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Elderwood At Waverly

37 North Chemung Street, Waverly, NY 14892 · For profit - Individual · 200 certified beds · (607) 565-2861 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0744)1 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$120,884 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • inspectors cited 1 immediate-jeopardy problem — 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $120,884 in federal fines (most recent 2026-03-11)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (68%) runs well above the national median (45%)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
29 N Chemung St · (607) 565-9975 · Call to confirm hours
Pharmacy
443 Cayuta Ave · (607) 565-2390 · Call to confirm hours
Grocery
468 Cayuta Ave · (607) 565-5075 · Call to confirm hours
Park
60 Ithaca St · (607) 565-8106 · Typically dawn to dusk
Place of worship
38 State Route 34 · (607) 565-9342

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.4%14.1%15.4%worse
Long-stay residents who lose too much weight11.3%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.5%0.9%better
Long-stay residents with a urinary tract infection2.9%1.3%2.0%worse
Long-stay residents with depressive symptoms10.6%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury8.0%3.1%3.3%worse
Long-stay residents whose ability to walk worsened19.8%12.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.5%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine94.6%95.3%95.3%typical
Long-stay residents with pressure ulcers7.1%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control33.6%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table23.3%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.4%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine74.5%78.8%79.4%typical
Short-stay residents rehospitalized after admission23.8%20.6%22.6%typical
Short-stay residents with an outpatient ER visit13.5%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.821.701.67typical
Long-stay outpatient ER visits per 1,000 resident days0.931.361.80better

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

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

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

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

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

61.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 304 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.8%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
54.9%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.01hours / resident / day
Occupational therapy

Met the expected recovery: 54.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 164 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.8%CMS range 57.0–67.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.9–12.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge43.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 4.0–9.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.36
RN hours/ resident / day
0.59
LPN hours/ resident / day
1.71
Aide hours/ resident / day
2.66
Total nurse hours/ resident / day
0.22
RN hoursweekends
67.5%
Total nursing turnover
64.0%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 178.9 residents a day — about 89% occupied, or roughly 21 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 2.66 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.71 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.18 hrs/resident/day on weekends vs 2.86 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.42 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-03-28)
13
at the previous standard inspection (2023-04-27)

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.

ABCDEFGHIJKL

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

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2026-03-11 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews during the facility failed to protect residents from sexual abuse for six (6) of six (6) residents (Residents #3, #4, #5, #6, #7, and #8). Specifically, Resident #2 was found in separate sexually inappropriate situations with six (6) residents, all of whom had impaired cognitive function with the exception of Resident #5. The facility's failure to protect residents from sexual abuse placed all 176 residents in the facility at risk of abuse. This resulted in actual harm for Residents #3, #4, #5, #6, #7, and #8 that was Immediate Jeopardy and Substantial Quality of Care for residents' health and safety. Findings include: The facility policy, Abuse Prevention, Identification, Investigation, Protection and Reporting, dated 04/30/2024, documented all staff would be trained on prevention of all forms of abuse. Training would include recognizing forms of abuse. Prevention included on-going assessments, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect including wandering into other's rooms 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2025-01-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the abbreviated survey (NY00369096), the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding Advance Directives to the staff responsible for the resident's care for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 updated their Medical Orders for Life-Sustaining Treatment to reflect a change in their wishes from cardiopulmonary resuscitation (attempt to restart the heart) to do not resuscitate (allow natural death). The paper medical record (Medical Order for Life Sustaining Treatment form) and electronic medical record code status orders did not match to reflect the resident's Advance Directives wishes to allow natural death (do not resuscitate). Subsequently, when the resident was found without signs of life, nursing staff verified their status with the prior Medical Orders for Life-Sustaining Treatment form and initiated cardiopulmonary resuscitation. When nursing staff noted in…

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

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-03-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the abbreviated survey (iQIES reference #2740895), the facility failed to ensure residents were free from physical abuse for one (1) of seven (7) residents (Resident #1) reviewed. Specifically, Resident #1 was combative during care, struck Support Aide #2, and Support Aide #2 struck the resident back in the left shoulder. The 04/30/2024 facility policy, Abuse Prevention, Identification, Investigation, Protection and Reporting documented all staff would be trained on prevention of all forms of abuse. Training would include recognizing forms of abuse. The facility would ensure supervision of staff on all shifts would occur to identify inappropriate staff behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, and directing residents that need assistance with the bathroom to urinate or defecate in their beds. Prevention included on-going assessments, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as physically aggressive behavior such…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · F2025-03-28 · tag F0909 — failed to maintain a comfortable temperature — widespread
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    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 3/24/2025-3/28/2025, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 7 of 7 resident beds (beds for Resident #15, #29, #31, #38, #91, #99, and #106) reviewed. Specifically, Resident #15's mattress was not securely placed within the bedframe brackets; Resident #29's mattress did not fit within the bedframe mattress brackets resulting in a gap between the mattress and the assist rail; Resident #99's mattress was not securely placed in the bedframe brackets resulting in an entrapment zone that exceeded the United States Food and Drug Administration's recommended dimensional limits; and Residents #31's, #38's, #91's, and #106's assist rails were not routinely inspected for possible zones of entrapment. The facility policy, Bed Rail use (Side Rails, Assist Rails, Transfer Rails, Bed Enablers), revised 9/27/2018, documented upon installation and routinely 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 observations, record review, and interviews during the recertification survey conducted 3/24/2025 to 3/28/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 7 residents (Resident #142) reviewed. Specifically, Resident #142 was not provided with supervision and maximum cueing with eating and was not provided meals in the dining room as planned. Findings include: The facility policy [Activities of Daily Living] Assistance and Supervision. approved 1/18/2018, documented the Unit Manager and licensed practical nurse team leaders monitored the activity of daily living and supervision provided to the residents and gave appropriate guidance and assistance to nursing staff. The certified nurse aides provided the activities of daily living assistance and supervision to their assigned residents. The personal care profile and care plan were referenced for the type of activities of daily living 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 13 residents (Residents #164, and #171) reviewed. Specifically, -Resident #171 had dysphagia (difficulty swallowing), was on aspiration (inhaling food/fluid into the lungs) precautions and the resident was provided ice chips without a physician order or supervision. -Resident #164 was at high risk for elopement (leaving premises/safe area without facility knowledge), the resident frequently wandered in non-residential areas, and there was no documented evidence of a plan to limit the resident's wandering to potentially unsafe areas. Additionally, the resident's wander alert device was not checked for function as planned. Findings include: The facility policy Aspiration Precautions Guidelines, revised 7/24/2018 documented if orally fed, maintain the resident's head of bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-28 · tag F0744 — failed to care for residents with dementia — isolated
    Provide 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 observations, record review, and interviews during the recertification and abbreviated (NY00343302 and NY00370767) surveys conducted 3/24/2025-3/28/2025 the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Residents #143) reviewed. Specifically, Resident #143's telepsychiatry recommendations for non-pharmacological interventions for behavioral symptoms were not implemented. Findings include: The facility policy SEASONS Memory Care Program, updated 12/20/2019, documented the program provided the residents a safe environment while enlarging their life with appropriate and purposeful activity that accommodated the individual's strengths, interests, and needs while promoting autonomy and assisting them in maintaining their level of ability. This was to reduce anxiety and boredom driven behaviors. The facility policy Behavior Monitoring, approved 2/10/2020, documented the facility ensured that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 5 medication rooms (Unit 1 North and Unit 3) reviewed. Specifically, lorazepam (a controlled substance) was stored in unlocked refrigerators (not double locked) that were not permantly affixed in Unit 1 North's and Unit 3's medication rooms. The facility policy Medication Rooms on Nursing Units, revised 7/30/2024, documented a double locked box in the refrigerator would be used for the storage of controlled substances that required refrigeration. The facility policy Medications Administration Methods, revised 1/25/2024, documented controlled substances should be stored in a double-locked cabinet until immediately before administration. During an observation on 3/25/2025 at 9:22 AM, the medication refrigerator in the Unit 1 North medication room had an exterior lock on the main door that was not engaged and a locked interior drawer…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-28 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure the provision of food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals tested (3/24/2025 and 3/28/2025 lunch meals). Specifically, the 3/24/2025 lunch meal entree was difficult to cut; and the 3/28/2025 lunch meal was not served at palatable and safe temperatures. Findings include: The facility policy Food Temperature Requirements and Holding Time, revised 6/28/2019, documented the Director of Dining Services or designee was responsible for assuring the proper temperatures and holding times of foods were maintained during the preparation and service of meals. The 3/24/2025 posted lunch menu documented cube steak with brown gravy, garlic mashed potatoes, peas and onions, and pineapple chunks. The following observations and interviews were made during the 3/24/2025 lunch meal: - at 12:41 PM Resident #383 stated sometimes the food was served cold and tasted bland. - at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-28 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. Specifically, the main kitchen had food items past their expiration dates, undated food items, the walk-in freezer had ice buildup on an open box of food, and food was stored on the floor. Findings include: The facility policy Dietary Food and Supply Orders-Storage, revised 10/26/2018, documented food and non-food supplies were stored in a food storeroom and in refrigeration or freezer areas of the kitchen, in conformance with applicable sections of the New York State Health Code, rules and regulations. Containers of food were stored at a minimum of six inches above the floor to protect the food from splash and other contamination. Food was protected from contamination by dust, insects, rodents, unclean equipment and utensils, unnecessary handling, drainage and overhead leakage at all times during storage. Food removed from…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-28 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review during the recertification survey conducted 3/24/2025 through 3/28/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the facility matrix for all residents and access to all resident electronic health records requested by the New York State Department of Health (NYS DOH) surveillance team in a timely manner. Findings include: The Centers for Medicare and Medicaid Services survey form Entrance Conference Worksheet provided to the Administrator/designee upon survey entrance documented the following items were required during the recertification survey: - the complete matrix for all residents within 4 hours of entrance. - access to all resident electronic health records and specific information on how surveyors could access the electronic health record outside of the conference room by the end…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 abbreviated survey (NY00369577), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 did not receive assistance at meals as care planned. Findings include: The facility policy, Activities of Daily Living Assistance and Supervision, revised 1/4/2018 documented the Unit Manager/designee would ensure that a plan of care for receiving activities of daily living assistance and/or supervision was incorporated into the daily nursing care of each resident. Resident #2 had diagnoses including Alzheimer disease and self-feeding difficulties. The 11/28/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, required partial/moderate assistance with eating, and received a mechanically altered diet. The Comprehensive Care Plan updated on 12/5/2024 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Ecited before2023-12-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview conducted during the abbreviated survey (NY00327113 and NY00327592), the facility did not ensure adequate supervision was provided to prevent accidents for 8 of 14 residents (Residents #3, #5, #6, #7, #8, #9, #10, and #11) reviewed. Specifically, Residents #7, #8, and #9 had histories of behaviors towards other residents and adequate supervision was not implemented to prevent further resident to resident incidents towards Residents #3, #5, #6, #8, #10, and #11. Findings include: The 1/8/2020 Enhanced Supervision Policy documented enhanced supervision was an integral part of a therapeutic plan and ensured the safe sensitive monitoring of a residents' physical and psychosocial well-being. The three levels of Supervision included: Level 1 (routine checks); Level 2 (designated staff assigned to monitor the resident's whereabouts at specific time intervals), and Level 3 (one to one supervision). The designated staff were to document on the supervision flowsheet and scan the form into the resident's medical record upon completion. All residents on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-27 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 occupied resident floors (First, Third, and Fourth floors) reviewed. Specifically, - the fourth floor had stained ceiling tiles and the elevator alcove had a loose handrail. - the third floor had a damaged bathroom sink, the soiled utility room did not have a paper towel dispenser, and the dining room window was cracked. - the first floor had damaged walls and ceilings, unsealed penetrations, an open junction box in the education classroom closet, and the library had two sliding windows that opened more than 6 inches. Findings include: The undated facility Window Policy documented the Environment: Common Areas/Nursing Units/Service Hall/Lobby Audit form would be reviewed at the monthly risk management meetings. The following observations were made on the Fourth Floor: - on 4/19/23 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety for 1 of 1 kitchen (main kitchen) reviewed. Specifically, the main kitchen's tray service line cooler was propped open and not maintaining proper temperature, floors were in disrepair, the ceiling was damaged, and cooking and storage equipment was unclean. Findings include: The facility policy Dietary Food and Supply Orders-Storage dated 10/26/2018, documented refrigerator storage was to be 41 F (Fahrenheit) or below. The facility policy Kitchen, Dining and Dietary Equipment Routine Cleaning dated 9/7/2018 documented daily staff assignments included areas of equipment to be cleaned or kept in order after each meal service including the general cooking area, and general kitchen area. Cooking surface of the grill was to be cleaned at least once daily and kept free of encrusted grease and other soil. The monthly cleaning schedule included all counters…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted 4/19/23 -4/27/23 the facility failed to determine if medication self-administration was clinically appropriate for 1 of 1 resident (Resident #98) reviewed. Specifically, Resident #98 was observed on 5 days with Odomzo (generic name sonidegib, a chemotherapeutic medication) in a cup at their bedside and there was no assessment to determine the resident's ability to safely self-administer medications or a physician order for self-administration of medications. The facility policy Self Administration of Medication dated 5/2018 documented residents who desired to self-administer medications required review and approval of the interdisciplinary care planning team members and an order from the attending physician. The medications would be stored in a locked drawer in the resident's room, and the self-administered medications would be monitored by licensed nursing staff. Resident #98 was admitted to the facility with diagnoses including basal cell carcinoma of the skin. The 2/17/23 Minimum Data…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification survey conducted 4/19/23-4/27/23 the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #438) reviewed. Specifically, Residents #438 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (expiration date 1/31/26) documents that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 must be issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 survey conducted 4/19/23-4/27/23, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 10 residents (Residents #108 and 109) reviewed. Specifically, Resident #108 was not assisted with shaving, nail care, or eating; and Resident #109 was not assisted with eating. Findings include: The facility policy, ADL Assistance and Supervision revised 1/8/18 documented the nursing assistant would provide assistance with daily activity (ADL) assistance/supervision to assigned residents and assist other nursing assistants in providing (ADL) care as needed. The Team Leader would monitor the (ADL) assistance/supervision provided for residents throughout the shift and give appropriate guidance to the nursing assistants. The Unit Manager would record the ADL assistance on the EMR (electronic medical record), monitor assistance/supervision provided for residents, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 2 of 4 residents (Residents #66 and #93) reviewed. Specifically, Resident #93 was not wearing their bilateral palm devices (helps prevent hand contractures) as care planned during multiple observations; and Resident #66 did not have their neck brace applied appropriately and was not wearing positioning and palm devices as care planned for multiple observations. The facility policy Splint, Brace Care updated 5/23/2018 documented that appropriately trained nursing staff would provide assistance as needed through a scheduled program of applying and removing a splint or brace, monitor the resident's skin and circulation under the device, and reposition the limb as needed. The program for use of splints and/or braces was documented by therapy on the interdisciplinary care plan and the nursing assistant…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 4 of 10 medication carts (medication carts 1 and 2 on Unit 100 South and medication carts 1 and 2 on Unit 3) inspected. Specifically, there were 4 insulin pens and 1 eye drop bottle observed without pharmaceutical labels including resident information, medication name, medication dosage, and administration instructions. Findings include: The facility policy, Medication Label and Container Requirements revised 5/20/2018 documented medications accepted from a Pharmacy Services Provider or administered to residents of the facility must be packaged in compliance with all applicable state and federal laws; labels must clearly indicate specific information legibly and completely. Medications will not be accepted at this facility if the general…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for 2 of 3 meals (4/20/23 and 4/21/23 lunch meals) reviewed, and food items in 1 of 1 steam table observed. Specifically, lunch meals trays on 4/20/23 and 4/21/23 were not served at palatable and appetizing temperatures; and the main kitchen steam table was not holding the temperature for hot food items. Findings include: The facility policy Food Temperature Requirements and Holding Time modified 6/28/2019, documented steamtable thermostats would be turned on 30 minutes prior to meal service and set to maintain hot food between 140-160 degrees F (Fahrenheit). The undated facility policy Test Tray Process documented the Director of Dining, the Assistant Director of Dining, Dietitians, and Diet Technicians were assigned to complete test tray…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 residents (Residents # 38 and #52) reviewed. Specifically, Residents #38 and 52 were provided food items that were not consistent with the physician ordered diet. Findings include: The facility's 11/2009 Level 1 (Pureed) diet description documented the food items should be homogenous (smooth) and cohesive (adhere together) and should be pudding - like. There should be no coarse textures, raw fruits/vegetables, or nuts. Any food that required bolus (soft mass) formation, controlled manipulation, or mastication (chewing) were excluded. The diet was designed for residents who had moderate to severe dysphagia (difficulty swallowing). The facility's undated Puree, Chicken Fajita recipe documented to prepare the meat per recipe, place the meat in the food processor…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 4/19/23-4/27/23, the facility failed to special eating equipment and utensils for residents who needed them for 2 of 2 residents (Residents #30 and 38) reviewed. Specifically, Resident #38 was not provided with adaptive curved utensils or a Kennedy cup (spill-proof drinking cup); and Resident #30 was not provided with weighted utensils and an inner lip plate as care planned. Findings include: The facility policy Adaptive Equipment dated 1/19/18 documented that the Director of Rehabilitation or designated therapy staff would ensure that each resident, as appropriate, was provided any necessary equipment and training in its use, designed to facilitate the resident's ability to function independently. This applied to equipment designated to aid self-feeding. The equipment would be listed on the resident's care plan as appropriate. Certified nurse aides (CNA) would notify the Unit Manager and therapy staff of any decline…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    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 4/19/23-4/27/23, the facility failed to dispose of garbage and refuse properly for 1 isolated area (the waste fryer oil drums outside the main kitchen). Specifically, the waste fryer oil had been spilled on the ground surrounding the waste drums outside of the main kitchen. Findings include: The undated facility policy Fryer Oil and Grease Removal Guidelines documented after the grease was completely cooled it could be transported to the grease trap or other receptacle designed for environmental oil recycling. Look and check the levels in the environmentally responsible container and see if it needed to be emptied by the oil recycling company. Check the area traveled during the removal process to ensure that oil was not spilled or smudged. If any area was soiled with grease or oil, the area must be cleaned. During observations on 4/20/23 at 1:11 PM and 4/25/23 at 12:55 PM, there were two 55 gallon drums dedicated for waste fryer oil storage outside the back door of the kitchen. The ground…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification and abbreviated (NY00275715 and NY00300682) surveys conducted 4/19/23-4/27/23, 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 1 of 3 residents (Resident #178) reviewed. Specifically, during Resident #178's wound treatment licensed practical nurse (LPN) #5 did not perform appropriate hand hygiene. Findings include: The facility policy, Wound Cleansing, modified on 4/25/18 documented wound cleansing would be provided to optimize wound healing and to decrease the potential for wound infection. The procedure included wash hands thoroughly, prepare supplies, apply non-sterile gloves, remove soiled dressing and discard in appropriate receptacle, remove and discard gloves, wash hands thoroughly and apply clean gloves, cleanse wound per physician order, apply treatment and dressing per physician order, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-04-27 · tag F0577 — widespread
    Allow 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, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the results of the most recent Federal health recertification survey conducted 10/16/20 were not posted in a location that would allow individuals to examine the survey results without having to ask to see them; and the results of the most recent Life Safety Code Federal survey conducted on 10/15/20 were not posted. Findings include: During a Resident Council meeting on 4/20/23 at 10:03 AM an anonymous resident stated they did not know where the previous survey results were posted. The remaining 10 residents agreed. During an observation on 4/21/23 at 9:27 AM the Plan of Correction three-ring binder was in the lobby behind the front desk and did not include the Life Safety Code Federal survey results from 10/15/2020. During an interview on 4/21/23 at 9:28 AM, the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$120,884 in federal fines across 2 penalties.

  • $110,520 — penalty dated 2026-03-11
  • $10,364 — penalty dated 2025-01-30

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.

Part of a chain

This home belongs to ELDERWOOD — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.5-1.5 vs chain
Health inspection 1 of 52.5-1.5 vs chain
Staffing 1 of 52.1-1.1 vs chain
Quality measures 2 of 53.2-1.2 vs chain
The other 16 homes this chain runs (chain average 2.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
COLE, WARRENIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL50%since 10/14/2011
RUBIN, JEFFREYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL50%since 10/14/2011
LANDY, MARIAIndividualW-2 MANAGING EMPLOYEEsince 01/31/2013

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$21.0M
Net patient revenuemost recent cost report
-20.1%
Operating marginrevenue minus expenses
$3.7M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 8%Other / private 23%

This home reported $3.7M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$385per resident / day
operating cost
$11,717per month
≈ monthly operating cost
$321per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335346. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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