Samaritan Keep Nursing Home INC
133 Pratt St, Watertown, NY 13601 · For profit - Corporation · 272 certified beds · (315) 785-4400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,020 in federal fines (most recent 2026-02-20)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 4 of 5 |
| Long-stay residentspeople who live here | 3 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 | 13.1% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.8% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.5% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.3% | 19.5% | 6.5% | better 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 | 5.8% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.0% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.1% | 13.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 81.4% | 95.3% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.3% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.3% | 13.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 73.8% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 9.8% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.1% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.37 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.44 | 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.
35.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 89 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 35.0%CMS range 25.7–43.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.6–15.6 | 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 | 56.2% | 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 | 37.1% | 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 | 55.1% | 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 | 98.1% | 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 | 25.6% | 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 | 1.0% | 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 | 4.8% | 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 | 7.0%CMS range 4.4–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 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 272 beds and averages 254.1 residents a day — about 93% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.86 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 4.38 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.35 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2026-02-20 · 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 interviews during the survey (Complaint #756448), the facility failed to ensure residents were free from abuse and neglect for one (1) of three (3) residents (Residents #3) reviewed. Specifically, on 03/24/2024 at approximately 12:00 AM, Resident #3 was zip tied (a fastener with a locking, self-snagging nylon strap used to secure items) to the able riser (enabler bar) on their bed by Licensed Practical Nurse #7, for approximately 45 minutes to one (1) hour. This resulted in Immediate Jeopardy Past Non-Compliance for Resident #3 and placed all residents at risk for abuse. Findings include:The facility policy Prevention of Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, revised 02/10/2023, documented abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Involuntary seclusion was confinement to his/her room against the resident's will. In addition to orientation, all employees should be in-serviced annually regarding: the appropriate…
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.
- Immediate jeopardy · Jcited before2023-08-08 · 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
Based on observation, interview, and record review during the abbreviated and extended surveys (NY00319112 and NY00294178), the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 3 residents reviewed (Residents #1, 2, and 3). Specifically, Residents #1, #2, and #3 were reportedly found by staff engaging in sexual activity, indicative of inadequate supervision of these residents with impaired cognition who reside on a secured unit. On three separate occasions, Resident #1 was found to be engaging in sexual acts with 2 other residents (Residents #2 and 3). Appropriate supervision interventions were not put in place to prevent recurrence, resident care plans were not updated or were not updated timely, and staff were not trained to prevent recurrence or how to provide appropriate supervision. On 7/18/2023, while onsite, a surveyor observed an unsupervised wandering resident on the secured unit enter Resident #1's room. This failure to provide adequate supervision places at risk the 38 residents of the secured unit who lacked decision…
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.
- Immediate jeopardy · J2023-08-08 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview during the abbreviated and extended surveys (NY00294178 and NY00319112), the facility failed to provide the appropriate treatment and services to attain and or maintain his or her highest practicable physical, mental, and psychosocial well-being for residents diagnosed with dementia for 1 of 5 residents (Resident #5) reviewed. Specifically, Resident #5 had severe dysphagia (swallowing difficulty), was on thickened liquids and puree diet consistency, wandered on the unit and ingested thin liquids resulting in aspiration pneumonia (inhalation of food/fluids into the lungs). Following an incident of wandering and ingesting thin liquids on 5/18/2023, nursing progress notes documented the resident was wandering, obtaining, and drinking thin fluids and/or eating regular consistency foods on 12 occasions between 5/25/2023 and 7/14/2023. There was no documented evidence of medical or speech therapy evaluation following the multiple incidents of ingesting thin liquids or regular consistency foods. The resident's care plan remained unchanged,…
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 · E2026-03-20 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure residents had the right to a dignified existence for two (2) of two (2) residents (Residents #184 and #257) reviewed. Specifically, Residents #184 and #257 had their side rails removed and there was no documented evidence they were provided with education, a therapy evaluation, side rail alternatives, or an opportunity to discuss their concerns prior to the side rails being removed. This resulted in a decline in bed mobility for Residents #184 and #257. Findings include:The facility policy Bed Rail Use - Side Rails, Assist Rails, Transfer Rails, Bed Enablers, revised 09/03/2025, documented assignment of a bed rail would be considered only after all non-bed rail alternatives are attempted; side rails may only be considered to treat a resident's medical symptoms or as an assistive device to assist with mobility and transfer of residents; the resident/representative will be provided education on the risks versus the benefits of using the device so that the resident/resident representative can make an…
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 · D2026-03-20 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #133) reviewed. Specifically, Resident #133 had a medication cup at their bedside containing one white round pill and one half of a round white pill. There was no documented evidence of assessments and/or physician orders for the residents to safely self-administer medications.Findings included:The facility policy Administration of Medication Guidelines, last reviewed 04/02/2025, documented the nurse was personally responsible for every drug they administered. They stayed with the resident until they swallowed the drug, and medications were not left with the resident, except with a doctor's order.The facility policy Self-Administration of Medications, created 02/18/2026, documented residents who desired to self-administer medication would be allowed to do so under guidelines in the policy. Residents were evaluated for desire 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 · Dcited before2026-03-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for one (1) of three (3) residents (Resident #281) reviewed. Specifically, Resident #281 was admitted with a Stage 2 (partial thickness skin loss) pressure ulcer and did not have admission orders for wound care.Findings include:The facility policy Wound Care and Pressure Injury Prevention and Treatment, last reviewed 02/11/2026, documented the facility would implement a systemic interdisciplinary process for the prevention, identification, assessment, treatment, and monitoring of wounds and pressure injuries to ensure pressure injuries were prevented and that existing wounds received appropriate and timely treatment. The nurse managers were responsible for performing comprehensive wound and skin assessments, initiating/updating care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-20 · 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
Based on observations, record review, and interviews, the facility failed to ensure adequate supervision to prevent accidents for one (1) of one (1) resident (Resident #215) reviewed. Specifically, Resident #215's elopement safety interventions of 30 and 60-minute safety checks and wander guard tag checks were not completed as planned/ordered. Findings include:The facility policy Elopement Prevention, revised 01/11/2023, documented the assigned nurse would check the resident every shift to ensure the wander guard tag was in place and had a blinking red light indicating it was functioning properly. The facility policy Elopement - Resident Evaluation for Potential, revised 02/16/2024, documented elopement precautions would be addressed on the care plan, implementing measures as indicated.The facility policy Increased Supervision-Visual Monitoring Checks and 1 to 1, revised 10/11/2021, documented a resident on increased supervision would have a staff person assigned to do a visual check on the resident within consecutive 30 or 60-minute intervals as necessary; interventions would be…
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 · D2026-03-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 the facility failed to provide the necessary services and treatment for indwelling urinary catheter use for two (2) of six (6) residents (Residents #1 and #13) reviewed. Specifically, Resident #1 did not have a provider recommended voiding trial completed; and Resident #13 had an indwelling urinary catheter with a history of bladder infections and did not receive assistance with changing between their urinary collection leg bag (a small, wearable, and discreet receptacle used to collect urine) and a large capacity urinary collection bag. Findings include: The facility policy Foley Catheter, revised 04/21/2015, documented the facility ensured all residents with an alteration in urinary continence had been assessed and provided the interventions that best meet their needs and the physician's order would be checked for an appropriate medical justification. There was no documented policy addressing care and maintenance of an indwelling urinary catheter. 1)…
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 · D2026-03-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews during the survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) Residents (Resident #197) reviewed. Specifically, Resident #197 had significant weight loss, was not assisted with meals as care planned, and there was no documented evidence a medical provider addressed the resident's weight loss.Findings included:Resident #197 had diagnoses including Alzheimer's disease and abnormal weight loss. The 01/29/2026 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision/touching assistance with eating, and had a 5% or weight loss in the last month or 10% more in the last 6 months and was not on a physician-prescribed weight-loss regimen.The 08/19/2025 Comprehensive Care Plan, revised 11/18/2025, documented the resident had inadequate oral intake related to decreased appetite and sleeping during meals as evidenced by poor recorded intakes and significant weight loss of 11 pounds in 90 days. The goal was to consume 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 · D2026-03-20 · 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 interviews, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (1) of one (1) resident (Resident #257) reviewed. Specifically, Resident #257 had a bilevel positive airway pressure machine (non-invasive mechanical ventilator that keeps airway open when sleeping) that was not cleaned per professional standards; was not maintained with water in the reservoir; did not have an order for supplemental oxygen use when used; was not documented as administered on the medication administration record; and there was no documented evidence of ongoing assessment of the resident's respiratory status, response to the therapy, documentation of the equipment settings or when to use the equipment.Findings include:The facility policy CPAP (continuous positive airway pressure) BIPAP (bilevel positive airway pressure) Therapy, revised 06/01/2021, documented the facility would provide bilevel positive airway pressure therapy in accordance with physician orders,…
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 · D2026-03-20 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to ensure that a resident who required dialysis (a process that filters blood during kidney failure) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #13) reviewed. Specifically, Resident #13 received dialysis at a community-based dialysis center, and the facility did not perform ongoing assessments of their condition or monitor for complications before and after dialysis treatments and there was inconsistent communication between the dialysis center and the facility. Findings include: The facility policy Dialysis, revised 03/01/2023, documented communication with the dialysis team would be maintained to ensure quality care of the resident; the purpose of the communication book was to share information/ask questions, not requiring immediate responses with the dialysis center; the unit manager/designee was responsible for writing in the communication book; and the resident would be monitored for such things as signs of fluid retention or dehydration,…
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 · D2026-03-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of seven (7) medication carts (8th floor and 4th floor medication carts); one (1) of four (4) medication rooms (4th floor medication room); and one (1) of seven (7) treatment carts (3rd floor treatment cart) reviewed. Specifically, one medication cart on the 8th floor was unlocked and unsupervised; one medication cart on the 4th floor contained pre-poured, unlabeled medications; the 4th medication room refrigerator contained an open, undated multi-dose tuberculin purified protein derivative vial; and the 3rd floor treatment cart was unlocked and unattended.Findings included:The facility policy Storage of Medications, last reviewed 02/10/2026 documented medication supply was only accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts,…
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 before2026-03-20 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure residents received and the facility provided a diet in a form designed to meet individual needs for one (1) of one (1) resident (Resident #241) reviewed. Specifically, Resident #241 received a whole regular brownie instead of a pureed brownie as ordered; and the resident's person-centered Comprehensive Care Plan did not include the ordered altered food consistency. Findings include:The facility policy Altered Consistency-Texture Modified Diet-Dysphagia difficulty swallowing) Management, reviewed 04/02/2025, documented residents received food and fluids in a consistency that was safe, palatable, and met their nutritional needs, in accordance with physician orders, clinical assessment, and regulations of the New York State Department of Health. Texture-modified diets and fluid consistencies were implemented as clinically indicated and reduced the risk of aspiration, choking, and malnutrition, while resident rights and preferences were honored. Food texture level Pureed (Level 1) was homogeneous,…
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 17 citations
- Potential for harm · Dcited before2026-03-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1 was on transmission-based precautions (enhanced barrier precautions) and Certified Nurse Aide #37 did not perform hand hygiene prior to entering the resident's room, emptied the resident's urinary catheter without wearing required personal protective equipment, and did not perform hand hygiene with glove changes. Findings include: The facility policy Enhanced Barrier Precautions, reviewed 03/06/2026, documented any resident with an indwelling medical device such as a urinary catheter was placed on enhanced barrier precautions. Personal protective equipment including gloves and gown was required to be worn during any high contact…
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 · D2024-04-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews during the abbreviated surveys (NY00308228 and NY00322916) the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported to the New York State Department of Health as required. Specifically, Resident #2 sustained a fracture from a transfer with a mechanical lift and Resident #3 eloped (exited, undetected by staff) to a non-resident area and the incidents were not reported as required. Findings include: The Accident and Incident Investigating and Reporting policy revised 10/18/2022 documented: - any alleged violation of abuse, mistreatment, neglect, injuries of unknown origin, or misappropriation of resident's property will be reported to the New York State Department of Health if and when the reasonable cause threshold has been achieved. - The policy references included the 2016 New York State Department of Health Nursing Home Incident Reporting Manual. The New York State Department of Health Nursing Home Incident Reporting Manual dated 8/2016…
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 before2024-03-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 2/26/2024-3/1/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 7 of 7 residents (Resident #33, #103, #212, #124, #75, #68, and #92) reviewed. Specifically, Resident #33 did not have pressure relief for their heels as planned and Residents #33, #103, #212, #124, #75, #68, and #92 had air mattresses (a specialty mattress that provides air flow to relieve pressure) in use that were not monitored for functioning. Findings include: The facility policy Skin Care Program dated 5/2023 documented the Interdisciplinary Team would evaluate the need for additional pressure relieving support surfaces and/or pressure relieving devices based on the resident's assessment. Pressure reduction included a therapeutic mattress that would be…
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 · D2024-03-01 · 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 record review and interview during the recertification survey conducted 2/26/2024 -3/1/2024, the facility did not ensure a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 1 resident (Resident #7) reviewed. Specifically, Resident #7 had a wedge positioning pillow (a wedge-shaped pillow used to aid with positioning) tucked under their fitted bedsheet that was not included on their comprehensive person-centered care plan. Findings include: The facility's policy Comprehensive Care Plan revised 10/2023 documented the comprehensive care plan would include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs. The care plan would be individualized for each resident. All disciplines were responsible for reviewing the plan of care, documenting goals, interventions, monitoring notes, and updating as needed. The facility's policy Positioning and Positioning Device revised 12/2018 documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · 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 observation, record review, and interview during the recertification and abbreviated (NY00302726, NY00316052, NY00322441) surveys conducted 2/26/2024- 3/1/2024, 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 2 of 8 residents (Residents #638 and #109) reviewed. Specifically, Resident #638 was not assisted with meals and Resident #109 was observed with unwanted facial hair. Findings include: The facility policy Standard of Care-Activities of Daily Living reviewed 11/6/2023 documented residents maintained adequate nutrition and adequate intake of each meal by encouraging, cueing, prompting, and feeding as needed. Residents were assisted to keep clean, neat, and well-groomed including shaving. Shaving was provided on shower days and as needed. 1) Resident #638 was admitted to the facility with diagnoses including Parkinson's (a progressive neurological disorder), generalized anxiety disorder, and dementia. The admission Minimum…
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 · D2024-03-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 2/26/2024-3/1/2024, the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion and proper positioning for 2 of 4 residents (Residents #166 and #124) reviewed. Specifically, Resident #166 did not have bilateral hand splints in place as ordered and planned and Resident #124 did not have hand splints in place as planned. Findings include: The facility policy Rehab-Splints/Upper Extremities dated 1/2019 documented the occupational therapy evaluation and recommendation would be documented in the medical record. The splint would be fitted to the resident and issued on the unit. The care plan would be updated, a wearing schedule would be provided to the resident, and the nursing staff would be educated regarding application and use. Nursing would contact occupational therapy anytime the resident was no longer wearing the splint for any reason and would be re-evaluated…
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 before2024-03-01 · 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 (NY00322441) surveys conducted 2/26/2024-3/1/2024, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 9 residents (Residents #4 and #162) reviewed. Specifically, Resident #4 was care planned to be out of bed for meals with use of specific swallowing strategies and was left in bed unsupervised during a meal; Resident #162 had a diagnosis of dysphagia (difficulty swallowing) with aspiration precautions and was observed eating meals alone in their room. Findings include: The facility policy Assistance with Meals last reviewed 9/2023, documented residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who need assistance will be assisted with attention to safety, comfort, and dignity. The facility policy Aspiration Policy and Procedure last revised 6/2023 documented encourage chewing and swallowing during oral…
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 · D2024-03-01 · 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 record review and interview during the recertification and abbreviated surveys (NY00316052) conducted 2/26/2024-3/1/2024 the facility did not ensure residents were free of significant medication errors for 1 of 3 residents (Resident #21) reviewed. Specifically, Resident #21's medications were crushed, combined, and administered all at once through their gastrostomy tube (feeding tube). Additionally, prednisone (corticosteroid) was ordered to be given orally and was given via the gastrostomy tube. Finding include: The 2009 American Society for Parenteral and Enteral Nutrition The Enteral Nutrition Practice Recommendations guide documented each drug should be administered separately through a feeding tube diluting the drugs as appropriate. The medications should be flushed before, between and after each administration. Avoid mixing two or more medications together, whether solid or liquid formulations, as this can create a new unknown entity with an unpredictable release and bioavailability. The facility policy Administration of Medication Guidelines revised 12/18/2023…
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 before2024-03-01 · 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, interview, and record review during the recertification survey conducted 2/26/2024-3/1/2024, 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 infection for 1 of 3 residents (Residents #92) reviewed. Specifically, Resident #92's wound care was completed by licensed practical nurse #1 without performing appropriate hand hygiene and precautions to prevent contamination of the wound and clean supplies. Findings include: The facility policy Wound Care last reviewed/revised 1/2018, documented the procedure included to use a disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Wash and dry hands thoroughly. Put on exam gloves and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Wash wound and peri wound per order.…
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 before2023-08-08 · 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 (NY00319112), the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 2 of 3 residents reviewed (Resident #1 and 3). Specifically, Residents #1 and 3 had a sexual encounter and were deemed unable to consent to sexual activity and the facility did not put a plan in place to protect Resident #1 from further potential abuse while the investigation was process; did not identify abuse occurred; did not identify inconsistencies in the plan of care related to the level of supervision planned for Residents #1 and 3, and did not rule out neglect. Findings include: The 10/24/2022 Accident/Incident Investigating and Reporting policy documented the policy was to ensure all accidents and incidents not consistent with the routine operations or routine care of the resident was to be immediately and thoroughly investigated, documented, and reported. Such allegations shall be documented, and actions taken to prevent further potential abuse while the investigation…
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 · D2023-08-08 · tag F0948 — isolatedEnsure that paid feeding assistants have the training they need.
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 abbreviated surveys (NY00294178 and NY00319112), the facility did not ensure individuals working in the facility as paid feeding assistants had successfully completed a State-approved training program for 1 of 3 employees reviewed (hospitality aide, HA #37 ). Specifically, there was no documentation HA #37 received the required training and was observed feeding Residents #7 and 8. Findings include: The [DATE] Mealtime Considerations policy documented: - The HA or designee encourages staff to start the meal according to posted mealtimes. - The HA or designee begins setting up meal tickets on trays with assigned adaptive equipment, napkin, straws, silverware, and beverages. - After the meal, HAs clear and clean out room trays. - For residents needing to be fed, directions included caregivers and did not specify staff roles assigned to feeding. The undated Job Description Report - Hospitality Aide, Long Term Care Nursing documented: - The minimum…
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 before2021-09-03 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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 (NY00278827 and NY00279852) surveys conducted from 8/30/21-9/3/21, the facility failed to ensure allegations of abuse, exploitation, or mistreatment were thoroughly investigated for 5 of 7 residents (Residents #1, 153, 165, 189, and 239) reviewed and did not take appropriate corrective action to prevent abuse for 2 of 7 residents (Residents #46 and 199) reviewed. Specifically, Resident #165 exhibited signs of at-risk behavior and was not provided adequate supervision to prevent abuse towards Residents #46 and 199; Resident #239 made an allegation of abuse that was not investigated; and Residents #1, 153, and 189 were involved in physical altercations with another resident that were not investigated by the facility to rule out abuse, neglect, or mistreatment. Findings include: The facility policy Accident and Incident Investigating and Reporting, reviewed 11/2020 documents: - Any incident not consistent with the routine operations or the routine care of residents shall be reported,…
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 before2021-09-03 · tag F0880 — failed to prevent and control infections — patternProvide 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, interview and record review during the recertification survey conducted 8/30/21 - 9/3/21 the facility failed to 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 all 246 residents of the facility. Specifically, there was cross-contamination of dirty and clean laundry. Findings include: The facility policy Infection Prevention and Control in the Laundry Department revised on 6/16/2021, documented these guidelines were to ensure the appropriate handling and processing of clean and dirty linen to minimize the risk of infection transmission. During an observation of the facility laundry room on 9/2/21 at 10:00 AM with the Director of Facilities present, there were five washing machines and four dryers. There was with only one door to the room for entrance and exit. There were three gowns hanging in the laundry room worn by staff when handling infectious items. During an interview on 9/2/21 at 10:00 AM…
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 · D2021-09-03 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 8/30-9/3/21, the facility failed to ensure reports with respect to any surveys, certifications and complaint investigations and any plan of corrections, were made available for any individual to review upon request. Specifically, the facility did not post all survey results or notice of availability of such reports including standard, extended and complaint investigation surveys from the 3 preceding years. Findings include: During a Resident Council Meeting on 8/31/21 at 10:27 AM, 3 residents stated they were not familiar with the location of the state survey results or what they entailed. On 8/31/21 at 11:15 AM, a binder labeled as Department of Health (DOH) survey results was located next to the facility's reception window. The binder contained the results from the 7/13/19 Health and Life Safety Code Recertification Surveys. There were no survey results with plans of correction following this date and no notice of the availability of survey reports. During an interview with administrative…
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 · D2021-09-03 · 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 and interviews during the recertification survey conducted from 8/30/21- 9/3/21, the facility failed to maintain a safe, clean, comfortable, and home-like environment for 2 of 7 resident units (Units 6 and 8). Specifically, there were stained, non-waxed and sticky floors, plastic raceways (protective plastic covers over wires running from the plug to the computers on the walls) hanging from the walls, a stained chair and water condensation observed on the resident units. Findings include: On 8/30/21 at 11:35 AM and 8/31/21 at 9:58 AM, 11:16 AM and 1:30 PM the following observations were made on Unit 8: - The dining room floor had dark colored and rust stains in multiple areas. - A wall within the Unit 8 dining room had a plastic raceway that was hanging from the wall, and the electrical outlet the wire was plugged into was loose. - The wall outside room [ROOM NUMBER] had a plastic raceway that was hanging from the wall and the electrical outlet the wire was plugged into was loose. - 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 before2021-09-03 · 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
Based on observation, interview and record review during the recertification and abbreviated surveys (NY00281073) conducted from 8/30/21- 9/3/21, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 of 6 residents (Residents #67 and #153) reviewed. Specifically, Resident #67 was not assessed, or care planned to use side rails, and Resident #153 was not care planned for protection from potential accident hazards. Findings include: The facility's 12/2020 Bedside Assessment for Siderail Appropriateness policy documented staff should observe the resident at bedside to assess functional abilities. Observe the resident's bed movement and mobility to determine if the resident is able to assume a sitting position, able to swing legs over the side of the bed to touch the floor, able to sit at the side of the bed steady and unsupported, able to sit on the side of the bed and return to a lying position or able to come to a full standing position. Can the resident get out of bed at all or does the resident demonstrate a desire to get out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-03 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 8/30/21-9/3/21, the facility failed to ensure each resident received food and drink prepared in a form to meet individual needs for 1 of 3 residents (Resident #150) reviewed. Specifically, Resident #150 had a physician order to receive a mechanically altered level 2 diet (consisting of foods that are moist, soft-textured, and easily formed into a bolus) and received a regular consistency entrée. Findings include: The facility's revised 8/2019 Speech Language Pathology (SLP) - Diet and Liquid Consistency Order Changes policy documented each resident must have an initial diet consistency ordered by the Physician, Physician Assistant (PA) or Nurse Practitioner (NP). SLP will make diet consistency modifications per clinical findings and in collaboration with the resident, family, and interdisciplinary team (IDT). All diet consistency orders and changes are to be entered in the electronic medical record (EMR). The facility's revised 1/2019 Mealtime Considerations policy documented mealtime was…
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
$14,020 in federal fines across 1 penalty.
- $14,020 — penalty dated 2026-02-20
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 |
|---|---|---|---|
| BRIGGS, MAXINE | Individual | W-2 MANAGING EMPLOYEE | since 08/01/2019 |
| CALARCO, FRANCES | Individual | CORPORATE DIRECTOR | since 04/01/2022 |
| CARMAN, THOMAS | Individual | CORPORATE DIRECTOR | since 04/01/2010 |
| HOCHGRAF, CHRIS | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| MCLAUGHLIN, CARL | Individual | CORPORATE DIRECTOR | since 03/31/2017 |
| O'CONNOR, LINDA | Individual | CORPORATE DIRECTOR | since 03/31/2022 |
| ORMSBY, BARRY | Individual | CORPORATE DIRECTOR | since 03/31/2017 |
| PURINGTON, SAM | Individual | CORPORATE DIRECTOR | since 01/01/2016 |
| SCHMITT, MELISSA | Individual | CORPORATE DIRECTOR | since 03/31/2021 |
| TREADWELL-WOODS, JOAN | Individual | CORPORATE DIRECTOR | since 03/01/2010 |
| VALENTINE, TRACY | Individual | CORPORATE DIRECTOR | since 03/31/2021 |
| VARS, ADDISON | Individual | CORPORATE DIRECTOR | since 03/31/2018 |
| WALTON, PETER | Individual | CORPORATE DIRECTOR | since 03/01/2010 |
| WARDWELL DONAHUE, MARY | Individual | CORPORATE DIRECTOR | since 03/31/2018 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% 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 $958K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 335431. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-20, 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.