Willow Point Rehabilitation And Nursing Center
3700 Old Vestal Road, Vestal, NY 13850 · Government - County · 300 certified beds · (607) 763-4400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $166,364 in federal fines (most recent 2024-03-29)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 | 21.9% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.3% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.9% | 1.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.7% | 19.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.4% | 0.2% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 6.4% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.9% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.9% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 6.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.6% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.6% | 13.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.1% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.2% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.45 | 1.36 | 1.80 | better |
‡ 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.
50.8% 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 265 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.3% 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 137 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 50.8%CMS range 43.8–57.0 | 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 | 9.7%CMS range 7.3–12.3 | 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 | 61.3% | 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 | 49.6% | 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 | 49.6% | 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 | 24.6% | 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 | 55.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 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 | 2.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 5.5–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 300 beds and averages 254.7 residents a day — about 85% occupied, or roughly 45 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.25 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 2.42 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.73 hrs/resident/day on weekends vs 4.46 on weekdays — 16% thinner on weekends. RN hours go from 0.50 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. 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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · L2024-03-29 · tag F0883 — failed to offer flu and pneumonia vaccines — widespreadDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 recertification survey conducted 3/18/2024-3/29/2024, the facility failed to vaccinate eligible residents with the pneumococcal vaccination (a vaccination developed to minimize the risk of acquiring, transmitting, or experiencing complications of pneumonia) for 44 of 245 residents who consented to the pneumococcal vaccine. Specifically, from 9/5/2023 through 3/25/2024, Residents #12, #14, #17, #18, #24, #27, #31, #43, #45, #57, #63, #74, #82, #95, #102, #103, #108, #109, #117, #118, #126, #129, #134, #165, #173, #177, #186, #192, #213, #214, #215, #216, #219, #222, #224, #226, #229, #235, #484, #533, #585, #586, #587, and #633 consented to and had medical orders to receive the pneumococcal vaccine and did not receive it. Subsequently, 7 of the 44 residents (Resident #24, #95, #109, #126, #215, #229, and #484) were diagnosed with pneumonia and one resident (Resident #95) was hospitalized twice for the treatment of pneumonia. Additionally, a request to purchase 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.
- Actual harm · Hcited before2024-03-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 (NY00314754, NY00319010, NY00320020, NY00327419, NY00331182, and NY00334923) surveys conducted 3/18/2024-3/29/2024 the facility failed to provide adequate supervision to prevent accidents for 4 of 10 residents (Residents #114, #174, #191, and #213) reviewed. Specifically, Residents #114, #191, and #213 were subjected to physical aggression and sexually abusive behaviors by Resident #174 and the facility failed to develop or implement strategic interventions for Resident #174 to protect other residents from victimization. Subsequently, Resident #174 pushed Resident #114 causing Resident #114 to sustain a hip fracture; Residents #174 and #213 were found in sexually inappropriate situations three times; and Resident #174 pushed Resident #191 causing them to hit their head against a wall causing an abrasion. This resulted in harm to Residents #191 and #114 that was not immediate jeopardy. Findings include: The facility policy Abuse Prevention modified 3/2019 documents the facility would 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.
- Potential for harm · Ecited before2025-06-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 6/09/2025-6/13/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for one (1) of one (1) main kitchen reviewed. Specifically, the main kitchen had dented cans in use; dishes were not air dried; food was not discarded in a timely manner; and food was stored less than 18 inches from the ceiling. Additionally, food was uncovered while being transported through the North Lower Level hallway. Findings include: The facility policy Dented Cans, revised 4/2023, documented there was a designated place in the storeroom for dented cans, which were then destroyed to prevent the use of spoiled or contaminated food. The Food and Nutrition Services Department does not use foods in dented or damaged cans. The facility policy Dishware Storage, revised 5/2023, documented dishware would be stored appropriately to prevent food soil, dust, or any other debris from adhering to the surface. After coming out of the dish machine,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 6/9/2025-6/13/2025 the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records for four (4) of four (4) residents (Residents #1, #93, #141, and #208) reviewed. Specifically, Residents #1, #93, #141, and #208 identifying and personal information was posted in a public area visible to others. Findings include: The facility policy Corporate Compliance Code of Conduct, revised 7/2018, documented all employees had the responsibility of protecting the confidentiality of resident information. Employees should not reveal in any form of communication (verbal, written, fax, electronic) any personal or confidential information such as diagnosis or treatments. The facility policy Resident Rights, revised 3/2018, documented resident medical, social, and financial records would be released only to those staff members who needed them. During observations on 6/10/2025 at 12:37 PM, 6/11/2025 at 10:31 AM, and at 12:36 PM personal identifying…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · 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
Based on observations, record review, and interviews during the recertification survey conducted 6/9/2025 - 6/13/2025, the facility did not 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 one (1) of two (2) residents (Resident #197) reviewed. Specifically, Resident #197 did not have a care plan for anticoagulant (blood thinner) use. Findings include: The facility policy Care Plans, revised 2/2002, documented the interdisciplinary team met after each admission of a resident and on a regular basis to evolve a comprehensive plan of care which would best meet the individual needs of the resident. The comprehensive care plan was developed for each resident within 48 hours of admission and included goals, medications, treatments, and diet and was reviewed with the residents and/or their representative and documented in the electronic medical record. Resident #197 had diagnoses including stroke and pulmonary embolism (blood clot in the lung). The 6/5/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-13 · 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 and abbreviated (NY00371020) surveys conducted 6/9/2025-6/13/2025, 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 two (2) of six (6) residents (Residents #127 and #226) reviewed. Specifically, Residents #127 and #226 were not provided with facial grooming/shaving care. Findings include: The facility policy Activities of Daily Living, last revised 3/2015, documented the facility provided residents with Activities of Daily Living care and support in accordance with current standards of practice, State and Federal regulations, and based on the resident's assessed needs, personal preferences, and goals of care. Facial hair was groomed per the resident's preference and/or needs. 1) Resident #127 had diagnoses including Pick's disease (a form of dementia), depression, and anxiety. The 3/28/2025 Minimum Data Set assessment documented the resident had severely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the recertification and abbreviated (NY00344862) surveys conducted 6/9/2025-6/13/2025, the facility did not ensure accommodation of resident food preferences for two (2) of two (2) (Residents #127 and #195) reviewed. Specifically, Residents #127 and #195 were missing preferred food items on their meal trays. Findings include: The facility policy Food Preferences, revised 5/2023, documented resident food and beverage preferences were obtained upon admission and periodically as needed to assist Food and Nutrition Services department in providing preferred food and beverages to enhance/maintain quality of life and nutritional status. 1) Resident #127 had diagnoses including Pick's disease (a form of dementia), mild protein calorie malnutrition, and dysphagia (difficulty swallowing). The 1/4/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required set up assistance with eating, was unable to speak, weighed 95 pounds, had an unplanned 5% or more weight loss, and received a mechanically…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-13 · 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 observations, record review, and interviews during the recertification survey conducted 6/9/2025-6/13/2025, the facility did not 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 during one (1) of four (4) lunch meal observations. Specifically, during the lunch meal observation on 6/11/2025 Food Service Aide #27 did not perform hand hygiene after removing their gloves. Findings included: The facility policy Hand Hygiene, revised 5/2025 documented hand hygiene would be performed at a minimum after handling trash, handling soiled linen or supplies, and after contact with blood, bodily fluids, and visibly contaminated surfaces. During a lunch meal observation on the North Lower Level on 6/11/2025 at 12:31 PM, Food Service Aide #27 was serving the lunch meal. While plating a resident tray, they dropped a towel on the floor, picked up the towel with their gloved hand and continued serving the meal without…
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 · D2024-04-30 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 record review and interview during the abbreviated survey (NY00339000), the facility did not promote and facilitate the resident's right to self-determination through support of resident choice, including the resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 refused care and staff continued to provide care following multiple refusals. Findings include: The undated Resident Rights policy documented each resident had the right to be treated with dignity and respect in recognition of their individual preferences; to refuse treatment and be free from abuse. Resident #1 had diagnoses including anxiety disorder, major depressive disorder, and mild cognitive impairment. The 3/5/2024 Minimum Data Set assessment documented the resident had intact cognitive function and did not exhibit behavioral symptoms. The resident required substantial/maximum assistance with dressing, bathing, hygiene, and required moderate assistance with transfers.…
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 · D2024-04-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the abbreviated survey (NY00339000), the facility did not ensure residents were free from abuse, including but not limited to corporal punishment and any physical restraint not required to treat the resident's medical symptoms, for 1 of 3 residents reviewed (Resident #1). Specifically, licensed practical nurse #4 pushed multiple wet washcloths into the resident's face when the resident declined to receive care and certified nurse aides #5 and 6 held the resident's hands while licensed practical nurse #4 provided care that the resident declined. Findings include: The Abuse Prevention Policy, modified 3/20/2019, documented the facility will not permit residents to be subjected to abuse by anyone, including staff members and residents will be provided with appropriate clinical care and treatment and will be cared for according to the individualized care plan. Resident #1 had diagnoses including anxiety disorder, major depressive disorder, and mild cognitive impairment. The 3/5/2024 Minimum Data Set assessment documented the resident had…
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 · D2024-04-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the abbreviated survey (NY00339000), the facility did not ensure all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and did not ensure further potential abuse was prevented for 1 of 3 residents (Resident #1) reviewed. Specifically, - certified nurse aide #5 witnessed alleged abuse by licensed practical nurse #4 towards Resident #1 and did not report the alleged abuse immediately resulting in licensed practical nurse #4 continuing to have access to residents for the remainder of the shift while the investigation was pending. - Statements from staff, given the facility, documented additional potential abuse and those allegations were not investigated. - The resident was not assessed by a qualified professional timely following allegation of abuse. Findings include: The Abuse Prevention Policy, modified 3/20/2019, documented the facility must ensure that all alleged violations involving mistreatment, neglect, exploitation, or abuse are reported immediately to the Administrator. The facility shall…
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 · F2024-03-29 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 3/18/2024-3/29/2024, the facility did not ensure that licensed nurses had the appropriate competencies and skill sets necessary to provide nursing care and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well- being for each resident for 4 of 4 licensed nurses (licensed practical nurses #31, #45, #48, and registered nurse #51) reviewed. Specifically, licensed practical nurses #31, #45, #48 and registered nurse #51 did not receive routine competency evaluations that covered key skill-set areas including accessing venous access devices, vacuum assisted wound closure devices (wound VACs), hand hygiene, and medication administration. Deficiencies were identified in the areas of Parenteral/IV (intravenous) fluids (F694), Free from Significant Medication Errors (F760), Quality of Care (F684), and Infection Control (F880). Findings Include: The Facility Assessment for 2023 documented annual in-services and competencies 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.
Show the remaining 14 citations
- Potential for harm · F2024-03-29 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the recertification survey conducted 3/18/2024-3/29/2024 the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 5 of 5 certified nurse aides (certified nurse aides #35, #41, #42, #43, and #44) reviewed. Specifically, there was no documented evidence certified nurse aides #35, #41, #42, #43, and #44 had performance reviews at least once every 12 months. Findings include: The facility policy titled Staff Evaluations, last modified 11/9/2018, documented the facility would provide ongoing feedback to all staff members regarding their performance at specific intervals to encourage continuous improvement as needed. All staff members would receive an annual performance evaluation. If there were any identified areas of weakness, they would be referred to staff education to address the identified areas and assist with performance improvement. Annual performance evaluations were documented as follows: - Certified nurse aide #35: 1/2/2022. - Certified nurse aide #41: 12/29/2021. - Certified nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-03-29 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 3/18/2024-3/29/2024 the facility's governing body did not establish and implement policies regarding the management and operation of the facility. Specifically, there was not consistent communication between the governing body and the facility Administrator to ensure regulatory compliance. Multiple deficiencies including an immediate jeopardy in Influenza and Pneumococcal Immunizations (F883) were identified during the recertification survey. Findings include: The undated facility policy Quality Assurance Performance Improvement Committee (QAPI) Plan documented: - Quality assurance performance improvement addresses clinical care to continuously improve clinical care. Care data would be reviewed by the committee to proactively identify areas in need of improvement; and address resident choice to ensure decisions affecting the residents were made based on individual preference and care needs. - Administration is responsible for guiding and participating in the quality assurance performance improvement…
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 · D2024-03-29 · 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 and abbreviated (NY00328316) surveys conducted 3/18/2024-3/29/2024 the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #223) reviewed. Specifically, Resident #223 had an order for a vacuum assisted closure device (a device that uses negative pressure for wound healing) and the device was observed unplugged and not functioning. Findings include: The facility policy titled Wounds-Nursing care of a V.A.C. (vacuum assisted closure) Pump last modified 1/9/2019 documented the vacuum assisted closure device should always be in optimum working order while being used to heal a resident. During each shift, the pump should be checked to ensure it was on. If unable to maintain integrity of the system after 30 minutes, contact the Wound Care Nurse. Resident #223 was admitted to the facility with diagnoses including surgical aftercare following surgery on the skin 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 · D2024-03-29 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 3/18/2024 -3/29/2024, the facility did not ensure parenteral fluids (delivery of fluid or medication through a vein) were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #207) reviewed. Specifically, Resident #207 had an intravenous access device, the physician orders did not include the length of the external catheter or directions for measuring the catheter (to ensure it did not migrate or dislodge); licensed nurses did not know the type of the catheter the resident had; documentation of catheter care was inconsistent; and the care plan did not include daily care and monitoring of the device. Additionally, deficiencies related to intravenous therapy were identified in the areas of Significant Medication Errors (F760), and Competent Nursing Staff…
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 · D2024-03-29 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 (NY00328316) surveys conducted 3/18/2024-3/29/2024, the facility failed to ensure that residents were free of any significant medication errors for 1 of 1 resident (Resident #207) reviewed. Specifically, Resident #207 was given an incomplete dose of an intravenous antibiotic, 1 late administration of an intravenous antibiotic, and the intravenous access site was not flushed as ordered. Additionally, deficiencies in quality of care related to parenteral/intravenous fluids, and competent nurse staffing were identified in the areas of Parenteral/IV fluids (F694), and Competent Nursing Staff (F726). Findings include: The facility policy Medication Administration System revised 11/10/2020 documented all medication orders are checked against the [electronic medication administration record] and the physician's order in the electronic medical record before administering any drugs the first time. A nurse is responsible for questioning a drug order, if, in their judgment the order is in error or if…
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 before2024-03-29 · 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 and interview during the recertification and abbreviated (NY00311514) surveys conducted 3/18/2024-3/29/2024 the facility did not 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 4 of 5 residents (Residents #3, #147, #195, and #212). Specifically, licensed practical nurse #45 did not perform hand hygiene between medication administrations to Residents #3, #147, #195, and #212. (Refer to F 726 Competent Nursing Staff). Findings include: The facility policy Medication Administration System last modified 11/20/2020 documented nurses perform hand hygiene immediately before preparing medications. The facility policy Hand Hygiene last modified 7/29/2020 documented hand hygiene is done before and after any contact with residents, after handling trash, after handling soiled linen or supplies, before and after personal care, before and after feeding residents, and after restroom use. Hand…
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 · D2024-01-02 · 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
Based on observation, record review, and interview during the abbreviated survey (NY00301138) the facility did not assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 3 of 3 residents (Residents #1, #2, and #3) reviewed. Specifically, for Residents #1, #2, and #3 there was no documented evidence bed rail assessments were completed, and consents were obtained prior to bed rail installation; there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives prior to bed rail use; and there were no care plans that included the use and monitoring of bed rails. Findings include: The facility policy Assist Rails reviewed 2/5/2019, documented the facility would provide assist rails on beds as indicated to aid the resident in turning, positioning, and bed mobility. Upon resident request and/or determination by nursing and/or rehab that an assist rail…
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 · D2021-10-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 10/25/21-10/29/21, the facility failed to ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission for 2 of 35 residents (Residents # 165 and #187) reviewed. Specifically, there was no documentation that a Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was completed for Residents #165 and #187 by a qualified screener prior to admission to the facility. Findings include: Resident #187 was admitted to the facility with a history of major depressive disorder. The 3/2/21 Minimum Data Set (MDS) admission assessment documented the resident was cognitively intact, felt depressed several days, had not been evaluated by Level II PASARR and required extensive assistance with most activities of daily living (ADL's). Resident # 165 was admitted with diagnoses including depression. The 1/10/2019 comprehensive Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition,…
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 · D2021-10-29 · 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 record review and interview during the recertification survey conducted from 10/25/21-10/29/21, the facility failed to ensure the participation of the resident and the resident's representative(s) in the development of a comprehensive care plan for 1 of 1 resident (Resident #191) reviewed. Specifically, Resident #191 was not invited to attend their comprehensive care plan meeting and the resident expressed a desire to participate. Findings include: The 2/5/19 Care Plans facility policy documented the resident and/or resident's representative will be invited to attend and participate in the Interdisciplinary Team care plan meeting, and if unable or unwilling to attend, the plan of care will be discussed with them by the social worker and noted in the progress notes. Resident #191 was admitted to the facility with diagnoses including chronic kidney disease, hypertensive heart disease with heart failure, and morbid obesity. The 7/31/21 Minimum Data Set (MDS) annual assessment documented the resident was cognitively intact and required extensive assist of two staff for most…
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 before2021-10-29 · 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 10/25/21- 10/29/21, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #38) reviewed. Specifically, Resident #38 did not receive incontinence care as care planned and was observed inappropriately dressed. Findings include: The 6/2015 facility policy Toileting documented residents would be assisted with toileting every 2-4 hours and upon request during the day, when awake and at other times as directed. If a resident is on a toileting assistance schedule that specifies a designated time, they will be assisted with toileting according to the specific schedule. Resident #38 had diagnoses including dementia, anxiety, and depression. The 8/2/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, physical…
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 before2021-10-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification and abbreviated surveys (NY00283499) conducted from 10/25/2021 through 10/29/2021, 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 4 residents (Residents #37), 2 resident bathrooms and 1 shower room reviewed. Specifically, Resident #37 sustained a burn to their left ankle after a staff member spilled a reheated bowl of oatmeal on the resident and the facility did not develop a plan to prevent reoccurrences. Additionally, the hot water from bathroom sinks in South Unit resident room [ROOM NUMBER] and South Unit resident room [ROOM NUMBER] was over 120 degrees Fahrenheit (F), and the South Unit 2 shower room had a water temperature over 120 F. Findings include: REHEATING FOOD The undated facility policy Storage of Resident Food Brought in from Outside of the Facility 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 · D2021-10-29 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview during the recertification survey conducted 10/25/21-10/29/21, the facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 6 residents (Resident #202) reviewed. Specifically, Resident #202 was withdrawn and seclusive in their room and was refusing food and medications and a referral for behavioral health services was not completed as ordered. Findings include: The undated facility policy Behavioral Health Services documented all residents receive the necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Behavioral health care plans shall be reviewed and revised quarterly, annually, and as needed such as when interventions are not effective or when the resident experiences a change in condition. Resident #202 had diagnoses including dementia, anxiety, 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 · D2021-10-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview during the recertification survey conducted 10/25/21-10/29/21, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 nursing unit medication rooms and 1 of 5 medication carts (South 2B unit medication room and medication cart) reviewed. Specifically, the facility did not dispose of expired medications and biologicals in the medication room and medication cart on South 2B unit. The facility policy Medication Storage revised 2/6/19 documented all medications were to be stored according to pharmacy instructions and manufacturer recommendations. The policy did not document protocol for monitoring for expired medications or biologicals. On 10/27/21 at 9:26 AM during a medication cart storage observation on South 2B unit with licensed practical nurse (LPN) #8, there was a stock bottle of Calcium 600 milligrams (mg) with Vitamin D3 400 units that had a manufacturer expiration date…
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 before2021-10-29 · 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, interview, and record review during the recertification survey conducted from 10/25/21-10/28/21, 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 reviewed. Specifically, the main kitchen had an unclean/unsanitary empty storage room floor, multiple dirty/stained ceiling tiles and multiple unlabeled and outdated food items. Findings included: The facility policy Food Safety Product Labeling and Dating Guideline revised 1/29/21, documented ready to eat food, time/ temperature control (TCS) food prepared and held longer than the subsequent meal period must be marked to indicate the date or day which food should be consumed or discarded by. The facility Food Service Worker job description dated 3/2016, documented the general responsibilities included assisting with the preparation of hot and or cold foods, properly storing food, utilizing knowledge of temperature requirements and spoilage, and complying with all Hazard Analysis Critical Control Point (HACCP)…
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
$166,364 in federal fines across 1 penalty.
- $166,364 — penalty dated 2024-03-29
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 / manager | Type | Role | Since |
|---|---|---|---|
| BROOME COUNTY | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 11/01/1967 |
| JERZAK, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/26/2024 |
CMS files one row per role, so the 3 rows in the source record cover these 2 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.
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 74% 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. 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 335291. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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 →
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