifies the nurse, diet technician (DT) or registered dietitian (RD) when a resident…

    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 · D2021-12-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview during the recertification survey conducted 12/1/21-12/7/21, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for 2 of 18 nursing units (Buffalo and Amherst) and 1 of 1 (Resident #88) resident reviewed. Specifically, the Buffalo Unit dining room had a missing section of flooring material and there were sections of floor in Buffalo Unit resident room D101 and in Amherst Unit resident room D201 that were uneven and potential tripping hazards. Resident #88 was observed on multiple days in a soiled Broda (type of geriatric positioning chair) chair. Findings include: The undated facility policy Guidelines for Household Equipment Cleaning documents each household was responsible for the cleaning of household equipment. Cleaning assignments were specific and completed per schedule (weekly, monthly, and quarterly). Wheelchairs/specialty chairs will be cleaned on a weekly basis by the 11-7 shift certified nurse aide (CNA). All scheduled cleaning will be verified completed by staff documentation on the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-12-07 · 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 observation, record review, and interview during the recertification survey conducted 12/1/21 through 12/7/21, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents (Resident #187) reviewed. Specifically, Resident #187 was care planned for the use of an extra-large (XL) mechanical lift sling (used when transferring a resident from surface to surface) and staff transferred the resident using a large size sling. Findings Include: The facility policy Interdisciplinary Comprehensive Care Plans (IDCP) revised 11/2016 documented the IDCP will be completed in conjunction with the MDS (Minimum Data Set) assessment, each discipline will be responsible to evaluate the resident and identify strengths and needs, will be reviewed/updated as changes occur, and as changes occur, and any changes in the resident care plan will be reflected in the resident profile. The facility policy Safe Patient…

    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 before2021-12-07 · 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 interview during the recertification and abbreviated (NY00257278) surveys conducted from 12/1/21-12/7/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident # 164 and #78) reviewed. Specifically, Resident #164 had a fall from a mechanical lift and a complete and thorough investigation was not completed. Findings include: The facility policy Accidents/Incidents/Near Misses reviewed 8/2021, documented the purpose was to provide documentation of accident/incident or a near miss so that it can be investigated with the goal of reducing the risk of reoccurrence. An incident is defined as any happening not consistent with the routine of the facility. Falls and equipment malfunction are both listed as examples of incidents. Any Immediately identifiable causes or hazards will be addressed/rectified, and interventions will be placed on the care plan when it was appropriate to do so.…

    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 · D2021-12-07 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview during the recertification and abbreviated surveys (NY00275746) conducted 12/1/21-12/7/21, the facility failed to post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent place readily accessible to residents and visitors for 5 of 5 days reviewed. Specifically, the facility did not post the most current, daily resident census and nurse staffing information as required. Findings include: The daily resident census and nurse staffing information was observed posted in the glass cabinet of the main lobby and was one day late for each of the five days of survey. - On 12/1/21 at 10:02 AM the daily resident census and staffing information posted was dated 11/30/21. - On 12/2/21 at 11:09 AM the daily resident census and staffing information posted was dated 12/1/21. - On 12/3/21 at 8:02 AM the daily resident census and staffing information posted was dated 12/2/21. - On 12/6/21…

    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 · Dcited before2021-12-07 · 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

    Based on record review and interview during the recertification survey conducted from 12/1/21- 12/7/21, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents reviewed (Resident #240). Specifically, Resident #240's blood pressure medication was administered, and the resident's blood pressure was not obtained prior to administration per physician ordered parameters. Findings include: The facility policy Medication Administration revised 11/2019 documents any medication that requires parameters, for example blood pressure, pulse, or glucose levels, will be documented in the electronic record per policy. Resident #240 had diagnoses including congestive heart failure (CHF) and atrial fibrillation (abnormal heartbeat) and orthostatic hypotension (low blood pressure when standing up from sitting or lying down). The 11/18/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required supervision with setup or one-person physical assistance with most activities of daily living (ADL). A physician order 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-12-07 · 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 observation and interview during the recertification survey conducted 12/1/21-12/8/21 the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 9 medication carts (Forestport and [NAME] households) reviewed. Specifically, the Forestport medication cart had stock medications that were expired or outdated beyond the manufacturer expiration date and the [NAME] medication cart had resident insulin pens that were not labeled with an opened date. Findings include: During an observation of the [NAME] medication cart on 12/2/21 at 2:55 PM, there were two open insulin pens (Lispro Kwik pen and Humalog Kwik pen) that were not labeled with the date they were opened. During the observation, licensed practical nurse (LPN) #5 stated the insulin pens were used for current residents and the pens were considered expired because they were…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-12-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview during the recertification survey conducted from 12/1/21-12/7/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen and two resident unit kitchenettes (Buffalo and [NAME] Units) reviewed. Specifically, there were dented cans of food in the main kitchen dry storage room; and the Buffalo Unit and [NAME] Unit kitchenette refrigerators contained undated and unlabeled foods Findings include: The resident assistant (RA) Training Form #4 Sanitation Before, During, & After Meal Service dated 2/2021 documents the refrigerators must not be over full. Please discard items that are not labeled or dated, expired and/or not necessary. The undated facility Food from Home procedures documents any food which is not to be eaten right away should be transported in a clean, sealed container. The container should be small enough to fit into the household/resident refrigerator.…

    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

$88,433 in federal fines across 1 penalty.

  • $88,433 — penalty dated 2025-11-12

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

Owner / managerTypeRoleSince
RAFFLE, ROBERTIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 01/01/2010
WYNNE, JILLIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 08/15/1994
FILIPPIDIS, GEORGEIndividualCORPORATE OFFICERsince 12/16/2019
GETMAN, GEORGEIndividualCORPORATE OFFICERsince 05/01/2014
HEINRICH, KEITHIndividualCORPORATE OFFICERsince 05/03/2016
HOUGH, CHRISTOPHERIndividualCORPORATE OFFICERsince 05/17/2019
LIPPER, NATHANIndividualCORPORATE OFFICERsince 05/01/2014
MORRIS, GEORGEIndividualCORPORATE OFFICERsince 05/03/2016
SAGLIMBENE, JOSEPHIndividualCORPORATE OFFICERsince 05/03/2016
SIEGEL, MICHAELIndividualCORPORATE OFFICERsince 05/05/2015
SPENCER, DAVIDIndividualCORPORATE OFFICERsince 05/05/2015

CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$32.0M
Net patient revenuemost recent cost report
-85.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 66%Medicare 4%Other / private 30%

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

$619per resident / day
operating cost
$18,830per month
≈ monthly operating cost
$334per 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 335541. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-06, 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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