918 James Street, Syracuse, NY 13203 · Onondaga County · (315) 474-1561
440 certified beds, about 296 residents a day · For profit - Corporation · Medicare and Medicaid since 1971
CMS Care Compare ratings, data as of September 1, 2026 · CCN 335338 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 5, 2026, inspectors cited 15 health deficiencies (the New York average is 8.1, the national average 9.2).
Of 52 health citations since December 2023, 11 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 3 fines totaling $726,980 in the last three years; the largest was $378,437, and the latest is dated July 22, 2026.
Nurses and nurse aides worked 3.52 hours per resident per day, against 3.63 across New York and 3.86 nationally. Registered nurses accounted for 0.33 of those hours.
55.7% of nursing staff left within the year CMS measured (New York average 40.3%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 52 health citations on file.
Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received adequate supervision to prevent accidents. Specifically, on 05/03/2026, Resident #1 was visiting another resident on a different nursing unit. Licensed Practical Nurse #8 misidentified the resident as a visitor and escorted them out of the building at 2:00 AM. Staff on the resident's unit were not aware the resident was missing until 7:00 AM. On 05/03/2026 at approximately 11:00 AM, a former employee recognized the resident at an event approximately three miles from the facility and returned the resident to the facility. The resident sustained an abrasion to their head and hand, was disoriented, and had soiled clothing due to incontinence. [...]
Inspectors wroteBased on record review and interviews, the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Specifically, on 05/03/2026 at 2:00 AM, Resident #1 was misidentified as a visitor and escorted out of the facility by Licensed Practical Nurse #8 who did not verify the resident's identification prior to escorting them out. The facility was unaware Resident #1 was missing until 7:00 AM, and the resident was found at approximately 11:00 AM with an abrasion to their head, hand, and wearing soiled clothing due to incontinence.
Inspectors wroteBased on record review and interviews (#2994892) the facility failed to ensure intravenous fluids (fluids that were administered directly into a vein) were administered consistent with professional standards of practice and in accordance with physician orders. This was identified for one (1) of two (2) residents (Resident #1), reviewed for hydration and receiving intravenous therapy. Specifically, Resident #1 had an order for fluids via intravenous route, the fluids were not provided as ordered, and the resident received 1000 cubic centimeters all at once, instead of over time. Nursing staff did not monitor the rate of the fluid infusion. The physician telephone order was not transcribed as an order and was not included on the Medication Administration Record and was not documented as administered. [...]
Inspectors wroteBased on observations, record review, and interviews (IQIES 2984903), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for five (5) of seven (7) residents (Residents #4, # 8, #13, #100, and #209) reviewed. Specifically: - Resident #8 had multiple pressure ulcers including a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum (lower back between the hip bones) that were not routinely assessed (determining stage, size and wound characteristics, appropriateness of treatment) by a qualified individual; newly identified pressure ulcers were not assessed by a qualified individual; [...]
Inspectors wroteBased on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety and did not follow proper sanitation practices to prevent the outbreak of food borne illness in one (1) of one (1) main kitchen and one (1) unit refrigerator (D South). Specifically, ten pans of prepared or leftover food in walk in coolers were not labelled; ten pans of fish were prepared and not labelled or dated; the dish machine wash temperature did not reach the required temperature; the dish machine sanitizer concentration was not monitored; Assistant Administrator #16 was in the main kitchen without a beard cover; there was debris and dried food built up on the floor and along the walls in the coolers and production areas; the reach in cooler gaskets had built up dried residue; and the unit refrigerator on D South had a dried sticky substance.
Inspectors wroteBased on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in one (1) of one (1) main kitchen. Specifically, the main kitchen walk-in freezer had ice built up on the floor and the compressor was leaking.
Inspectors wroteBased on observations and interviews the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and principles for two (2) of twelve medication carts (Unit C North and Unit 3 medications carts) and one (1) of two (2) treatment carts (Unit C South) reviewed. Specifically, the Unit C North medication cart was unlocked and unattended and contained pre-poured medications, expired eye drops and inhalers, and unlabeled insulin; the Unit 3 South medication cart had open unlabeled lidocaine (anesthetic) and expired insulin pens; and the Unit C South treatment cart was unlocked and unattended and contained scissors, antifungal cream, and antiseptics.
Inspectors wroteBased on observations and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) test trays (04/28/2026 lunch and 04/29/2026 breakfast); and 12 of 17 anonymous residents present at the Resident Council meeting and two (2) of two (2) residents (Residents #346 and #20) interviewed. Specifically, the 04/28/2026 lunch tray and the 04/29/2026 breakfast tray included hot foods served below 140 degrees Fahrenheit and cold foods served above 41 degrees Fahrenheit and were not palatable; 12 anonymous residents at the Resident Council meeting stated the food was cold and overcooked; and Residents #346 and #20 stated the food was not palatable.
Inspectors wroteBased on observations, record review, and interviews (IQIES intake 2799654), the facility failed to ensure a safe, clean, comfortable, and homelike environment for four (4) of seven (7) resident units (Units 2, A, D and C) and one (1) of one (1) resident (Resident #333) reviewed. Specifically, Resident #333 was not provided with a key to a nightstand drawer to secure valuables; Units A and D had clogged, sinks with foul smelling water; Unit C had areas that were unclean and in disrepair: and Unit 2's tub room had an active leak.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for two (2) of two (2) residents (Residents #267 and #290) reviewed. Specifically, Resident #267 alleged they were sexually abused and Resident #290 alleged they were physically and verbally abused and there was no documented evidence the facility completed a thorough investigation in response to the allegations or reported the allegations to the New York State Department of Health as required.
Inspectors wroteBased on observations, record review, and interviews (iQIES Intake 2799654, 2969603, and 2969139) the facility failed to ensure that 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 one (1) of eight (8) residents (Resident #100) reviewed. Specifically Resident #100 was not toileted or changed when they were soiled.
Inspectors wroteBased on observations, record review, and interviews (IQIES intakes 2796359 and 2984903), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #15) reviewed. Specifically, Resident #15 sustained a fall, was transferred to the hospital, returned to the facility with a fractured clavicle (collarbone), medical was not notified to address the fracture, a sling was not ordered as recommended, and there was no documented evidence the resident received an orthopedic follow up consultation as recommended.
Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure that residents who required dialysis services (a process that filters blood when the kidneys do not work efficiently) received such services consistent with professional standards of practice for one (1) of two (2) residents (Resident #70) reviewed. Specifically, Resident #70 did not have their fistula site (access for dialysis) checked and dressing removed as ordered and did not consistently have post dialysis assessments completed. Findings Include:Resident #70 had diagnoses including end stage kidney disease and dependence on dialysis. The 04/03/2026 Minimum Data Set assessment documented the resident had moderate cognitive impairment and required dialysis treatment. The comprehensive care plan initiated 10/01/2025 documented the resident received dialysis on Tuesdays, Thursdays, and Saturdays. [...]
Inspectors wroteBased on observations, record review, and interviews, the facility failed to obtain consent and review the risks and benefits of bed rails (side rails) with a resident or the resident representative prior to installation of bed rails for one (1) of one (1) resident (Resident #209) reviewed. Specifically, Resident #209 had bed rails installed, and physician orders and informed consent were not obtained, and risks and benefits were not reviewed until after the installation of the bed rails; the use of bed rails was not included in the comprehensive care plan; and there were no ongoing assessments to ensure the bed rails continued to meet the resident's needs.
Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure that licensed nurses had the appropriate competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for three (3) of three (3) licensed nurses (Licensed Practical Nurses #9 and #10, and Registered Nurse #13) reviewed. Specifically, Licensed Practical Nurses #9 and #10 performed wound assessments without registered nurse direct oversight; Registered Nurse #13 failed to identify and stage wounds on Resident #179's right and left legs; and Licensed Practical Nurses #9 and #10 and Registered Nurse #13 did not have competencies for wound care as part of the facility's designated wound care team. Substandard of Care was identified in treatment and services to prevent and heal pressure ulcers (F686).
Inspectors wroteBased on observations, record review, and interviews (iQIES Intake 2969603) the facility failed to ensure that residents were free of any significant medication errors for one (1) of two (2) resident (Resident #209) reviewed. Specifically, Resident #209 had a physician order for baclofen (a muscle relaxant and antispasmodic used to treat neurological conditions) four times a day and the medication was not administered within the prescribed time frame causing the resident discomfort.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide routine and emergency dental services to meet the needs of each resident for one (1) of one (1) resident (Resident #296) reviewed. Specifically, Resident #296 was unable to have a dental procedure completed due to their anticoagulant (blood thinner) medication not being held prior to the procedure.
Inspectors wroteBased 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 two (2) of six (6) residents (Residents #8 and Resident #270) reviewed. Specifically, Resident #8 was on enhanced barrier precautions and Licensed Practical Nurse #6 administered the resident's tube feeding and completed a dressing change without appropriate personal protective equipment; and Resident #270 was on enhanced barrier precautions and Licensed Practical Nurse #25 completed the resident's wound dressing without appropriate personal protective equipment.
Inspectors wroteBased on record reviews and interviews (IQIES Intake 2801048), the facility failed to ensure all services being provided met professional standards of quality for one (1) of three (3) residents reviewed (Resident #5). Specifically, Resident #5 had an unwitnessed fall on 03/06/2026, was sent to the emergency department for evaluation and was diagnosed with a left proximal humerus fracture (left upper arm broken bone). The facility failed to implement the hospital discharge instructions for the resident's arm fracture, complete a re-admission reassessment, notify the medical provider to update the medical orders for the sling, and update the comprehensive care plan when they returned to the facility on [DATE].
Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 5/12/2025 - 5/16/2025, the facility did not ensure the environment accommodated residents' needs for two (2) of two (2) residents (Residents #7 and #122) reviewed. Specifically, Residents #7 and #122 did not have their call bells within reach.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/12/2025-5/16/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for two (2) of seven (7) resident units and one (1) pantry area (Units A and C, and the Sunshine Room pantry) reviewed. Specifically, - Unit A room [ROOM NUMBER] smelled strongly of urine; room [ROOM NUMBER] had a sticky floor: and rooms [ROOM NUMBERS] were missing paint and had unclean floors - Unit C room [ROOM NUMBER] had brown stained privacy curtain. - the Sunshine Room pantry had dirty floors and tables, the pantry did not have hand soap, and the sink was not functioning properly.
Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00375456, NY00376994, and NY00378104) surveys conducted 5/12/2025- 5/16/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for one (1) of six (6) residents (Residents #145) reviewed. Specifically, Resident #145 was observed with brown debris underneath long, untrimmed fingernails.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/12/2025 - 5/16/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of two (2) residents (Resident #128) reviewed. Specifically, Resident #128 did not have wound treatments completed as ordered for two (2) days.
Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00375456) surveys conducted 5/12/2025 - 5/16/2025 the facility did not ensure residents were free of significant medication errors for one (1) of one (1) resident (Resident #47) reviewed. Specifically, on 4/9/2025 Licensed Practical Nurse #4 administered Resident #47 medications ordered for Resident #116. This resulted in past non-compliance with no actual harm with potential for more than minimal harm.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/12/2025 - 5/16/2025, the facility did not ensure they established and maintained 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 #47) reviewed. Specifically, Resident #47 received two (2) injections from insulin pens belonging to Resident #116.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/20/2024, the facility did not ensure resident rights to privacy and confidentiality of their personal and medical records for 14 of 29 residents on the 2 North Unit. Specifically, the Narcotics Logbook (a logbook with resident names and narcotic administration information) with confidential information for 14 residents on the 2 North unit was left unsecured in a resident's room with a resident present. The facility policy, Resident Rights, revised 5/28/2024, documented residents had the right to privacy and confidentiality. During an observation on 12/16/2024 at 10:39 AM, Licensed Practical Nurse #18 left the Narcotic Logbook on the dresser in Resident #17's room. The resident was in the room. [...]
Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00351261) surveys conducted 12/16/2024-12/20/2024, the facility did not ensure that prompt efforts were made to resolve grievances for 11 of 11 anonymous residents and for 1 of 1 additional resident (Resident #127) reviewed. Specifically, 11 of 11 residents in attendance at the resident group meeting stated their grievances were not always acted upon timely and they were not provided with an explanation why. Additionally, Resident #127's family member filed 3 grievances and they did not receive prompt resolutions.
Inspectors wroteBased on record review and interviews during the recertification survey conducted 12/16/2024-12/20/2024, the facility did not ensure residents who required dialysis (a process that filters the blood for people in kidney failure) received such services consistent with professional standards of practice for 2 of 2 residents (Residents #14 and #29) reviewed. Specifically, the facility did not consistently assess Resident #14 and #29' medical condition and monitor for complications before and after dialysis treatments. Additionally, there was inconsistent communication and collaboration with the dialysis facility regarding care and services for Residents #14 and #29.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 12/16/2024 - 12/20/2024, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen. Specifically, 2 of 4 walk-in coolers in the main kitchen were out of service for a prolonged period-of-time and the working walk-in coolers had unclean and uncleanable surfaces.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 12/16/2024 - 12/20/2024, the facility was operating an unapproved dialysis den and was not in compliance with Federal, State, and Local Laws and Professional Standards. Specifically, the facility was providing hemodialysis (a process that filters blood for residents individuals with kidney failure) treatment in an unapproved space.
Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00357875) surveys conducted 12/16/2024-12/20/2024, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 1 of 3 residents (Resident #110) reviewed. Specifically, Resident #110 was unshaven and had visible chin and lip hair.
Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00362924) surveys conducted 12/16/2024-12/20/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 4 residents (Resident #29) reviewed. Specifically, Resident #29's room had black, and gray build up approximately 1 to 3 inches from the base of the wall near the entrance of the room, extending to the two-drawer dresser.
Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00351261, NY00351349, NY00362924, and NY00362952) surveys conducted 12/16/2024-12/20/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 2 residents (Resident #127) reviewed. Specifically, Resident #127 did not have their Scopolamine patch (used to treat nausea and vomiting and decrease respiratory secretions) monitored for placement as ordered.
Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/20/2024, the facility did not post daily current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place readily accessible to residents and visitors for 5 of 5 days reviewed. Specifically, the current daily resident census and nurse staffing data was posted in an enclosed glass bulletin board across from the elevators of the 918 building, approximately 5 feet from the ground and not readily accessible to residents and visitors.
Inspectors wroteBased on observation, record review, and interviews during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility failed to ensure that pain management was provided to residents who required such services consistent with professional standards of practice for 3 of 7 residents (Resident #28, #37, and #64) reviewed. Specifically, -Resident #28's physician ordered pain cream was not administered as ordered and was documented as administered. -Resident #37 did not receive Lyrica (used to treat nerve and muscle pain) as ordered for 3 days; -Resident #64 was not aware of an as needed order for acetaminophen (pain reliever) and pain cream and was not offered the medications when in pain. Subsequently, Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life. [...]
Inspectors wroteBased on observation, interview, and record review during the extended recertification and abbreviated (NY0033160) surveys conducted 6/4/2024-7/11/2024, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 of 5 residents (Resident #41, #126, #153, #235, and #250) reviewed. Specifically: - Resident #41 had an extensive mental health history, did not have person-centered mental health interventions, and was seen by a licensed psychologist and their recommendations were not implemented into the resident's plan of care. There were no documented social services follow ups with the resident following their behaviors. [...]
Inspectors wroteBased on record review and interview during the extended recertification and abbreviated (NY00335379) surveys conducted 6/4/2024-7/11/2024, the facility failed to ensure the ordering physician was notified promptly when a laboratory result fell outside of clinical reference range for 3 of 3 residents (Residents #153, #260, and #529) reviewed. Specifically, - Resident #529 had abnormal laboratory results including a high white blood cell count, a low lymphocyte count, and high sodium, blood urea nitrogen, and blood urea nitrogen/creatinine ratio (indicating possible dehydration and infection) that were not reviewed by facility staff in a timely manner, and the medical provider was not notified in a timely manner of the abnormal lab results. Subsequently, the resident was hospitalized 3 days later with pneumonia and dehydration. [...]
Inspectors wroteBased on observation, record review, and interview during the extended recertification and abbreviated (NY00331669) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure the physician was consulted and the resident's representative was notified when there was a significant change in the resident's physical, mental, or psychosocial status for 4 of 4 residents (Residents #37, #147, #153, and #528) reviewed. Specifically: - Resident #37 did not receive their Lyrica (used to treat nerve pain) on the day shift (7:00 AM-3:00 PM from 6/22/2024-6/24/2024 due to the facility not having the medication and the provider was not notified. Subsequently, the resident had complaints of uncontrolled pain. [...]
Inspectors wroteBased on observation, record review, and interview during the extended recertification and abbreviated (NY00335306, NY00334736, NY00331600, NY00335937, NY00337529, NY00340292, NY00340725, and NY00335379) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure services provided met the professional standards of quality in 5 of 5 areas (pressure ulcers, medication administration, respiratory care, activities of daily living, and laboratory testing notifications). Specifically, medication administration was not completed in accordance with accepted standards of clinical practice (see F 554); provider notification was not completed for residents with significant changes in condition (see F 580); oral care and feeding assistance was not completed as ordered or planned (see F 677); pressure ulcer prevention services were not completed as ordered (see F 686); [...]
Inspectors wroteBased on observations, record review, and interviews during the extended recertification and abbreviated (NY00335306) surveys conducted 6/4/2024-7/11/2024, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 7 residents (Residents #222, #265, #271, and #826) reviewed. Specifically, Resident #826 had pressure injuries that were not assessed, and was not provided treatments to promote healing. Subsequently, Resident #826 was admitted to the hospital with a chronic sacral osteomyelitis (inflammation of bone tissue related to infection) with overlying cellulitis (skin infection). [...]
Inspectors wroteBased on observation and interview during the extended recertification and abbreviated (NY00336795) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 3 of 3 meals reviewed (6/5/2024 lunch meal on the 2nd floor, and 6/6/2024 lunch meals on the 3rd floor and on the C Unit). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 6/5/2024 and 6/6/2024; 9 of 9 anonymous residents at the Resident Council meeting complained the food was not appetizing; and 9 residents (Residents #11, #36, #64, #105, #147, #151, #197, #255, and #265) interviewed stated the food did not taste good.
Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 6/4/2024-6/12/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 8 of 8 resident floors (Units 1, 2, 3, 4, A, B, C, and D), the main kitchen, and 1 of 2 basement floors (918 basement) reviewed. Specifically, walls, windows, ceiling, floors, furniture, and sinks were damaged or unclean on Units 1, 2, 3, 4, A, B, C, and D; rodent droppings were on the Unit D floor; the main kitchen had a water leak; and the cage area of the 918 basement laundry area had a damaged section of solid ceiling.
Inspectors wroteBased on observation, record review, and interviews during the extended recertification and abbreviated (NY00331600, NY00335937, NY00337529, NY00340292, and NY00340725) surveys conducted 6/4/2024-7/11/2024, 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 11 residents (Residents #154 and #226) reviewed. Specifically, Resident #154 did not receive oral hygiene as ordered; and Resident #226 did not receive assistance with eating as planned.
Inspectors wroteBased on observation, record review, and interview during the extended recertification and abbreviated (NY00332367 and NY00346149) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 2 of 13 residents (Resident #41 and Resident #250) reviewed. Specifically, Resident #41 exhibited exit seeking behaviors, had a history of removing their wander alert device, and the security guard allowed the resident to walk out the front door before the receptionist was able to alert them the resident had exited. Resident #250 had a wander alert device and there was inconsistent documentation of when the device was implemented.
Inspectors wroteBased on observation, interview, and record review during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 6 residents (Resident #133) reviewed. Specifically, the medical provider was not notified when Resident #133 had a severe weight loss and recommendations for an appetite stimulant were not discussed with the medical provider.
Inspectors wroteBased on observation, record review, and interview during the extended recertification and abbreviated (NY00334736) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 residents (Resident #64) reviewed. Specifically, Resident #64's did not receive the appropriate Bilevel Positive Airway Pressure (mechanical non-invasive ventilator for breathing assistance) mask.
Inspectors wroteBased on observation, interview, and record review during the abbreviated survey (NY00330825), 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 when 1 of 2 buildings (918 building) including 21 resident rooms (221, 222, 223, 224, 225, 226, 259, 260, 261, 262, 263, 321, 322, 323, 324, 325, 326, 360, 361, 362, 363) where 26 residents resided was affected. Specifically, resident rooms 221, 222, 223, 224, 225, 226, 259, 260, 261, 262, 263, 321, 322, 323, 324, 325, 326, 360, 361, 362, and 363 and their occupants (26 residents) were evacuated from their rooms following a flood from a broken hot water line and the facility did not notify the New York State Department of Health. [...]
Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00327344) surveys conducted 11/27/2023-12/5/2023, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life for 4 of 5 residents (Residents #31, #109, #121, and #522) reviewed. Specifically, Resident #31 did not receive toileting assistance and was observed lying in a urine soaked incontinence brief (refer to F 677 ADL Care for Dependent Residents); Resident #109 did not have appropriate footwear for community visits outside the facility and had bed linens that were in poor condition, resulting in the resident feeling humiliated (refer to F 684 Quality of Care); [...]
Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00323973, NY00324500, NY00324681, NY00325947, NY00326310, and NY00327344) conducted 11/27/2023-12/5/2023, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 9 of 11 residents (Residents #4, #18, #21, #55, #85, #121, #239, #265, and #521) reviewed. Specifically, -Resident #18 had blood glucose levels that were outside of parameters and medical was not notified as ordered. (Refer to F 600 Free from Abuse and Neglect) -Resident #21 had an unwitnessed fall, neurological checks (evaluation of nervous system functioning) were not completed, and the medical provider was not notified. [...]
Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00324500) surveys conducted 11/27/2023-12/5/2023 the facility failed to ensure residents were free from neglect for 2 of 6 residents (Residents #18 and 31) reviewed. Specifically, Resident #18 had blood glucose levels that were outside of parameters and medical was not notified as ordered. The resident continued to have high blood glucose levels and was sent to the hospital for evaluation (Refer to F 684 Quality of Care). Resident #31 was not assisted with toileting per their care plan and as requested resulting in the resident being incontinent and being told to defecate in a brief (Refer to F 677 Activities of Daily Living Care). This resulted in actual harm of emotional distress from neglect of care to Resident #31 and hospitalization of Resident #18.
Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY00325947) conducted 11/27/2023-12/5/2023, the facility failed to ensure the development of an effective transfer or discharge planning process including documentation in the resident's medical record and appropriate communication with the receiving health care institution for 1 of 1 (Resident #265) resident reviewed. Specifically, Resident #265 was admitted to the facility and did not receive medications timely and was sent to a local acute care hospital emergency department the same day without a physician's order, and without comprehensive information for the acute care hospital to provide adequate care for the resident. The resident was denied admission back to the facility, after being discharged from the acute care hospital emergency department. [...]
Inspectors wroteBased on interview and record review during the recertification and abbreviated (NY00325947 and NY00327344) surveys conducted 11/27/2023-12/5/2023, the facility did not ensure the discharge needs of each resident were identified and resulted in the development of a discharge plan for 1 of 3 residents (Resident #521) reviewed. Specifically, Resident #521 expressed the intention to be discharged to the community and was not assisted with discharge planning or updated on the status of their discharge plan.
42 fire safety citations on file: 20 on May 5, 2026, 10 on May 16, 2025, 11 on December 20, 2024, 1 on October 13, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| July 22, 2026 | Fine | $27,378 |
| July 11, 2024 | Fine | $378,437 |
| July 11, 2024 | Payment Denial | 50 days from August 6, 2024 |
| December 5, 2023 | Fine | $321,165 |
| December 5, 2023 | Payment Denial | 42 days from April 16, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | New York | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.52 | 3.63 | 3.86 |
| Registered nurses | 0.33 | 0.71 | 0.69 |
| All nursing staff on weekends | 2.88 | 3.18 | 3.42 |
| Nurse aides | 2.19 | ||
| Licensed practical nurses | 1.00 | ||
| Nursing staff turnover (share who left in a year) | 55.7% | 40.3% | 45.8% |
| Registered nurse turnover | 66.7% | 39.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.81 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.77 on weekdays and 2.88 on weekends, 24% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 6.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.64 in April to June 2025 to 3.52 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.52 | 0.33 | 3.77 | 2.88 | 6.4% | 0 of 90 | 296 |
| Oct to Dec 2025 | 4.17 | 0.37 | 4.39 | 3.61 | 9.9% | 0 of 92 | 237 |
| Jul to Sep 2025 | 4.40 | 0.36 | 4.65 | 3.74 | 11.6% | 0 of 92 | 219 |
| Apr to Jun 2025 | 4.64 | 0.40 | 4.96 | 3.85 | 14.6% | 0 of 91 | 215 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| New York, Jan to Mar 2026 | 3.55 | 0.68 | 3.72 | 3.13 | 9.8% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| New York, all employers | |||
| CNAs (nursing assistants) | $23.36 | $21.04 to $24.99 | 87,990 |
| LPNs and LVNs | $32.30 | $29.52 to $37.00 | 39,400 |
| Registered nurses | $52.62 | $45.60 to $62.34 | 205,810 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | New York | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.7 | 14.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.0 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.0 | 1.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.7 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.6 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 14.1 | 12.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 10.2 | 6.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.1 | 13.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.7 | 20.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.8 | 9.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.2 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.0 | 1.4 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Bishop Rehabilitation and Nursing Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (26.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
26.5% this home
Worse than the national rate
US median of homes 51.5% · New York: 101 better, 157 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 90 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · New York: 12 better, 5 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 119 eligible stays.
6.7% this home
No different from the national rate
US median of homes 7.1% · New York: 7 better, 21 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 70 eligible stays.
30.6% this home
Median of homes: New York60.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 36 residents counted.
0.0% this home
Median of homes: New York0.6% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 51 residents counted.
4.1% this home
Median of homes: New York2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 51 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: New York98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 8 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: CLINTON SQUARE OPERATIONS LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Farbenblum, Edward | 5% or greater direct ownership interest | Individual | 91% | 09/07/2022 |
| Rozenberg, Eli | 5% or greater direct ownership interest | Individual | 9% | 02/08/2022 |
| Goldman, Nathan | Managing control - governing body | Individual | 01/01/2025 | |
| Hendrix, Heidi | Managing control - governing body | Individual | 01/01/2025 | |
| Lantzitsky, Aharon | Managing control - governing body | Individual | 01/01/2025 | |
| Deslauriers, Marty | Operational/managerial control | Individual | 10/24/2025 | |
| Kaur, Gurinder | Operational/managerial control | Individual | 08/04/2025 | |
| Abramchik, Amir | Adp of the SNF | Individual | 02/08/2022 | |
| Deslauriers, Marty | Adp of the SNF | Individual | 10/24/2025 | |
| Farbenblum, Edward | Adp of the SNF | Individual | 02/08/2022 | |
| Kaur, Gurinder | Adp of the SNF | Individual | 08/04/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its New York inspection record.
These are the official offices in New York. NursingHomeClear cannot take or act on complaints.