135 Meridan St., Rochester, NY 14612 · Monroe County · (585) 663-0930
229 certified beds, about 190 residents a day · For profit - Partnership · Medicare and Medicaid since 1972
CMS Care Compare ratings, data as of September 1, 2026 · CCN 335082 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on December 22, 2025, inspectors cited 24 health deficiencies (the New York average is 8.1, the national average 9.2).
Of 89 health citations since January 2024, 25 were rated as actual harm or immediate jeopardy to residents (12 immediate jeopardy).
CMS lists 3 fines totaling $960,884 in the last three years; the largest was $460,490, and the latest is dated December 22, 2025.
Nurses and nurse aides worked 3.51 hours per resident per day, against 3.63 across New York and 3.86 nationally. Registered nurses accounted for 0.56 of those hours.
67.0% of nursing staff left within the year CMS measured (New York average 40.3%).
CMS links it to Hurlbut Care, an affiliated group of 13 nursing homes.
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 89 health citations on file.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement an effective Infection Prevention and Control Program to identify, investigate, monitor, and analyze infections to prevent the development and transmission of communicable diseases and infections for one of nine residents reviewed (Resident #139). Specifically, the facility failed to identify and investigate Resident #139's recurrent urinary tract infections (an infection affecting any part of the urinary system) through its infection surveillance program and failed to ensure Enhanced Barrier Precautions (an infection prevention strategy requiring the use of gowns and gloves during high-contact resident care activities) were followed while providing care to Resident #139. [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain proper grooming and personal hygiene for four of seven residents reviewed (Residents #43, #51, #152, and #162). Specifically, Resident #51 was observed on multiple occasions to have long chin hair and Resident #162, who was dependent for toileting care, had a strong scent of urine and was not provided care for over 12 hours. Residents #43 and #152 were observed on multiple occasions with overgrown facial hair and long finger nails with dark debris under their nails. Additionally, the facility lacked documented evidence staff consistently offered, provided, or documented grooming services or refusals in accordance with residents' assessed needs and preferences.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly maintain the resident call system for two (North One and [NAME] One) of seven resident units. Specifically, a central station monitor for the nurse call system did not function properly and call lights above doors did not function as intended.
Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for six (6) of 21 residents (Residents #33, #42, #90, #179, #204, and #209) reviewed. Specifically,-Resident #209 returned from the emergency department on 10/01/2025 and there was no documented evidence the resident was assessed and their treatment in the emergency department was reviewed upon return, or the physician was made aware of their return. Subsequently, the resident was hospitalized on [DATE] for an untreated, worsening urinary tract infection. -Resident #42 returned from the hospital on [DATE] and was not started on an antibiotic per hospital discharge recommendations until 11/07/2025. [...]
Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure adequate supervision to prevent accidents for three (3) of seven (7) residents (Resident #34, #44, and #100) reviewed. Specifically:-Resident #100 who was cognitively impaired and wore a wander alert device, left the faciity on [DATE] undetected, and attempted to enter staff vehicles in the parking lot. The resident was not provided 30-minute checks as ordered following the incident. The elopement was not reported to the New York State Department of Health as required. Additionally, the resident was observed attempting to exit through stairwell doors without their wander alert device alarming; and staff were observed silencing the wander alert alarm without checking the area for residents. [...]
Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care resulting from the cumulative effect of noncompliance cited for F684 Quality of Care, F677 Activities of Daily Living, F689 Accident Hazards, F865 Quality Assurance and Performance, and for 242 of 242 residents residing in the facility. This noncompliance was found to be widespread and created an environment reflecting pervasive disregard for one (1) or more residents' well-being and quality of life, which caused or was likely to cause serious injury, harm, impairment or death that was Immediate Jeopardy and Substandard Quality of Care.
Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure the interdisciplinary team determined a resident's ability to self-administer medications was clinically appropriate for one (1) of one (1) resident (Resident #147) reviewed. Specifically, Resident #147 had expired and/or discontinued medications and used insulin needles in their room.
Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (1) of seven (7) residents (Resident #132) reviewed. Specifically, Resident #132 was not assisted with showering, incontinence care, removal of facial hair, and getting out of bed as planned. Additionally, staff documented care was completed when it was not. The lack of regular and consistent care resulted in psychosocial harm to Resident #132 that was not Immediate Jeopardy.
Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and wound care for one (1) of six (6) residents (Resident #10) reviewed. Specifically, Resident #10 had a leg immobilizer that was not removed for skin checks that resulted in an unstageable pressure ulcer. This resulted in actual harm to Resident #10 that was not Immediate Jeopardy.
Inspectors wroteBased on observations and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of one (1) Resident (Resident #34) reviewed. Specifically, Resident #34 who had a history of abnormal weight loss and dysphagia (difficulty swallowing) had significant weight loss and weekly weights were not obtained per the registered dietitian's recommendations. This resulted in harm to Resident #34 that was not Immediate Jeopardy.
Inspectors wroteBased on observations, record review, and interviews during the survey, the facility failed to provide specific services outside the facility when they did not employ a qualified professional to furnish the specific service for one (1) of four (4) residents (Resident #17) reviewed. Specifically, Resident #17 was not provided with neurology follow up appoints as recommended. This resulted in harm to Resident #17 that was not Immediate Jeopardy.
Inspectors wroteBased on observations and interviews during the survey, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen. Specifically, the main kitchen was in disrepair, including cracked and uneven flooring, worn grout, damaged door thresholds, corroded plumbing, and broken shelving; personal items were stored with clean food service equipment; and food storage practices did not support the prevention of potential cross-contamination.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration failed to ensure residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F689 Free of Accident Hazards and F684 Quality of Care. Administration failed to ensure policies and procedures were properly identified, communicated, and consistently implemented and were not aware of the extent of the deficient practices cited. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program that put forth good faith attempts to develop, implement, and maintain an appropriate plan of action to address identified issues that impacted resident safety or ensured corrective actions were set around safety, quality, rights, choice and respect. [...]
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 six (6) of six (6) residents (Residents #10, #188, #192, #77, #217 and #17) reviewed and five (5) of ten (10) staff (Certified Nurse Aides #62 and #91, Registered Nurse Manager #38, and Licensed Practical Nurses #35 and #71) reviewed for influenza vaccination. Specifically:-Resident #10 had an unstageable pressure ulcer to the left ankle and was on enhanced barrier precautions. [...]
Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for one (1) of one (1) main kitchen reviewed. Specifically, there was evidence of roaches in the main kitchen. Findings Include:The facility policy Pest Control, reviewed 03/2026, documented the facility would implement a continuing and effective pest control prevention and monitoring program to maintain the facility as pest and rodent free as possible. The third-party vendor pest control customer service reports documented the following:-On 02/12/2026, a liquid preventive and a dust bait were applied by the dishwasher area and joining wall bathroom and a recommendation was made for an after-hour escalation treatment.-On 02/16/2026, a treatment for German roaches was applied in the kitchen; [...]
Inspectors wroteBased on observations, record review, and interviews 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 two (2) of five (5) residents (Residents #8 and #5) and for 5 of eight (8) resident rooms (201B, 202A, 202B, 209 and 324B) reviewed. Specifically, Residents #8 and #5 were observed on multiple occasions being transported in their padded reclining wheelchair facing backwards on multiple occasions and rooms 201B, 202A, 202B, 209 and 324B were not clean, sanitary and homelike.
Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure residents resided in a safe, clean, sanitary, and homelike environment for eight (8) resident rooms (rooms 102 A, 105, 116, 201 B, 202 A, 202 B, 209, and 324 B) and four (4) of six (6) resident units (North 1, [NAME] 1, South 1, and South 2) reviewed.
Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure residents were provided ongoing programs to support each resident in their choice of activities for three (3) of five (5) residents (Residents #9, #104, and #184) and on three (3) of seven (7) units (South 3, North 1 and [NAME] 1) reviewed. Specifically, Residents #9 and #104 were not invited or assisted to meaningful activities that included their interests and preferences; Resident #184 did not have a plan for meaningful activities that included their interests or preferences; there were no unit specific activities conducted on the South 3 unit from 12/02/2025 - 12/11/2025; the posted activity calendar on North 1 reflected the month of November; and the activity calendar on [NAME] 1 reflected the month of October.
Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to ensure alleged violations involving abuse and neglect were reported immediately to the State Agency in accordance with State Law for one (1) of one (1) resident (Resident #100) reviewed. Specifically, Resident #100 who was cognitively impaired and wore a wander alert device, eloped from the facility on 10/18/2025 and there was no documented evidence the incident was reported to the New York State Department of Health as required.
Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for one (1) of one (1) resident (Resident #121) reviewed. Specifically, the Preadmission Screening and Resident Review (PASRR, New York State Department of Health Form 695) documented Resident #121 had a serious mental illness and the section for Level II referrals and Level II recommendations were not completed.
Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for two (2) of two (2) residents (Residents #132 and #170) reviewed. Specifically, Resident #132 had orders for a carrot orthotic (a device placed in the hand) for a left hand contracture (shortening of muscle or tendons preventing normal movement) and bilateral ankle boots for leg contractures that were not applied as ordered; and Resident #170 had an order for bilateral resting hand splints and was observed not wearing them.
Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for two (2) of two (2) residents (Residents #15 and #187) reviewed. Specifically, Resident #15 was not administered their tube feeding formula volume as ordered, and Resident #187 was not administered their enteral water flushes as ordered.
Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure that residents who required dialysis services (a process that filters the blood when the kidneys do not work properly) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #77) reviewed. Specifically, Resident #77 did not receive pre-dialysis and post-dialysis assessments as ordered and the facility did not maintain ongoing communication and collaboration with the dialysis center.
Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure drugs and biologics were stored in accordance with manufacturer specifications and accepted professional standards for one (1) of one (1) resident (Resident #147) reviewed. Specifically, Resident #147 had medications that were expired and discontinued, and previously used insulin needles were stored in their room. Findings Include:Please refer to F 554 Resident Self-Administration of MedicationsThe facility policy Storage of Medications last reviewed January 2024, documented medications were stored securely in locked compartments, under proper environmental conditions, with controlled substances stored separately, refrigerated medications monitored daily for temperature, and access to medication storage limited to authorized staff. [...]
Inspectors wroteBased on observations and interviews conducted during the survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for one (1) of one (1) meal tray (12/10/2025 lunch meal) reviewed.
Inspectors wroteBased on record review and interview, the facility failed to ensure they provided the appropriate liability and appeal notices to Medicare beneficiaries for two (2) of three (3) residents (Residents #223 and #224) reviewed. Specifically, Residents #224 and #223 were discharged from the facility and were not provided with Notice of Medicare Non-Coverage (NOMNC) CMS-10123 as required.
Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility failed to provide an environment which supported and enhanced each resident's quality of life, which was the result of the cumulative effect of noncompliance cited for abuse/neglect, incontinence care, quality of care, pressure ulcers, accident hazards, sufficient staffing, significant medication errors, and infection prevention and control. This noncompliance was found to be pervasive and created an environment reflecting a complete disregard of one or more residents' well-being and quality of life, which has caused or is likely to cause serious harm that is Immediate Jeopardy, related to one or more residents' self-worth, self-esteem, and well-being. [...]
Inspectors wroteBased on observations, interviews and record review conducted during the Extended Recertification Survey and complaint investigations (NY00372404, NY00372850, NY00364319, & NY00372698) from 03/09/2025 to 05/09/2025, the facility failed to ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility (Units South One, South 2, South 3, North One, North Two, [NAME] One and [NAME] Two). Specifically, there was insufficient staff to meet all resident needs including showers, assistance with eating, toileting, personal hygiene, and receiving medications as ordered by the medical team due to lack of licensed nurses and certified nursing assistants. On 04/23/2025 the survey team identified and declared Immediate Jeopardy. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey and complaint investigations (NY00372404, NY00372850, NY00371489, and NY00372698) from 03/09/2025 to 05/09/2025, for four (4) (Residents #3, #32, #111, #459) of nine (9) residents reviewed, the facility failed to ensure that residents were free of significant medication errors. Specifically, there was no documented evidence that the residents received multiple significant medications over the course of several days including but not limited to insulin, antihypertensives (used to treat high blood pressure), antiplatelets (used to prevent blood platelets from forming clots), antidepressants, antipsychotics, antibiotics, antirejection medication (used for kidney transplants) and a medication used to treat kidney disease in dialysis patients. [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during an Extended Recertification Survey from [DATE] to [DATE], the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #82, #148, and #459) of 10 residents reviewed and one (1) of one (1) facility potable water systems (the collection, treatment, storage, and distribution of safe drinking water). Specifically, Issue one (1) includes: [...]
Inspectors wroteBased on observations, interviews, and record review conducted during an Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents for five (5) (Residents #4, #11, #83, #461 and #508) of five (5) residents reviewed for accidents and five (5) (West One, [NAME] Two, North First Floor, North Two, and South Three) of seven (7) resident areas observed for accident hazards. Specifically, the facility failed to ensure the residents, who were on aspiration precautions (precautionary steps taken by the facility to prevent inhalation of food or drink into the lungs due to swallowing difficulties), received adequate supervision and/or assistance during meals. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during an Extended Recertification Survey from 03/09/2025 to 05/09/2025, for 13 (Residents #3, #4, #11, #32, #62, #83, #111, #148, #158, #178, #459, #461, #508) of 13 residents reviewed, the facility failed to ensure that residents were free from neglect when it failed to provide the required structures and processes in order to meet the needs of one or more residents. Specifically, the facility failed to ensure sufficient nursing staff to provide nursing services to meet the residents' needs including showers, assistance with eating, toileting, personal hygiene, skin care, application of devices to prevent loss of range of motion, receiving medications as ordered by the medical team and supervision of residents on aspiration precautions to prevent choking. [...]
Inspectors wroteBased on observations, interviews and record review conducted during an Extended Recertification Survey and complaint investigation (NY00372698) from 03/09/2025 to 05/09/2025, the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice for 2 (Residents #178 and #459) of 41 residents reviewed. Specifically, Resident #178 was observed on several occasions not wearing custom-made hand splints as recommended by Occupational Therapy to maintain range of motion, resulting in lost range of motion to their hands. Resident #459 did not have orders for care of their nephrostomy tube (tube inserted directly into the kidney through the skin to drain urine) for an extended period of time. This resulted in actual harm to Resident #178 that was not immediate jeopardy.
Inspectors wroteBased on observation, interviews and record review conducted during the Extended Recertification Survey and complaint investigation (NY00372404) from 03/09/2025 to 05/09/2025, the facility did not 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 one (1) (Resident #158) of six (6) residents reviewed. Specifically, Resident #158 was identified by staff to have skin breakdown to their buttocks on 03/14/2025. There was no documented evidence that a medical provider was notified, or treatments initiated, until three days later. This resulted in actual harm to Resident #158 that was not Immediate Jeopardy.
Inspectors wroteBased on observations, interviews, and record review conducted during an Extended Recertification Survey from 03/09/2025 to 05/09/2025, for one (1) of one (1) main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, plates were not properly air dried and stored, floors were soiled with food debris throughout the kitchen, food items were undated and unlabeled, a stove top was dirty, food items were stored on the floor, a carton of milk was outdated, food was not stored at proper temperatures, a fan was dirty, and staff were not wearing proper hair restraints (beard guards).
Inspectors wroteBased on observations, record review, and interviews conducted during the Extended Recertification Survey 03/09/2025 to 05/09/2025 facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility did not establish and implement procedures and clear communication methods between the administrator and the governing body to ensure management and operation of the facility and regulatory compliance. Specifically, there were multiple serious deficiencies identified that included, but were not limited to, Immediate Jeopardy, harm, substandard quality of care, and multiple repeat deficiencies related to resident care.
Inspectors wroteBased on observations, interviews, and record review conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility did not ensure a Quality Assurance and Performance Improvement (QAPI) program that put forth good faith attempts to develop, implement, and maintain an appropriate plan of action to address identified issues that impacted resident safety or ensured corrective actions were set around safety, quality, rights, choice and respect. Specifically, the facility did not implement and maintain the approved plans of correction from the Extended Recertification Survey dated 09/17/2024 for F550, F565, F584, F677, F684, F686, F725, F761, and F812.
Inspectors wroteBased on observation and interviews conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility did not designate one (1) or more individuals as the Infection Preventionist responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have a designated Infection Preventionist qualified with specialized education, training, experience, or certification on a part time or full-time basis.
Inspectors wroteBased on observations, interviews and record review conducted during the Extended Survey from 03/09/2025 to 05/09/2025 for five (5) (Residents #114, #148, #191, #462, and #463) of six (6) residents reviewed, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Specifically, Residents #114 and #462 were seated in a designated resident space and staff were eating take-out pizza and breadsticks in the room. Resident #148 had a sign above the head of their bed that read 'I AM A FEEDER.' Resident #191 was observed in the hallway without pants on and their incontinence brief visible to other residents and visitors in the hallway. [...]
Inspectors wroteBased on interviews and record reviews conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025 for 15 residents reviewed for grievances, the facility did not ensure that grievances and/or recommendations of the Resident Council (resident group) concerning issues of resident care and life in the facility were acted on promptly. Specifically, during a special Resident Council meeting, Residents #31, #37, #53, #93, #96, #107, #159, and #203 voiced care concerns. Residents #3, #38, #53, #62, #93, #96, #104, #110, #128, and #147 had filed grievances with the facility between 12/31/2024 to 02/06/2025 for care concerns. [...]
Inspectors wroteBased on observations and interviews conducted during the Extended Recertification Survey from 03/9/2025 to 05/09/2025 it was determined that for five (5) (North One, South One, South Three, [NAME] One, [NAME] Two) of seven (7) resident units and two (2) (West and South basements) of two (2) basements observed the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, comfortable, and homelike interior. Specifically: [...]
Inspectors wroteBased on observations, interviews and record review conducted during an Extended Recertification Survey and complaint investigations (#NY00372404, #NY00372850, #NY00364319) from 03/09/2025 to 05/09/2025 the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for four (4) (Residents' #62, #148, #158 and #178) of eight (8) residents reviewed. Specifically, Residents' #62 and #148 reported no showers for several weeks and were observed with unwashed hair, Resident #178 had no documented showers for several weeks, was observed with unwashed hair, long uncut nails and was unshaven over multiple days and Resident #158 was observed incontinent for extended periods of time.
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Extended Recertification Survey and complaint investigation (NY00372850) from 03/09/2025 to 05/09/2025, the facility did not ensure that all drugs and biologicals in the facility were properly stored in accordance with State and Federal laws for three (3) (North One, North Two and South One) of seven (7) resident care units. Specifically, 218 blister packs (a type of packaging for some medications) of resident specific prescription medications were left on a counter and in unlocked cabinets behind the North One nurses' station; a five (5) drawer medication/treatment cart containing dozens of topical prescription medications was unlocked on the North Two hallway; a medication room was unlocked with multiple blister packs of residents' prescription medications sitting on the counter; [...]
Inspectors wroteBased on observation, interview, and record review conducted during an Extended Recertification Survey 03/09/2025 to 05/09/2025, the facility did not ensure food and drink were provided that was at a safe and appetizing temperature for one (1) test tray and for five (5) residents (Residents #3, #37, #62, #104 and #107) interviewed on the South One Unit. Specifically, food and beverages during the meal were served at suboptimal temperatures and were not palatable.
Inspectors wroteBased on observations and interview conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025 for three (3) (South One, South Three, North Two) of seven (7) resident units reviewed, the facility did not ensure compliance with all applicable state codes, including Subpart 713-1, New York State building construction standards for nursing home construction projects completed or approved prior to August 25, 1975. Specifically: beds were less than three (3) feet from windows and/or radiators, a resident room lacked an outside window, beds were located less than three (3) feet apart, and windowsills exceeded three (3) feet above the floor level.
Inspectors wroteBased on interviews and record review conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility did not maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, one (1) of who must be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide documented evidence the Infection Preventionist, or the Medical Director attended the Quality Assurance and Performance Improvement meetings on a consistent basis.
Inspectors wroteBased on interviews and record review conducted during the Extended Recertification Survey from [DATE] to [DATE] for 1 (Resident #308) of 12 residents reviewed, the facility did not ensure that an incident was thoroughly investigated to rule out abuse, neglect, mistreatment, or care plan violation. Specifically, Resident #308 had an unwitnessed fall on [DATE] and was found unresponsive in front of the nurse's station. The facility was unable to provide documented evidence (including statements from all involved staff members or potential witnesses) that the incident was thoroughly investigated to rule out abuse, neglect, mistreatment, or care plan violation.
Inspectors wroteBased on observation, interviews and record review conducted during an Extended Recertification Survey and complaint investigation (#NY00374153) 03/09/2025 to 05/09/2025 the facility did not ensure a resident with an indwelling urinary catheter (a tube inserted into the bladder to drain urine) received the care and services to manage the catheter for one (1) (Resident #1) of two (2) residents reviewed. Specifically, there were no medical orders for routine care of the indwelling urinary catheter upon admission to the facility, there was no care plan related to presence of an indwelling urinary catheter, including goals and interventions for the catheter and the medical team was not notified when the urinary catheter was pulled out and unable to be reinserted.
Inspectors wroteBased on observation, interviews, and record review, conducted during an Extended Recertification Survey from 03/09/2025 to 05/09/2025 the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice for one (1) (Resident #153) of three (3) residents reviewed. Specifically, there were no medical orders related to post dialysis (treatments to remove waste products and fluid from the blood when the kidneys fail to) and no documented evidence the resident's permcath (a catheter inserted into a vein to use for dialysis treatments) site was assessed for complications upon return to the facility after dialysis treatments.
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, for 2 (Residents' #17, #461) of 13 residents reviewed for accidents, the facility did not ensure food was prepared in a consistency to meet the residents needs per speech language pathologist recommendations and physician orders. Specifically, Resident #17 had a history of dysphagia (difficulty swallowing), was on a mechanically altered diet (a diet that consists of easy to chew and swallow foods), and received a food item that was not appropriate on their physician ordered diet. Resident #461 was on aspiration precautions (measures to prevent inhalation of food and liquids in the lungs), was on a mechanically altered diet and received a liquid drink in an inappropriate consistency.
Inspectors wroteBased on observations and interview during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, for one (1) (resident room [ROOM NUMBER]) of 114 resident sleeping rooms the facility did not provide enough usable space in a resident room. Specifically, a multiple resident bedroom did not have a minimum of 80 square feet of usable space per resident.
Inspectors wroteBased on observations and interview during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, for two (2) (resident rooms #221 and #223) of 114 resident sleeping rooms the facility did not provide resident sleeping rooms that were designed and equipped to assure full visual privacy for each resident. Specifically, privacy curtains were missing or inadequate to provide each resident full visual privacy.
Inspectors wroteBased on observations and interview conducted during an Extended Recertification Survey from 03/09/2025 to 05/09/2025 the facility did not ensure that all residents had adequate functional furniture that meet residents' needs. Specifically, resident #147 did not have private closet space within their resident room, such that each residents' clothing was kept separate from the clothing of their roommate. Observations on 03/10/2025 at 11:55 AM on the North Two Unit revealed Resident room [ROOM NUMBER], a four-person capacity room, lacked private closet space for its residents. There were three freestanding wardrobes for the four (4) residents in this room and one of the wardrobes was shared for resident #147 and another resident. [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, the facility did not ensure that all drugs and biologicals in the facility were properly stored in accordance with State and Federal Laws for eight (West Two Long Hall, South One Short Hall, North One Unit, North Two Unit, South Two Long Hall, South Two Short Hall, South Three Short Hall and South Three Long Hall) of nine medication carts and three (South One, North One, and [NAME] One) of four medication rooms reviewed. Specifically, medication carts contained expired medications, medications with no resident identifiers on them, open food for staff use, a medication with no pharmacy or manufacturer label, opened insulin pens that were in use and undated, and medications stored in containers with the wrong resident identifiers. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, it was determined that the facility and governing body failed to assure that the resident received appropriate quality of care by allowing the following deficient practices to exist putting the resident at risk for harm and serious injury: F550, F600, F677, F686, F760, F761, and F837. Specifically, there was inconsistent communication with the facility Administrator to ensure management of the facility and regulatory compliance. Multiple deficiencies were identified during the Recertification Survey and extended survey, including but not limited to, Immediate Jeopardy, Harm, Substandard Quality of Care, and multiple repeat deficiencies. [...]
Inspectors wroteBased on interviews, observations, and record reviews conducted during the extended Recertification Survey and complaint investigation (#NY00341657) from 07/08/2024 to 09/17/2024, the facility failed to ensure residents right to be free from abuse, mistreatment, or neglect for seven (Residents #70, #92, #106, #134, #140, #177, and #182) of eight residents reviewed for abuse. Specifically, for Residents #92, #134, #177, and #182, the facility did not implement interventions to protect the residents from sexual abuse. For Resident #70 who had reported to several staff members, ongoing abuse from their roommate, the facility failed to investigate the allegations. For Resident #106, the facility did not ensure incontinence care was received in a timely manner when the resident was left soiled for several hours on multiple occasions. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, the facility failed to ensure the resident received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening for one (Resident #106) of five residents reviewed. Specifically, the facility did not ensure that wound treatments recommended by the Wound Care Physician were accurately and timely transcribed and implemented, that wound treatments were provided as ordered, and Resident #106 was observed on several occasions with lack of incontinence care. These issues resulted in the potential likelihood of serious injury for all the residents in the facility (census 216) that was Immediate Jeopardy. [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during the extended Recertification Survey and complaint investigation (#NY00343730) from 07/08/2024 to 09/17/2024, for 32 (Residents #4, #17, #19, #33, #36, #40, #42, #44, #56, #59, #60, #68, #80, #83, #84, #85, #90, #104, #107, #114, #116, #117, #133, #140, #164, #167, #168, #179, #190, #358, #359, and #614) of 46 residents reviewed, the facility failed to ensure the residents were free from significant medication errors. Specifically, Resident #359 was not administered their anti-anxiety and respiratory medications (not available) and was sent to the hospital the following day. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey and complaint investigation (#NY00343916) from 07/08/2024 to 09/17/2024, for five (Resident #55, #92 #106, #140, and Resident #457) of seven residents reviewed, the facility did not ensure that the residents were treated in a respectful and dignified manner. Specifically, Resident #55 was observed in the dining room wearing only a t-shirt and an incontinence brief. Resident #92 was observed to be asleep in their bed and the bed was bare, with no sheets in place. Resident #106 was observed laying on a urine soiled incontinence pad. Resident #140 was observed lying on a mattress without sheets. Resident #457 was observed lying on wet linens over an extended period of time. Additionally, there were multiple observations of residents using paper plates and plastic utensils for meals. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for six (South 1, South 2, South 3, North 1, North 2, and [NAME] 2) of seven resident units, the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being for residents in the facility. Specifically, there were several observations of residents who were incontinent and had not received timely assistance with care, and several residents had not received significant medications on 07/04/2024, 07/05/2024, and 07/29/2024 due to no nurse being available to administer the medications. This resulted in actual psychosocial harm to Resident #106 that was not immediate jeopardy.
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey and complaint investigations (#s NY00339393, NY00343730, and NY00343916) from 07/08/2024 to 09/17/2024, for ten (Residents #69, #98, #106, #116, #122, #134, #140, #182, #456, and #457) of 13 residents reviewed, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #69 was lying in bed with no clothes on, there was a brown substance observed on their body, as well as, on the fitted sheet and the hospital gown that was underneath the resident's bottom. Resident #98 was in a wheelchair partially in the bathroom with their pants on the floor. There was stool on the floor near their bed and on the bed sheets with no staff in sight. [...]
Inspectors wroteBased on interviews and record reviews conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for six (Residents #4, #24, #80, #105, #201, and #613) of six residents, the facility did not ensure that grievances and recommendations of the Resident Council (resident group) concerning issues of resident care and life in the facility were acted on promptly. Specifically, during a special Resident Council meeting, the six residents voiced care concerns and a review of the previous six months of meeting minutes included issues such as long call bell wait times, residents not being provided personal care or receiving medications when scheduled, a shortage of linens, and a lack of staffing that were not investigated and/or addressed in a timely manner. This is evidenced by the following: [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey and complaint investigation (#NY00343730) from 07/08/2024 to 09/17/2024, for four (South 1, South 2, South 3, and [NAME] 2) of seven residential units reviewed, the facility did not ensure residents had a safe, clean, comfortable, and homelike environment. Specifically, there was not an adequate supply of clean bed and bath linens and linens that were available, were not in good condition preventing residents from receiving assistance with their activities of daily living in a timely manner. For Resident #106 they were given a bottom sheet for a top sheet and were observed laying on a urine soiled pink pad. Residents #92 and #140 were observed lying on their bare mattresses without sheets. Resident #457 was observed lying on wet linens over an extended period of time. [...]
Inspectors wroteBased on interviews and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for eight (Residents #13, #45, #70, #112, #149, #186, #559, and #607) of eight residents reviewed, the facility did not ensure that a written Baseline Care Plan summary was provided to the residents and/or resident representatives. Specifically, the facility was unable to provide evidence that a Baseline Care Plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents, that they were able to understand) had been completed within 48 hours and a written summary of the plan had been provided to any of the residents and/or their representatives. This is evidenced by, but not limited to the following: [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for one of one main kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, dishware was not properly air dried and stored, floors were soiled with food debris, a freezer was not properly maintained, and there was food spillage on a shelving unit.
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, the facility policy regarding use and storage of foods brought to residents by family and other visitors did not ensure safe and sanitary storage, handling, and consumption. Specifically, staff were not aware or educated on facility policies and procedures to label, date, and measure temperatures of resident food brought in from outside the facility, and items were not properly labeled and dated.
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for seven (Residents #45, #92, #134, #139, #177, #182 and #559) of nine residents reviewed, the facility did not develop and/or implement comprehensive person-centered care plans that included measurable goals and interventions to meet the residents' medical, nursing, and psychosocial needs as identified in their comprehensive assessments. Specifically, the comprehensive care plan for Resident #45 did not include catheter care. For Residents #92 and #177, the comprehensive care plans did not include a history of sexual-related behavior. For Residents #134 and #182, the comprehensive care plans did not include a history of any inappropriate behaviors towards other residents and/or staff. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for two (Resident #122 and #182) of 13 residents reviewed for Activities of Daily Living, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, Resident #122 was observed on several occasions with unwashed hair and long unshaven facial hair and Resident #182 did not receive nail care. In addition, the facility did not assist Resident #122 with an appointment with a stylist for a wash and cut as requested. This is evidenced by, but not limited to, the following: [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for four (Residents #66, #83, #106, and #607) of 10 residents reviewed for enhanced barrier precautions, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Affected residents resided on four (South 1, South 2, [NAME] 1, and [NAME] 3) of seven units. Specifically, Resident #66 was on enhanced barrier precautions and staff did not wear appropriate personal protective equipment (including gown and gloves) while flushing a feeding tube (tube inserted directly into the stomach to receive nutrition) and changing the feeding tube dressing. [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during the extended Recertification Survey and complaint investigation (#NY00345239) from 07/08/2024 to 09/17/2024, the facility did not ensure a resident with an indwelling urinary catheter received the treatment and care necessary to prevent urinary tract infections to the extent possible for one (Resident #45) of two residents reviewed. Specifically, Resident #45's urinary catheter and drainage bag were observed on the floor with no protective barrier on several occasions, were observed above the level of the bladder, and the facility did not develop a care plan to address the resident's urinary issues and care of their urinary catheter. This is evidenced by the following: [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for one (#66) of one resident reviewed, the facility did not ensure that a resident being fed by enteral means (a feeding tube placed in the stomach to receive nutrition) received the appropriate care and services to prevent complications. Specifically, Resident #66's tube feedings were not consistently labeled to ensure the physician orders were being followed with the correct formula, when the feeding was intiated or by whom and had no resident identifyers on the tube feedings. This is evidenced by the following: Resident #66 had diagnoses including dysphagia (difficulty swallowing) that required a feeding tube, malnutrition, and diabetes mellitus. [...]
Inspectors wroteBased on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for two (Residents #18 and #134) of two residents reviewed, the facility did not provide special eating equipment for residents who need them to maintain or improve the resident's ability to eat and drink independently. Specifically, Resident #18 was observed on multiple occasions consuming food from flat plates or plastic bowls instead of a divided plate as recommended by Occupational Therapy. Resident #134 was observed on several occasions consuming food from plastic bowls or a paper plate instead of a divided plate as care planned for. This is evidenced by the following: [...]
Inspectors wroteBased on interview and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, the facility did not ensure each resident received the pneumococcal immunizations for two (Residents #22 and #177) of five residents reviewed. Specifically, there was no documented evidence that either resident received the pneumococcal vaccine despite signing the consent forms requesting it. This is evidenced by the following: Per facility policy, Infection Control, Pneumococcal Vaccine, dated January 2024, all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Resident #22 had diagnoses that included dementia with psychotic disturbance (dementia with features of delusions or hallucinations), adult failure to thrive, and atrial fibrillation (an irregular and often rapid heart rhythm). [...]
Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey and complaint investigation (#NY00327300), it was determined that for six (West One and Two, North One and Two, and South One and Three) of seven resident units the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, window and privacy curtains were soiled, exhaust ventilation fan grates had a heavy accumulation of dust, the footboard of a resident's bed was loose, a bathroom door was damaged, a janitor closet was lacking exhaust ventilation, and a box of medical supplies was stored on the floor.
Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey, it was determined that for six (West One and Two, North One and Two, and South Two and Three) of seven resident units the facility did not ensure that the resident environment remained free of accident hazards. Specifically, the exterior of heating units accessible to residents had hot surfaces.
Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey and complaint investigations (NY0030887, NY00322420, NY00325155, NY00327300, NY00330486) it was determined that the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being for all residents in the facility. Specifically, there was insufficient staffing on multiple units on multiple days and shifts to ensure residents remained free of significant medication errors, that medications were administered timely per physician orders and that personal care was provided timely and in accordance the resident's comprehensive assessment and plan of care. This is evidenced by but not limited to the following: For additional information see Centers for Medicare/Medicaid Services Form 2567: [...]
Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for five (Residents #19, #42, #66, #109 and #112) of five residents reviewed for unnecessary medications, the facility did not ensure that the Medication Regimen Review completed by the Pharmacist was reviewed by the physician for irregularities/recommendations and action taken if any and/or a rationale if no action taken. Specifically, the Pharmacist made recommendations for each of the identified residents during the period of August 2023 through December 2023 and the facility was unable to provide evidence that the recommendations had been addressed by the physician in a timely manner. This is evidenced by but not limited to the following: The facility policy and procedure, Medication Therapy/Drug Regimen Review, last reviewed January 2024 included: [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined for three (Residents #66, #98 and #112) of five residents reviewed for unnecessary medications, the facility did not ensure residents who were receiving psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, all three residents were receiving psychotropic medications (used to treat mental health problems) and the facility was unable to provide documented evidence that a gradual dose reduction of the psychotropic medications had been attempted or that a gradual dose reduction was contraindicated for any of the residents. This is evidenced by the following: 1. Resident #66 had diagnoses including vascular dementia with behavioral disturbance and depression. [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for four of six unit medication carts and two out of three unit medication rooms reviewed for medication storage, the facility did not ensure that all drugs and biological were properly stored in accordance with State and Federal Laws. [...]
Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically: spoiled food products were stored in a walk-in cooler, cans with significant dents were stored with regular food stock, dishes were not air dried, food and non-food contact surfaces of equipment were soiled, the ice machine lid was in disrepair, food storage shelves were rusted, floors and walls were soiled, and a chest freezer had significant amounts of ice buildup.
Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one (Resident #116) of three residents reviewed for dignity, the facility did not ensure that the resident received care in a respectful and dignified manner. Specifically, Resident #116 did not receive timely assistance with incontinence care resulting in having to eat their meal while soiled. This is evidenced by the following: Resident #116 had diagnoses including left leg fracture, constipation, and depression. The Minimum Data Set Resident Assessment, dated 12/11/23, documented that Resident #116 was cognitively intact and required substantial/ maximal assistance with toileting. [...]
Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey and complaint investigation (NY00330887), it was determined for one (Resident #156) of one resident reviewed for reasonable accomodation of needs, the facility did not ensure that a resident received services with reasonable accommodation of the resident's needs and preferences. Specifically, Resident #156 was observed on several occasions without their call device within reach. This is evidenced by the following: Resident #156 had diagnoses including epilepsy (a neurological disorder that causes seizures), anxiety disorder, and polyneuropathy (malfunction of multiple nerves). The Minimum Data Set Resident Assessment, dated 11/24/23, revealed the resident had moderately impaired cognition, was occasionally incontinent of urine, and required assistance with their activities of daily living. [...]
Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigation (NY00327300 & NY00330486), it was determined that for three (Residents #19, #128, and #248) of seven residents reviewed for activities of daily living, the facility did not ensure the residents received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #128 and Resident #248 did not receive the assistance required for shaving, nail care, and incontinence care, and Resident #19 did not receive assistance with nail care. This is evidenced by the following: Review of the facility policy Resident Care with Activities of Daily Living dated January 2022 included the purpose of the policy was to accurately assist with the residents' need for basic activities of daily living function. [...]
Inspectors wroteBased on observation, interview and record review conducted during the Rectification Survey, the facility did not provide medical-related social services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident for one (Resident #152) of two residents reviewed for discharge planning. Specifically, Resident #152 expressed a desire to return to the community and a discharge plan based on the resident's preferences was not followed up on in a timely manner. This is evidenced by the following: Resident #152 was admitted to the facility approximately 11 months prior with diagnoses including aftercare following surgical amputation, diabetes without complications and depression. [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (NY00322420, NY00327300, NY00330486, NY00330887) it was determined for three (Resident #59, Resident #66, and Resident #98) of five residents reviewed the facility did not ensure residents were free from significant medication errors. Specifically, for Resident #59 there was no documented evidence that the resident received multiple doses of a prescribed immunosuppressant medication to prevent rejection of an organ transplant. For Resident #66, there was no documented evidence that multiple medications, including insulin, had been administered or blood glucose monitoring had been completed as ordered. [...]
Inspectors wroteBased on interview and record review conducted during the Recertification Survey for two (Residents #747 and #748) of three residents reviewed, the facility did not provide the appropriate appeal notices to Medicare beneficiaries. Specifically, for Resident #747 and #748 the facility could not provide documented evidence that the residents were provided with a Notice of Medicare Noncoverage letter including their appeal rights prior to discharge from the facility. This is evidenced by the following: Resident #747 was recently admitted to the facility under Medicare Part A services and discharged to the community. There was no evidence that a Notice of Medicare Noncoverage was given to resident #747 or their representative informing them at least two days before the end of Medicare covered Part A stay to notify them of their appeal rights prior to discharge. [...]
Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey it was determined that the facility did not consistently post the daily nurse staffing information and did not include the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift per the regulations. Additionally, the postings were not consistently updated to reflect staffing changes throughout the day. The finding is: During observations on 1/17/24 and 1/19/24 New York State Department of Health surveyors were unable to locate the posted nurse staffing information as part of the Standard Recertification Process. [...]
29 fire safety citations on file: 16 on December 22, 2025, 7 on May 9, 2025, 6 on September 17, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| December 22, 2025 | Fine | $460,490 |
| December 22, 2025 | Payment Denial | 102 days from February 14, 2026 |
| May 9, 2025 | Fine | $185,840 |
| September 17, 2024 | Fine | $314,554 |
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) | 3.51 | 3.63 | 3.86 |
| Registered nurses | 0.56 | 0.71 | 0.69 |
| All nursing staff on weekends | 2.82 | 3.18 | 3.42 |
| Nurse aides | 2.02 | ||
| Licensed practical nurses | 0.92 | ||
| Nursing staff turnover (share who left in a year) | 67.0% | 40.3% | 45.8% |
| Registered nurse turnover | 58.1% | 39.8% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.45 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 3.79 on weekdays and 2.82 on weekends, 26% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.77 in April to June 2025 to 3.51 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 | 3.51 | 0.56 | 3.79 | 2.82 | 4.5% | 0 of 90 | 190 |
| Oct to Dec 2025 | 3.44 | 0.56 | 3.68 | 2.83 | 0.0% | 0 of 92 | 197 |
| Jul to Sep 2025 | 3.38 | 0.57 | 3.65 | 2.72 | 0.0% | 0 of 92 | 190 |
| Apr to Jun 2025 | 2.77 | 0.40 | 2.96 | 2.27 | 1.5% | 0 of 91 | 201 |
| 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.
| 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 | 19.2 | 14.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.6 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.7 | 1.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.8 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 5.0 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.2 | 12.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.2 | 6.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.2 | 13.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.6 | 20.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.9 | 9.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.5 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 1.4 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Waterview Heights Rehabilitation and Nursing Cente's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (30.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
30.0% 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. 54 eligible stays.
10.3% 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. 73 eligible stays.
6.2% 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. 57 eligible stays.
18.4% 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. 87 residents counted.
3.3% 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. 151 residents counted.
2.4% 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. 151 residents counted.
92.3% this home
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. 26 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: THE SHORE WINDS, LLC.. CMS links this home to Hurlbut Care, a group of 13 nursing homes averaging 3.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Curletta, Mark | W-2 managing employee | Individual | 07/16/2021 | |
| Curletta, Mark | Corporate officer | Individual | 07/16/2021 | |
| Hurlbut Health Consulting, LLC | Operational/managerial control | Organization | 01/01/2020 | |
| Curletta, Mark | Operational/managerial control | Individual | 07/16/2021 |
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.
These are the official offices in New York. NursingHomeClear cannot take or act on complaints.