Ozanam Hall Of Queens Nursing Home Inc
42 41 201st Street, Bayside, NY 11361 · Non profit - Corporation · 432 certified beds · (718) 423-2000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.2% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.2% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.3% | 1.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.2% | 19.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 17.9% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 9.9% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.4% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 6.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.0% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.5% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 67.0% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.8% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.7% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.73 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.08 | 1.36 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 623 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 211 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.1%CMS range 51.9–60.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 7.2–11.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 37.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 32.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 43.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 5.9–9.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 432 beds and averages 406.3 residents a day — about 94% occupied, or roughly 26 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.26 hrs/resident/day on weekends vs 3.58 on weekdays — 9% thinner on weekends. RN hours go from 0.88 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · D2024-10-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, and interviews conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not ensure that residents are 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, recognizing each resident's individuality. This was evident for 6 (Residents #239, 106, 164, 160, 245 & 166) residents observed during the Dining Observation Task on Unit 6 and Unit 4. Specifically, 1). staff members were observed feeding residents (Residents #239, 106, 164, 160 & 245 ) while standing, and 2.) a resident (Resident #166) was observed in the dining room sitting at a table where another resident was served their lunch, and they were not served for an additional 30 minutes while the other resident ate at the table. The findings are: The facility policy titled Resident Rights-Promoting and Maintaining Resident Dignity During Mealtimes dated 03/16/2023, updated 03/21/2024 documented that it is the practice of this home to treat each resident with respect and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not ensure that residents were afforded the opportunity to participate in their care planning process This was evident for 1 (Resident #103) of 2 residents reviewed for Care Planning out of 38 total sampled residents. Specifically, Resident #103 or their representative were not invited to attend care planning meetings. The findings are: The facility policy titled Comprehensive Care Plan dated 02/09/2024, updated 03/21/2024 stated that the home will provide the resident and resident representative, when applicable, with advance notice of care planning conferences to enable resident/resident representative participation. Resident #103 was admitted with diagnoses that included Non-Alzheimer's Dementia, Malnutrition, and Psychotic disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had severe impairment in cognition and was dependent on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 09/26/24 to 10/03/24 the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain grooming, and personal hygiene. This was evident for 1 (Resident #43) of 6 residents reviewed for Activities of Daily Living out of 38 sampled residents. Specifically, Resident #43 was observed unkempt with brown, dirty looking clothing and also noted with a strong urine odor. The finding is: The facility policy and procedure titled Completing the Activity of Daily Living Support created 5/6/2022 stated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy also stated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment and care plan and the preferences of each resident, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 2 (Resident #347 and Resident #408) reviewed for Activities out of a sample of 38 residents. Specifically, Resident #347 and Resident #408 were observed on multiple occasions not engaged in any activity programs. The findings are: The facility policy and procedure titled Recreational Activities with a revision date of November 2022 stated that it is the policy of the facility to provide a comprehensive recreational program as part of the multidisciplinary care approach. The policy also stated that the programming, both facility-sponsored group and individual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews conducted during the Recertification Survey-09/26/2024 to 10/03/2024 facility did not ensure that residents received proper treatment and assistive devices to maintain hearing abilities. This was evident for 1 (Resident #287) of 1 resident reviewed for Communication/Sensory out of a sample of 38 residents. Specifically, Resident #287 with a hearing impairment did not receive an audiology consultation or assistive devices to improve hearing ability. The finding is: Upon request, the Director of Nursing stated that the facility does not have a policy and procedure related to consultation, and that resident care is based on an individual plan of care. Resident #287 was admitted to the facility with diagnoses that included End Stage Renal Disease, Hypertension, benign prostatic hyperplasia. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #287 was moderately cognitively impaired, does not have hearing problems and no hearing aid or other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews conducted during the Recertification Survey from 9/26/2024 to 10/03/2024, the facility did not ensure that residents who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for 2 of 4 Residents (Resident #58 and Resident #127) reviewed for Respiratory Care out of a sample of 36 total sampled residents. Specifically, Resident #58 and Resident #127 who received continuous oxygen did not have pulse oxygen saturations appropriately monitored and there was no date on their nasal cannula/ tubing date indicating when the tubing was last changed. The findings are: The facility policy titled Oxygen Administration dated 02/27/2024 states that it is the policy to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated, date tubing when changed. The policy also stated that staff shall document the initial and ongoing assessment of the resident's condition warranting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, observation and record review during the Recertification and Complaint Survey (NY00349107) conducted from 09/26/2024 to 10/03/2024, the facility did not ensure that injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the New York State Department of Health. This was evident for 1 (Resident #148) of 5 residents reviewed for Falls out of a sample 38 residents. Specifically, Resident #148 was observed with discoloration of the chin and mouth of unknown origin which was not reported to New York State Department of Health. The finding is: Resident #148 was admitted to the facility with diagnoses which included Non-Alzheimer's' Dementia, Traumatic Brain Dysfunction, and Fracture of Nasal Bones. The Significant Change Minimum Data Set assessment dated [DATE] identified Resident #148 as severely cognitively impaired and able to make needs known, needed supervision of staff with Activities of Daily Living, including ambulation. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-19 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during a Recertification and Complaint (#NY00298552) survey, the facility did not ensure that there was sufficient staff available to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. This was evident for 2 (Resident #42 and Resident #238) of 5 residents reviewed for Activities of Daily Living (ADLs) out of a total sample of 38 residents, the Resident Council facility task, and the Sufficient and Competent Nurse Staffing facility task. Specifically, (1) Residents #42 and #238 did not receive showers for a 3-week period from 6/27/22 to 7/14/22. (2) The facility nurse staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment. The findings include but are not limited to: 1) Resident #42 was admitted to the facility with diagnosis which include Non-Alzheimer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-19 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment(s) were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. This was evident for 1 (Resident #4) out of 1 residents reviewed for Resident Assessment. Specifically, the MDS for Resident # 4 was scheduled for submission on [DATE] and was not submitted. The findings are: The policy titled MDS & Coding Integrity dated 10/19 documented discharge assessment for deaths in the facility will be transmitted within 7 days of death. The Death Certificate for Resident # 4 documented the resident expired in the facility on [DATE]. There was no documented evidence a MDS assessment for Resident #4's death in the facility was submitted to the CMSDS. On [DATE] at 10:48 AM, the MDS Coordinator was interviewed and stated Resident #4's MDS reporting the resident's death in the facility was not submitted on [DATE] as scheduled. The facility has a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview during the recertification survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 (Resident #314) of 38 sampled residents (Resident #314). Specifically, the MDS assessment for Resident #314 did not accurately reflect the resident's discharge to the community. The findings are: The facility policy titled MDS Process and Coding Integrity last revised October 2019 documented accurate MDS coding is based on documentation in the medical record. Resident #314 had diagnoses of right tibia fracture and difficulty walking. The Discharge Care Plan dated 4/14/022 documented resident planned to be discharged home. The Nursing note dated 4/29/2022 documented resident was discharged to the community. The MDS assessment dated [DATE] documented Resident #314 was discharged to the hospital. On 07/15/2022 at 12:37PM, an interview was conducted with MDS Coordinator #2 who stated Resident #314 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · Dcited before2022-07-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey, the facility did not ensure residents were provided with care and interventions to carry out Activities of Daily Living (ADL) in accordance with their needs and preferences. This was evident for 2 (Resident #283 and #42) of 5 residents reviewed for ADLs out of a sample of 38 total residents. Specifically, 1) Resident #283 and 2) Resident #42 were not provided with the ADL assistance to receive showers or bed baths in accordance with their needs and preferences. The findings are: The facility policy titled Certified Nursing Assistant Accountability Record (CNAAR) last revised January 2018, documented the Certified Nursing Assistant (CNA) will initial in the appropriate column, date, and shift at the completion of care each day, signifying that care listed on the CNAAR has been performed and will inform the nurse if unable to perform care. 1) Resident # 283 had diagnoses of cancer and decreased mobility. The Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interviews conducted during the recertification survey, the facility did not ensure infection control practices were maintained during meals. This was evident for 1 (Unit 4) of 7 Units observed during dining. Specifically, Certified Nursing Assistants (CNA) did not perform hand hygiene in between sanitizing residents' hands prior to meal service. The findings are: The facility policy titled Infection Control: Handwashing: revised 4/1/2022 documented hand hygiene prevents the spread of infections and personnel follow the handwashing/hand hygiene procedures. On 07/15/2022 at 12:06 PM, CNA #2 was observed in the Unit 4 dining room donning gloves and using sanitizer wipes to assist residents with hand hygiene prior to meal service. CNA #4 used a wipe to sanitize the hand of Resident #273, took a new wipe and sanitized the hands of Resident #261, took a new wipe and sanitized Resident #463's hands, and took another wipe and sanitized Resident #243's hands. CNA #4 was not observed performing hand hygiene in between sanitizing each residents' hands. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-21 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a quarterly assessment was not transmitted within 14 days after the completion date. This was evident for 1 of 5 residents reviewed for the Resident Assessment task out of a sample size of 38 residents. (Resident # 6) The finding is: The facility policy and procedure titled MDS/RAI Process and Coding Integrity revised in October 2019 documented it is the policy of this facility to provide an interdisciplinary approach in conducting and completing the Resident Assessment Instrument (RAI), including both OBRA and Prospective Payment System Assessments. All MDS activities are conducted in accordance with RAI Manual and Center for Medicare and Medicaid (CMS) guidelines. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure the resident's assessment accurately reflected the resident's status. Specifically, 1) a resident was coded as receiving Invasive Mechanical Ventilator care while a resident in the facility which the resident did not receive, and 2) weight loss of 10% or more in last six months was not captured for a resident who experienced a weight loss of 13.6%. This was evident for 2 of 4 residents reviewed for Resident Assessment Facility Task. (Resident # 51 and #220) The findings are: The facility policy titled MDS /RAI Process and Coding Integrity revised October 2019 documented accurate MDS coding is based on documentation in the medical record including but not limited to: disciplines notes and assessments; clinical assessments and flow sheets including CNA floor sheets, therapy assessment and progress notes; physician notes and orders; laboratory and other tests results; observations of the resident; communication with resident/patient and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-21 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that person-centered comprehensive care plan were revised and updated to reflect the current resident condition. Specifically, care plan was not revised to reflect that resident had a left heel pressure ulcer on admission that worsened. This was evident for 1 of 2 resident reviewed for Pressure Ulcer out of a sample size of 38 residents. (Resident #261) Complaint # NY 00244009 The findings are: The facility policy and procedure titled, Comprehensive Care Planning -Interdisciplinary Team dated October 2010 documented the duties and responsibilities of the Care Planning/Interdisciplinary Team include, but are not limited to 2. reviewing Care Plans to assure that a). they reflect the resident's medical and nursing assessment and 4. reviewing and revising the Care Plan as the resident's status changes. Resident #261 was admitted to the facility 07/24/19 with diagnoses that included Peripheral Vascular Disease, Diabetes Mellitus, Arthritis, Alzheimer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and staff interviews conducted during the recertification survey, the facility did not ensure that medications and biological were stored under proper temperature controls, were not dated when first accessed and were not discarded within 28 days of opening. This was evident during the Medication Storage Task on 2 of 10 units. The findings are: The facility policy Storage of Medications revised in December 2017 documented store drugs requiring refrigeration in the refrigerator specified for medication or medication administration supplies only, located in the medication room. The policy also documented drugs will not be kept on hand after the expiration date on the label. 1. On 10/16/2019 at 10:20 am, during the Medication Storage task an unopened bottle of Calcitonin Salmon Nasal Solution 3.7 ml was observed inside its box, stored in the top drawer of the medication cart on Unit 8, A label affixed to the packaging documented Calcitonin-Salmon refrigerate prior to use. Instructions in the pane on the box documented store unopened bottle in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2019-10-21 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that the survey results were posted in a place readily accessible to residents, resident representatives or legal representatives without having to ask for them. In addition, the facility did not post notice of the availability of the survey results in areas of the facility that are prominent and accessible to the public. Specifically, the survey results were located in a closed wooden credenza drawer in the corridor that housed administrative offices. The finding is: The facility policy and procedure titled Resident Right- Right to Survey Results/Advocate Agency Information effective Sep 2010 and revised August 2017 documented the facility will: 1. Post in a place readily accessible to resident/representatives/family members/visitors the result of the most recent survey of the facility and 3. Post the availability of such reports in areas of the facility that are prominent and accessible to the public. During multiple observations of prominent areas…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CARMELITE SISTERS FOR THE AGED AND INFIRMED — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.7 | -0.7 vs chain |
| Health inspection | 3 of 5 | 3.7 | -0.7 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 3.3 | +0.7 vs chain |
The other 2 homes this chain runs (chain average 3.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CARMELITE SISTERS FOR THE AGED AND INFIRM, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 06/14/1967 |
| ROMAN CATHOLIC DISOCESE OF BROOKLYN | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 03/18/1969 |
| BRENNAN, ROBERT | Individual | CORPORATE DIRECTOR | — | since 11/30/2021 |
| DEVLIN, LESLEE | Individual | CORPORATE DIRECTOR | — | since 06/11/2007 |
| DOMINO, LEDA | Individual | CORPORATE DIRECTOR | — | since 04/09/2025 |
| HALEY, MARGARET | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 04/09/2025 |
| HEERY, MARY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2015 |
| KASPER, ROSE | Individual | CORPORATE DIRECTOR | — | since 03/01/2015 |
| LYNCH, PATRICIA | Individual | CORPORATE DIRECTOR | — | since 05/02/1989 |
| MCALEER, MARTY | Individual | CORPORATE DIRECTOR | — | since 06/01/2018 |
| OGLE, SEAN | Individual | CORPORATE DIRECTOR | — | since 04/09/2025 |
| PFEFFER, THERESA | Individual | CORPORATE DIRECTOR | — | since 12/11/2023 |
| POWERS, KEITH | Individual | CORPORATE DIRECTOR | — | since 03/04/1997 |
| RANDALL, DIANE | Individual | CORPORATE DIRECTOR | — | since 01/01/2008 |
| REILLY, PATRICA | Individual | CORPORATE DIRECTOR | — | since 12/01/2013 |
| BOWDEN, MARY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2015 |
| FONTI, JOSEPH | Individual | CORPORATE OFFICER | — | since 05/09/2023 |
| GATHERS, PATRICIA | Individual | CORPORATE OFFICER | — | since 07/01/2021 |
| KEATING, PATRICK | Individual | CORPORATE OFFICER | — | since 05/27/2020 |
| THE CARMELITE SYSTEM, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/10/2013 |
| SONI, SHARAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2024 |
| MCWEENEY, BRIAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/01/2025 |
| O'BRIEN, DEBORAH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/01/2025 |
CMS files one row per role, so the 31 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.7M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335363. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-03, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.