Oneida Center For Rehabilitation And Nursing
1445 Kemble Street, Utica, NY 13501 · For profit - Corporation · 120 certified beds · (315) 732-0100 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (56%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.0% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.0% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 22.0% | 19.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.4% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.9% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.9% | 13.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 6.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 15.3% | 19.5% | 21.2% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.7% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.3% | 20.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.0% | 9.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.46 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.82 | 1.36 | 1.80 | worse |
‡ 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.
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.
40.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.9% 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 42 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.1%CMS range 29.4–52.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.6%CMS range 6.5–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 61.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 64.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.7%CMS range 5.6–18.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 116.2 residents a day — about 97% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 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 2.65 hrs/resident/day on weekends vs 3.24 on weekdays — 18% thinner on weekends. RN hours go from 0.27 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-05-06 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the providers wrote, signed, and dated their progress notes at each visit for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Nurse Practitioner #4 initiated and completed a federally mandated visit on Resident #1 including a physical assessment, after Resident #1 was discharged to the hospital and did not return to the facility. Findings include:The 10/2025 facility policy, Physician Documentation, revised 04/26/2023, documented at the time of each physician's visit; a progress notes shall be written, signed, and dated in the physical chart or electronic medical record. The physician shall document in accordance with accepted professional standards of practice, and current Federal and State Regulations. Physician documentation shall be complete and accurately reflect the resident's status throughout the length of their stay. The 03/25/2026 Provider Note by Nurse Practitioner #4 documented Resident #1's blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 4 of 5 residents (Residents #5, #58, #61, and #106) reviewed. Specifically, Resident #58 was not called by their preferred name and a certified nurse aide in the resident's room loudly communicated personal information to a nurse across the hall; Resident #61 was not provided with a toothbrush to complete oral care; and Residents #5 and #106 were transported backwards in their wheelchairs. Findings include: The facility policy, Resident Rights, revised 5/28/2024, documented all healthcare personnel were to treat the residents with kindness, respect, and dignity. All residents had the right to a dignified existence. Residents also had the right to participate in their care planning and treatment and self-determination. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure each resident had the right to be fully informed in a language that they can understand for 1 of 1 resident (Resident #104) reviewed. Specifically, Resident #104's primary language was not English, and the resident was not fully informed of their health care status in a language they understood, and communication tools were not used by direct care staff to determine the resident's needs. Findings include: This facility policy, Translation services, revised 1/2020, documented that a language access program would ensure that individuals with limited English proficiency would have meaningful access to information and services provided by the facility. Resident #104 had diagnoses including perforation of intestine, anemia, and hearing loss. The 9/30/24 Minimum Data Set assessment documented the resident wanted or needed an interpreter to communicate with a doctor or health care staff, the resident had absence of spoken word, had adequate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 12/3/2024 -12/10/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 3 units (3rd Floor) reviewed. Specifically, the 3rd Floor had multiple unclean floors and walls, damaged walls, and unpleasant odors. Findings include: The undated facility procedure for Resident Room Cleaning documented the cleaning schedule should be reviewed before cleaning as well as the rotational cleaning schedule. Supplies should be gathered and the following cleaned: dust surfaces including bedside tables, dressers and overhead lights; empty trashcans from bathroom and living spaces and replace liners; clean bathrooms with disinfectant, cleaning from dirty to clean, flush toilet after cleaning; high and low dust surfaces in rooms including under the bed frames; sweep and mop living areas; clean and mop the hallway floors; and clean and dust the hall pictures and handrails outside of rooms. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives to meet medical, nursing, and mental and psychosocial needs for 3 of 6 residents (Residents #58, #100, and #101) reviewed. Specifically, Resident #100 had a physician order to receive nothing by mouth and was care planned to be offered a bedtime snack; Resident #58 did not have a comprehensive care plan that addressed their diagnosis of liver disease, their care plan was not updated when their transfer status changed, and they did not have fall mats as planned; Resident #101 had physician orders for an antipsychotic medication and did not have a care plan to address the medication and non-pharmacological interventions. Findings include: The facility policy, Care Plans-Comprehensive, revised 8/2/2024 documented a comprehensive person-centered care plan that included measurable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 conducted 12/3/2024-12/10/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #86) reviewed. Specifically, Resident #86 had unclean and untrimmed fingernails. Findings include: The facility policy, Activities of Daily Living Care and Support, revised 3/13/2024, documented activities of daily living care and support would be provided for residents who were unable to carry out activities or daily living independently. That included but was not limited to supervision and assistance with hygiene, mobility, elimination, dining, and communication. Nail care would be provided as needed for the resident and residents with certain medical conditions might require a licensed nurse to perform. Resident #86 had diagnoses including absence of left above the knee amputation and chronic obstructive pulmonary disease (lung disease). The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 5 residents (Residents #100 and #101) reviewed. Specifically, Resident #101 was not invited to or assisted to attend activities that were meaningful to them and met their interests and preferences; and Resident #100 was not provided with in-room stimulation that met their interests and preferences. Findings include: The facility policy, Activity Programs, revised 5/2019, documented the facility must provide an ongoing program to support residents in their choices of activities based on the comprehensive assessment, care plan, and preferences of each resident. The activity program consisted of individual, small, and large group activities that were designed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure a resident who was 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 1 of 2 residents (Resident #100) reviewed. Specifically, Resident #100's tube feeding water flushes were not administered as ordered and the tube feeding was observed unlabeled. Findings include: Resident #100 had diagnoses including unspecified protein-calorie malnutrition and dysphagia (difficulty swallowing). The 11/4/2024 Minimum Data Set Assessment documented the resident had severely impaired cognition, was totally dependent for eating, did not have signs and symptoms of a swallowing disorder, weighed 126 pounds, did not have weight loss, and received nutrition through a feeding tube. The 5/1/2024 comprehensive care plan documented the resident required tube feeding related to dysphagia. Interventions were discussed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0700 — isolatedTry 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024 through 12/10/2024, the facility did not provide on-going assessment and did not obtain informed consent prior to the installation of bed rails (side rails) for 1 of 2 residents (Resident #68) reviewed. Specifically, Resident #68 had bed rails on both sides of the bed and did have informed consent for the placement of bed rails and was not regularly assessed to ensure the bed rails remained appropriate. Findings include: The 9/2019 facility policy, Side Rails, documented that each resident would be assessed for functional status on admission, readmission, quarterly, any significant change, and as needed. Side rails would only be used by a resident to assist with his or her bed mobility. The Rehabilitation Department might be asked to also evaluate the resident's need for side rails as determined by the Interdisciplinary Team. The staff should obtain consent for the use of side rails/enabler from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024 - 12/10/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the main kitchen had unclean surfaces and expired food items. Findings include: The facility policy, Food Storage, revised 5/10/2024, documented sufficient storage facilities would be provided to keep foods safe, wholesome, and appetizing. Food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination: -All stock would be rotated with each new order received. Rotating stock was essential to assure the freshness and highest quality of all foods. -All freezer units would be kept clean and in good working condition. The facility Sanitation Policy, last reviewed 1/2023, documented the food service area would be maintained in a clean and sanitary manner. Food service staff would be trained to maintain cleanliness throughout…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2024-12-10 · tag F0840 — isolatedEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification and abbreviated (NY00326659) surveys conducted on 12/3/2024-12/10/2024, the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for 1 of 2 residents (Resident #100) reviewed. Specifically, Resident #100 was referred to neurosurgery and pulmonology (lung specialist) and the facility did not follow up on these referrals in a timely manner. Findings include: The facility policy, Physicians-Consultations, revised 8/2019, documented the facility would ensure all residents received medical care in a timely manner. The attending physician would indicate the appropriate time frame within which the specialist would see the resident. A follow-up appointment was to be done within the time frame requested by the consultant and approved by the attending physician. The attending physician would consider the appropriateness of the consultant's recommendation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the abbreviated Survey (NY00323447), the facility did not immediately inform the resident's representative and did not consult with the physician when there was a significant change in the resident's physical status and/or a need to alter treatment significantly for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 did not have capacity to make medical decisions and their health care proxy (HCP, person appointed to make healthcare decisions when the individual can no longer do so) was not notified when the resident had changes in their medical status and treatments. Additionally, the medical provider was not notified when the resident missed 2 diagnostic cardiology appointment and they were not rescheduled and the HCP was not notified of scheduled diagnostic tests. Findings include: The 4/2019 Notifications Policy documented except in an emergency, the facility must consult with the resident immediately if the resident is competent, and notify the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 11/28/22-12/2/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 7 facility areas (main kitchen, third floor elevator hallway, third floor common area near resident room [ROOM NUMBER], main laundry area, and resident rooms 102, 114, 116, and 302). Specifically, there were multiple stained/damaged solid ceilings tiles; damaged equipment in the main kitchen; the laundry lacked an appropriate hand washing sink; and resident rooms 102, 104, 116, and 302 had multiple stained, unclean, and damaged areas. Findings include: The facility policy Disinfecting/Cleaning Environmental Surfaces revised 3/2020, documented environmental surfaces would be disinfected (or cleaned) on a regular basis (e.g., daily, three times a week), and when surfaces were visibly soiled. 1. Stained Ceiling Tiles The following observations of stained ceiling tiles were made: - on 11/28/22 at 10:34 AM, the third…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-02 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review during the recertification survey conducted 11/28/22-12/2/22, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 6 of 7 residents (Residents #30, 50, 66, 76, 78, and 103) reviewed. Specifically, Residents #50 and 103 (who resided on the dementia unit), and Residents #30, 50, 76 and 78 were not offered meaningful activities and were not provided with activities of their choosing. Additionally, Resident #78's room was not personalized with individual activity items, such as television, radio, and/or reading materials. Findings include: The facility's undated admission Agreement documented the facility would provide basic services including a therapeutic recreation (activities) program, including but not limited to a planned schedule of recreational, motivational, social, and other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 11/28/22-12/2/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 7 residents (Residents #30 and 85) reviewed. Specifically, Resident #30 was not shaved and did not receive assistance or adaptive equipment at 2 meals as planned; Resident #85 was observed on multiple occasions with their call bell out of reach. Findings include: The facility policy Call Light System- Resident Response dated 12/2017 documented providing timely response to residents in need of assistance was essential to ensuring high quality resident outcomes. When the resident was in bed or confined to a chair, be sure the call bell was within easy reach of the resident. The facility policy Meal Tray Set-up and Assistance revised 5/2020, documented staff would review the resident's care plan,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview during the recertification survey conducted 11/28/22-12/02/22, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident (Resident #87) reviewed. Specifically, Resident #87 had a urinary catheter (a tube used to empty the bladder and collect urine in a drainage bag), complained of urinary tract symptoms, had a physician order for a urinalysis (U/A) and culture and sensitivity (C&S) and the urine specimen was not collected and submitted to the laboratory timely. Additionally, there was no medical rationale, physician order, or comprehensive care plan (CCP) for the use of a urinary catheter. Findings include: The facility policy Lab Procedure revised 5/2019 documented the purpose of the policy was to check a resident's specimen as ordered by the physician and to maintain a record of the results. The facility policy, Care Plans-Comprehensive revised 10/2019 documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 11/28/22-12/2/22, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #73) reviewed. Specifically, Resident #73 was observed not receiving oxygen as ordered. Findings included: The facility policy Oxygen Therapy revised 1/2020 documented oxygen should be regarded as a drug and required prescribing in all but emergency situations. Failure to administer oxygen appropriately could result in serious harm to the resident. Oxygen was administered according to the physician order. The facility policy Oxygen- Cylinders dated 1/2020 documented oxygen was administered by licensed nurses with a physician's order to provide sufficient oxygen to blood and tissues. Orders should specify the oxygen equipment and flow rate required as routine or as needed. Resident #73 had diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-12-06 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review during the recertification survey, the facility did not inform each resident when changes in Medicare coverage occurred for 4 of 4 residents (Residents #14, 27, 465 and 466) reviewed for beneficiary notices. Specifically, Residents #14, 27, 465, and 466 were not provided with Notice of Medicare Non-Coverage (NOMNC) CMS (Centers for Medicare and Medicaid Services)-10123 letters. Findings include: The 3/31/18 Skilled Care and Health Insurance facility policy documented a NOMNC will be issued at least 47 hours prior to the last day of skilled care. Traditional Medicare has the facility issue the NOMNC when the facility deems appropriate and Medicare Advantage Plans issue the NOMNC once the plan's medical teams determine the resident to no longer be skilled. The Skilled Nursing Facility (SNF) Beneficiary Notice Initiate Guide documents a NOMNC should be provided when a resident with Medicare A is discharged home or to the community, and when they are staying in the facility and not being covered by Medicare B. 1) Resident #27 had diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-12-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review during the recertification survey the facility did not maintain drugs and biologicals used in the facility in accordance with currently accepted professional principles for 1 of 2 medication rooms and 2 of 3 medication carts reviewed for medication storage and labeling. Specifically, there were expired stock medications in the Unit 1 and 2 medication carts and Unit 2 had an open undated vial of Lidocaine (liquid anesthetic) on a medication room shelf. Findings include: The 1/2019 revised Medication Storage facility policy documented the facility will have medication stored in a manner that maintains integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health guidelines. The policy documented expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. The policy did not document the process for checking for expired medications or labeling medications when opened. During a medication room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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, the facility did not ensure the right to receive services with reasonable accomodation of needs and preferences for 1 of 2 residents (Resident #365) reviewed for choices. Specifically, Resident #365 had to purchase his own sheets for his bariatric bed (a heavy duty, extra wide bed). Findings include: The facility admission Packet provided to residents documented the following items and services are available to all reisdents and are included in the Medicare Part A, Basic Medicaid, and the Private Pay Room and Board Rate: a clean, healthful, sheltered environment, properly outfitted and fresh bed linen, changed at least twice weeklly or as often as required. Resident #365 had diagnoses including morbid obesity and peripheral vascular disease (PVD, poor circulation). The 11/20/19 Minimum Data Set (MDS) assessment documented that the resident was cognitively intact and required assistance with most activities of daily living. The comprehensive care plan (CCP) documented the resident had a bariatric bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not ensure the participation of the resident and the resident's representative in comprehensive care planning for 2 of 4 residents (Residents #53 and 92) reviewed for care plans. Specifically, Residents #53 and 92 or their designated representatives were not invited to participate in the development of their comprehensive care plan. Findings include: The 8/2019 Care Planning-Interdisciplinary Team policy documents the resident and the resident's family member are invited and encouraged to participate in the development of the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family. 1) Resident #53 had diagnoses including major depressive disorder, vitamin D deficiency, and anxiety. The 5/1/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for most activities of daily living, and participated in her assessment. The Care Plan Activity Report printed on 5/14/19 documented social worker #6…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification survey, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #37) reviewed for unnecessary medications. Specifically, Resident #37 had extreme fluctuations in his blood glucose levels and was not provided with sufficient diabetes management and did not receive an endocrine (specialist for diabetes management) consult as ordered to address his diabetes. Findings include: The 4/2011 Nursing Care of the Resident with Diabetes Mellitus policy documents the following: - Signs and symptoms of hyperglycemia (high blood sugar/glucose) and hypoglycemia (low blood sugar) - The physician will order the frequency of glucose monitoring and resident's whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring. - Normal blood glucose ranges are approximately 70-130 mg/dl before meals and <180 mg/dl after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-06 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (main kitchen), in 1 of 3 nourishment refrigerators (Unit 1), and for 1 of 21 residents (Resident #23) reviewed for dining. Specifically, there was outdated food in a nourishment refrigerator, unclean equipment in the kitchen, and Resident #23's food was served without safe food handling during a breakfast observation. Findings include: The 4/2010 revised Preventing Foodborne Illness-Food Handling documented all employees who handle food will be trained in the practices of safe food handling and preventing foodborne illness. The 11/2019 Dining Room/Meal Service Policy and Procedure documented to sanitize hands between tray delivery and meal service. There was no documentation regarding gloves during meal service. The undated policy taped to the Unit 1 nourishment refrigerator documented all cooked or prepared food brought in from a resident and stored in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview during the recertification survey, the facility did not 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 1 of 5 residents (Resident #365) reviewed for non-pressure skin conditions. Specifically, proper hand hygiene and glove use was not performed during a dressing change for Resident #365. Findings include: The 7/2019 Infection Control Program policy documents handwashing continues to be the primary means of preventing the transmission of infection. Staff are educated on technique and when to wash hands. Employees required to perform tasks that may involve exposure to blood/body fluids will be provided personal protective equipment (PPE) including gowns, gloves, masks, and eyewear. PPE worn should be based on fluid or tissue, potential exposure, and volume. Resident #365 was admitted to the facility with diagnoses including morbid obesity and peripheral vascular disease…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-06 · tag F0923 — isolatedHave enough outside ventilation via a window or mechanical ventilation, or both.
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, the facility did not have adequate outside ventilation by means of windows for 5 of 5 windows (resident rooms 203, 206, 209, 211, and 212) observed. Specifically, there were not operable windows in resident rooms. Findings include: There was no policy regarding windows. Resident #53 was admitted to the facility with diagnoses including major depressive disorder, vitamin D deficiency, and anxiety. The 10/13/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and was totally dependent on staff for most activities of daily living. On 12/3/19 at 11:56 AM, the resident was observed in her room. She stated she would like to have some fresh air in her room at times and the windows were screwed shut. On 12/4/19 between 2:34 PM and 2:48 PM, the windows in rooms 203, 206, 209, 211, and 212 were observed to be screwed shut and not could not be opened. In addition, there were no mechanical ventilation within the bedrooms themselves. When interviewed on 12/4/19 at 2:48 PM, 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CENTERS HEALTH CARE — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.2 | -1.2 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 1 of 5 | 2.1 | -1.1 vs chain |
| Quality measures | 1 of 5 | 3.8 | -2.8 vs chain |
The other 35 homes this chain runs (chain average 2.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| UTICA KR HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 99% | since 01/01/2018 |
| ROZENBERG, KENNETH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 95% | since 01/01/2018 |
| NORINE, HELEN | Individual | W-2 MANAGING EMPLOYEE | — | since 12/31/2017 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335794. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-10, 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.