Cycle 1
Health 2025-04-18 · Fire 2025-04-18
32 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Syracuse, NY
Van Duyn Center For Rehabilitation And Nursing
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $498,455 in total fines with 31 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
5075 West Seneca Turnpike, Syracuse, NY
(315) 449-6000
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
513
Certified beds
Average residents
485
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,241
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.52
Baseline 20.08% · Performance 21.19% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Healthcare-associated infections
1.06
Baseline 6.28% · Performance 7.52% · Measure score 1.06 · Achievement 1.06 · Improvement 0
Total nurse turnover
4.43
Baseline 46.51% · Performance 45.57% · Measure score 4.43 · Achievement 4.43 · Improvement 0
Adjusted total nurse staffing
4.95
Baseline 3.62 hours · Performance 4.49 hours · Measure score 4.95 · Achievement 4.95 · Improvement 3.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.26% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 204 · Observed rate 14.71% · Lower 95% interval 10.03% |
| Discharge to community | 31.1% |
50.57%
19.5 pts worse
|
Worse than the National Rate · Eligible stays 231 · Observed rate 21.65% · Lower 95% interval 24.14% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 194 · Denominator 194 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 194 |
| Discharge self-care score | 44.85% |
53.69%
8.8 pts worse
|
Numerator 61 · Denominator 136 |
| Discharge mobility score | 45.59% |
50.94%
5.3 pts worse
|
Numerator 62 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 194 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.52% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 150 · Observed rate 8.67% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 0.23% |
8.2%
8 pts worse
|
Numerator 2 · Denominator 880 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 54.41% |
56.45%
2 pts worse
|
Numerator 74 · Denominator 136 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 42 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 17.8% |
25.2%
7.4 pts worse
|
Numerator 21 · Denominator 118 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.5 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.7 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
91.2%
5.9 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 97.2% · Q3 97.7% · Q4 97.1% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
95.3%
3.9 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.0%
0.3 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.3% · Q3 3.3% · Q4 3.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
18.5%
18.3 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.1%
0.1 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.7% · Q3 5.8% · Q4 5.1% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
13.5%
0.2 pts worse
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 11.5% · Q3 14.9% · Q4 13.8% · 4Q avg 13.7% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.1% |
15.1%
3 pts better
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 13.8% · Q3 8.3% · Q4 6.9% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
15.5%
1.9 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.0% · Q3 12.5% · Q4 13.3% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.2% · Q4 0.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.4%
0.9 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.5% · Q3 0.2% · Q4 0.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
20.8%
6 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 30.2% · Q3 24.0% · Q4 22.8% · 4Q avg 26.8% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
6.9%
4.5 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.0% · Q3 1.2% · Q4 1.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.6% |
76.7%
2.9 pts better
|
81.7%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 76.9% · Q3 79.4% · Q4 81.6% · 4Q avg 79.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
9.7%
2.8 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 13.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.3% · Q3 2.4% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.9% |
78.8%
3.9 pts worse
|
79.7%
4.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
20.6%
0.1 pts worse
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 22.3% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-28 · Fire 2023-07-28
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-06-21 · Fire 2021-06-21
22 health deficiencies
Top issue: Resident Rights (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-28
F · Potential for more than minimal harm
2023-07-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-08-30
E · Potential for more than minimal harm
2021-06-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-08-11
E · Potential for more than minimal harm
2021-06-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-08-11
E · Potential for more than minimal harm
2021-06-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-11
Inspection history
Recent health citations
G · Actual harm
2026-01-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-03
F · Potential for more than minimal harm
2025-12-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-27
F · Potential for more than minimal harm
2025-12-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-27
F · Potential for more than minimal harm
2025-12-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-27
E · Potential for more than minimal harm
2025-12-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2026-01-27
D · Potential for more than minimal harm
2025-12-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-27
D · Potential for more than minimal harm
2025-07-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-19
K · Immediate jeopardy
2025-04-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-03
K · Immediate jeopardy
2025-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
H · Actual harm
2025-04-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-03
G · Actual harm
2025-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-04-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-04-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-18
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-18
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-03
G · Actual harm
2025-01-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-23
D · Potential for more than minimal harm
2023-10-26
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-29
J · Immediate jeopardy
2023-09-13
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-09-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-14
K · Immediate jeopardy
2023-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-28
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-30
E · Potential for more than minimal harm
2021-06-21
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-08-11
E · Potential for more than minimal harm
2021-06-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-11
E · Potential for more than minimal harm
2021-06-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-10-14
E · Potential for more than minimal harm
2021-06-21
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2021-08-11
E · Potential for more than minimal harm
2021-06-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-10-14
D · Potential for more than minimal harm
2021-06-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-11
D · Potential for more than minimal harm
2021-06-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-08-11
Penalties and ownership
What sits behind the stars
$117,000
2025-12-11
Fine
Fine · fine $117,000
Fine
$158,555
2025-04-18
Fine
Fine · fine $158,555
Fine
$9,620
2025-01-23
Fine
Fine · fine $9,620
Fine
$186,513
2023-09-13
Fine
Fine · fine $186,513
Fine
$26,767
2023-07-28
Fine
Fine · fine $26,767
Fine
Ownership
Koenig, Uri
5% Or Greater Direct Ownership Interest · Individual
Steif, Efraim
5% Or Greater Direct Ownership Interest · Individual
Augenstein, Jack
Corporate Officer · Individual
Steif, Efraim
Operational/Managerial Control · Individual
Wuertzer, Amy
Corporate Officer · Individual
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