Fishkill Center for Rehabilitation and Nursing
22 Robert R. Kasin Way, Beacon, NY 12508 · For profit - Corporation · 160 certified beds · (845) 831-8704 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $44,500 in federal fines (most recent 2024-01-11)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 2 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 | 13.9% | 14.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.7% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.2% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 36.6% | 19.5% | 6.5% | worse 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 | 2.1% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.6% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.0% | 13.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 6.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 34.8% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.6% | 13.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 91.6% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 12.1% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 2.0% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.47 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.43 | 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.
47.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 186 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.5% 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 132 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 47.6%CMS range 39.8–54.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 7.2–13.7 | 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 | 73.5% | 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 | 65.2% | 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 | 62.9% | 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 | 99.5% | 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 | 94.1% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 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 | 0.5% | 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 | 6.3%CMS range 3.8–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.28 | 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 160 beds and averages 153.3 residents a day — about 96% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 3.03 hrs/resident/day on weekends vs 3.59 on weekdays — 16% thinner on weekends. RN hours go from 0.59 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-01-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, during a recertification and extended survey from 1/2/2024 to 1/11/2024, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, a total of 26 residents on 2 of 2 resident floors were residing in 17 rooms where space heaters were in use (room M1, M2, R6, R2, R1, O1, O2, O3, O4, Q3, Q2, N1, N2 and N3 on the locked dementia unit with residents wandering in and out of the rooms, and rooms S1, S4, and X2). Additionally, facility staff reported that at times they had seen towels placed over the space heaters. Subsequently, residents were at risk for injury with the likelihood for harm or death that was Immediate Jeopardy (IJ) to the health and safety of the facility's 151 residents. The findings are: The facility admission History documented the facility admitted 21 residents in the month of October 2023, 21 residents in November 2023 and 13 residents in December 2023. These residents were admitted to rooms with heat. The undated policy titled Maintaining Electrical Equipment…
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.
- Actual harm · Gcited before2025-12-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for accidents. Specifically, a review of the facility's fall risk assessment revealed that on 08/12/2025, Resident #1 was identified as a high risk for falls and further review of the resident's medical record revealed that the facility failed to implement interventions to prevent the resident from potential falls or to mitigate harm from actual falls. On 09/27/2025, Resident #1, had a fall and was found in their room on the floor and sustained a swollen right eye, a hematoma to the right side of their forehead and a scratch to their right forearm. Resident #1 was transferred to the emergency room for further evaluation. This failure to implement interventions to prevent and or mitigate harm from falls resulted 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.
- Potential for harm · D2025-12-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (2650093), the facility did not ensure the residents representative were informed when there was a significant change in the resident's physical condition for 1 out of 3 residents (Resident #1) reviewed for notification. Specifically, Resident #1's had a fall and sustained injuries to the face, eyes and head on 09/27/2025. The family representative was not notified timely of the change in condition and physical status until they visited the resident on 10/30/2025. The findings are: The facility Accident and Incident policy last reviewed 02/12/2025 documented all accidents and incidents will be investigated and documented. The nurse manager or supervisor will notify the family or significant others regarding the accident or incident. Resident #1 was admitted with diagnoses including but not limited to Cerebral Infarction, Aphasia and Altered Mental Status. A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had severe cognitive…
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 before2025-12-26 · 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 during an abbreviated survey (2650093) the facility did not ensure the comprehensive care plans were reviewed, updated, and revised for 2 out of 3 residents (Resident #1, Resident #3) reviewed for care planning. Specifically, (1) Resident #1's cognitive impairment care plan had not been reviewed or updated since 10/18/2024. (2) Resident #3's cognitive impairment care plan had not been reviewed or updated since 08/27/2024.The findings are:The facility Comprehensive Care Planning policy last reviewed 02/14/2025 documented the interdisciplinary team: reviews care plans at a minimum of quarterly to ensure that all goals and interventions are current, appropriate and accurate and updates care plans as needed with changes in treatment, needs and conditions.1)Resident #1 was admitted with diagnoses including but not limited to Cerebral Infarction, Aphasia and Altered Mental Status.A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had severe cognitive impairment with…
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 · E2025-02-14 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review during the recertification survey conducted on 2/10/25-2/14/25, the facility did not ensure each staff and was screened, offered the most recent COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 10 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence Staff were offered, and education was provided for COVID vaccination for Dietary Aide #15, Housekeeping #16, Certified Nurse Aide #17, #18, #20, Licensed Practical Nurse #19, Registered Nurse #21, Social Worker #22, Dining Supervisor #23 and [NAME] #24. Findings include: The facility policy titled Management of COVID-19 and dated 11/30/24, documented the facility will offer consenting personnel the opportunity to receive any dose of the COVID-19 vaccine. Signage throughout the facility reminding personnel and residents that the facility offers COVID-19 vaccination will be posted. During an observation on 02/13/25 at 3:56 PM there were no visible signage promoting COVID-19 vaccination.…
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 before2025-02-14 · 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 observation and interview conducted during the recertification survey, the facility did not ensure that resident's dignity was maintained. Specifically,1) residents were being served milk and water in plastic storage cups with lids on 4 of 4 units (South 1, North 1, South 2 and North 2) and 2) and Certified Nurse Assistant #7 referred to Resident #26 as a feeder. In addition, a Resident progress note in the facility Electronic Medical Record also referred to Resident #26 as a feeder. The findings are: 1) Observations were made throughout survey from 2/10/25 to 2/14/25 on South 1, North 1, South 2 and North 2 units of residents being served milk and water out of plastic storage cups with lids. Observations were made on North 2 Unit on 2/10/25 at 12:24 PM and 2/11/25 at 12:21 PM, of residents being served milk and water out of plastic storage cups with lids. On 2/12/25 at 10:28 AM during the Resident Council Meeting 10 of 10 residents stated they were served milk and water in plastic storage cups and they preferred to use a hard plastic drinking cup. During interview 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 · D2025-02-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview conducted during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, North 2 unit rooms (S3, X1, X3, X6, V1, V3) had broken tiles, cracked walls, hanging curtains or damaged windows, the shower room had a damaged drain and the the hall window was open, resulting in the resident in room V3 offering complaints of feeling cold. The Findings include: During observation on 2/10/25 at 10:09 AM room X6 tiles under the bed were broken and chipped. During observation on 2/10/25 at 10:15 AM room X3 tiles under the closet were damaged. During observation on 2/10/25 at 10:16 AM room V1 had a cracked wall at the bottom right corner of window. During observation on 2/12/25 at 12:16 PM room V3, resident complained it was cold and the thermometer in the room registered 74 degrees. The hall window was open and blowing cold air into the room. During observation on 2/12/25 t 12:17 PM room S3 window curtain was hanging off the window. There was no documented evidence of a work order…
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 before2025-02-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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, interview, and record review during the Recertification Survey from 2/10-2/14/25 the facility did not ensure comprehensive person centered care plans were developed for 1 of 3 residents (#37) reviewed for Limited Range of Motion. Specifically, Resident #37 did not have a care plan with goals and interventions specific to the use of a cervical collar. The findings include: The Facility Policy titled Comprehensive Care last reviewed 7/2/2024, documented the facility will develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Resident #37 was admitted with diagnoses including but not limited to Alzheimer's Disease, Fracture, and Heart Failure. The Nursing Progress Note dated 1/4/25 documented Resident #37 was received at the facility at 4:30 PM, cervical collar in place. Cervical collar to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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, interview, and record review during the recertification survey from 2/10/25-2/14/25, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 1 (Resident # 15) residents reviewed for pain management. Specifically, there were multiple omissions on the medication and treatment administration records for medications and treatments related to pain management for Resident #15. The findings include: The policy titled Administering Medications dated 4/20/2021 documented medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication will document that the medication was administered. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the refusal. Resident #15 was admitted to facility with diagnoses that included Coronary…
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 · D2025-02-14 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review during the recertification survey from 02/10/25 through 02/14/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, three of five Certified Nurse Aides (#2, #3, #4) did not have a performance review documented at least once every 12 months. Findings include: There was no documented evidence that performance reviews were completed in the last 12 months for Certified Nurse Aide #2 with a hire date of 2020, Certified Nurse Aide #3 with a hire date of 2018 and Certified Nurse Aide #4 with a hire date of 2017 During an interview on 2/13/25 at 10:42 AM the Human Resource Director stated unit supervisor/s were responsible for completion of Certified Nurse Aide performance reviews. The Human Resource Director stated Certified Nurse Aide performance reviews should be filed in employee folders, once completed. The Human Resource Director stated they did not realize Certified Nurse Aide performance reviews were not completed for Certified Nurse Aide #2, #3 and #4. During an…
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 · D2025-02-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the recertification and abbreviated surveys (NY00341482) conducted from 1/10/25 to 1/14/25, the facility did not ensure residents were free from significant medication errors for one of one residents (Resident #399) reviewed for Neglect and Medications. Specifically, staff administered a medication not physician prescribed to Resident #399 which resulted in Resident #399 being transferred to an acute care hospital for evaluation. The findings include: Resident #399 was admitted with diagnoses including but not limited to Chronic Hepatitis C, Diabetes Mellitus, and Liver Cirrhosis. The facility policy titled Administering Mediations dated 4/20/21 documented: medications are administered in a safe and timely manner, and as prescribed. The individual administering medications verifies the resident's identity before giving the resident their medications. Methods of identifying the resident include: a. checking identification band; checking photograph attached to medical record; and c. if necessary, verifying resident identification with 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 · Dcited before2025-02-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview conducted during the recertification survey from 2/10/25 through 2/14/25 the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, beverages stored in nutrition and storage refrigerator/s were not labeled and were outdated, and a parcel of flour was left open not dated on the shelf. Findings include: The facility policy titled Food Receiving and Storage dated 6/26/2028 documented dry foods that are stored in bins will be removed from the original package, labeled and dated (use by date). Beverages must be dated when opened and discarded after 3 days. Other opened containers must be dated and sealed or covered during storage. An initial tour of the kitchen was conducted on 2/10/25 at 9:50 AM and the following were observed: - unlabeled 4 ounce cups were filled with white liquid dated 2/4, in the nutrition and storage refrigerator. - unlabeled 4 ounce cups were filled with brown liquid dated 2/4, in the nutrition and storage refrigerator. - unlabeled 4 ounce cups with thickened yellow…
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 18 citations
- Potential for harm · D2025-02-14 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview conducted during the recertification survey conducted 2/10/25 through 2/14/25, the facility did not ensure proper disposal of garbage and refuse. Specifically, the garbage compactor /dumpster was left open and there were large metal containers, old furniture, and debris on the ground around the dumpster. The findings are: The facility policy titled Food-Related Garbage and Rubbish Disposal dated 6/26/24 documented all garbage and rubbish containers should be provided with tight fitting lids or covers and must be kept covered when stored. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter. During an observation on 2/12/25 at 10:10 AM: -cardboard boxes in the dumpster and the dumpster was left open. -compactor was filled with old furniture and was left open -old furniture, large metal containers and debris were on the ground around the dumpster. During an interview on 2/14/25 at 9:31 AM, the Administrator stated the maintenance department were responsible for ensuring the dumpster…
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 · D2025-02-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 conducted 02/10/25-02/14/25, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 5 residents (Residents #9, #50) reviewed. Specifically, there was no documented evidence Resident #9, and Resident #50 were offered, declined, or educated about the pneumococcal immunization. Findings include: The facility policy for Pneumococcal Vaccination dated 10/01/2007 and last reviewed 1/4/2025 documented, in order to prevent the spread of infectious disease and to mitigate the risk of morbidity and mortality associated with pneumococcal pneumonia, the facility will offer pneumococcal vaccinations to all residents and staff. Resident #9 had diagnoses including Morbid Obesity, Type II Diabetes Mellitus and Major Depressive Disorder. The Minimum Data Set, an assessment tool, dated 12/2/24 documented the resident was cognitively…
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 · E2024-01-11 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Observation, record review and interview conducted during the recertification survey (1/2/24-1/11/24) the facility did not ensure that operative oversight for an effective system was in place to maintain health, safety, and the highest practicable well-being of residents reviewed for accidents. Specifically, space heaters were in use for 26 residents in 17 rooms (M1, M2, N1, N2, N3, R1, R2, R6, O1, O2, O3, O4, Q2, and Q3 on the locked dementia unit with residents wandering in and out of the rooms) and rooms S1, S4, X2. The findings are: Review of the undated policy titled Electrical Safety for Residents documented portable space heaters are placed in the facility only on a case-by-case basis. The heaters would be inspected on a weekly basis by the Director of Maintenance or designee. Results of inspection will include vacuuming the unit, inspection of cords and touch test of placing hand unit. During an observation on 1/2/24 at 10:00 AM of the locked dementia unit, which houses residents diagnosed with dementia space heaters were found in 11 out of 28 residents' rooms M1,…
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 · E2024-01-11 · tag F0837 — patternEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews conducted during the recertification survey (1/2/2024-1/11/2024), it was determined the governing body did not establish and implement policies regarding the management and operation of the facility. The governing body did not maintain consistent communication with the Administrator who was responsible for the management of the facility to ensure regulatory compliance. Specifically, multiple deficiencies were identified on the recertification survey including in the areas of accidents and hazards (F689), and space heaters not permitted (K781). Findings include: The policy titled Administrative Management (governing board) dated 2/17/2021: documented the governing board shall be responsible for the management and operation of the facility. Review of the undated policy titled Electrical Safety for Residents documented portable space heaters are placed in the facility only on a case-by-case basis. The heaters would be inspected on a weekly basis by the Director of Maintenance or designee. Results of inspection will include vacuuming…
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 before2024-01-11 · 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, interviews, and record review during a recertification survey 1/02/2024-1/11/2024, the facility did not ensure residents had the right to a dignified existence for 6 residents (#38, #69. #80, #139 #82 and #98) observed during dining observation. Specifically, Residents #38, #69 and #80, were observed being fed by staff while staff were standing over the residents, Resident # 139 was heard being called a feeder by staff and Residents #82 and #98 had blood drawn in the common diningroom/dayroom while in the presence of other residents. The findings are: The facility policy for Assistance with Meals dated 2/1/17 documented residents who cannot feed themselves will be fed with attention to safety comfort and dignity, for example, not standing over residents while assisting them with meals. The facility's policy titled residents rights dated 2//5/21 documented residents have a right to a dignified experience and be treated with respect, kindness, and dignity. 1. Resident #38 had diagnoses including but not limited to Alzheimer's Disease, Hypertension, and Dementia.…
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 · D2024-01-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview conducted during the recertification and abbreviated surveys (# NY00320640) from 1/2/2023 to 1/11/2024, the facility did not ensure all injuries of unknown origin were thoroughly investigated for 1 of 2 residents reviewed for abuse. Specifically, Resident #54 had an injury of unknown origin was not thoroughly investigated to rule out abuse. The investigation did not include interviews or statements from staff working with the resident. Findings include: Resident # 54 was admitted with diagnoses including Dementia, Coronary Artery Disease, and anemia. A review of the Policy and Procedure Prevention/Prohibition of Abuse, Neglect, Mistreatment, Exploitation, injury of unknown source and Misappropriation of Property dated 12/1/2017 and revised on 11/1/2019, documented the facility shall conduct a thorough investigation of all alleged violation/sexual abuse involving mistreatment, neglect or abuse including injuries of unknown origin. A Quarterly Minimum Data Set (MDS) documented Resident #54 had severely impaired cognition and required supervision…
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 before2024-01-11 · 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
F657 Based on record review and interview conducted during the recertification survey, from 1/2/24 through 1/11/24, the facility did not ensure that the comprehensive care plan was reviewed and revised in timely manner for 1 of 3 residents (Resident #69), reviewed for care planning revision. Specifically, Resident #69's care plan was not updated as planned to reflect the need of a 2 person assist for personal cares after a fall. Findings include: Resident #69 was admitted to the facility with diagnoses and conditions including but not limited to Unspecified Dementia, Cerebral infarction and Osteoarthritis. Review of the care plan Activities of Daily Living (ADL) dated 11/21/23 documented bathing provide 1 person assist with personal hygiene/bathing to complete tasks. Review of Accident/Incident report dated 10/9/23 documented, resident rolled off the bed when while receiving personal care, being assisted by 1 staff. The recommendation was for the resident to be assisted by 2 staff, for personal cares, for safety intervention. Review of the progress note dated 10/10/23 documented to…
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 · D2024-01-11 · 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, interview and record review conducted during a recertification survey from 1/2/24 to 1/11/24, the facility did not ensure residents received the necessary assistance for bathing to maintain personal hygiene for 2 of 4 residents (Residents #12 and #88), reviewed for activities of daily living (ADLs). Specifically, Resident #12 and #88 did not receive twice weekly showers as scheduled. Findings include: The facility policy dated 3/1/2017 for Bathing /Showering documented showering and bathing were to promote cleanliness, provide comfort to the resident and to observe the condition of the skin. 1) Resident # 12 was admitted to the facility on [DATE] with diagnoses including Hypertension, Diabetes and Bipolar Disorder. The residents Minimum Data Set (an assessment tool) dated 12/12/23, documented the resident was cognitively intact, had moderately impaired vision, and a shower/bath was very important to them. The assessment documented the resident needed partial/moderate assistance with…
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 · D2024-01-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 1/2/2024 through 1/11/2024, the facility did not ensure 1 of 1 resident (Residents #100) reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #100 was observed on multiple occasions not wearing their heel lift suspension booties and oxygen tubing ear protectors as per physician orders. Findings include: The facility's policy titled wound care dated 5/12/2022 documented the purpose of this procedure was to provide guidelines for the care of wounds to promote healing. Resident #100 was admitted to the facility with diagnoses including but not limited to chronic kidney disease, dementia, and parkinson's disease. The 10/23/2023 Minimum Data Set (MDS) assessment documented Resident #100 had severe cognitive impairment, had one stage two pressure ulcer present on admission, one unstageable pressure ulcer present 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 before2024-01-11 · 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 interview conducted during a Recertification Survey from 1/2/24-1/11/24, the facility did not ensure that all drugs and biologicals were stored in accordance with professional standards. Specifically, medication carts on the S1 unit were observed unlocked and unattended on 2 separate occasions, and morning medicines were left in Resident #99's room. The findings are: The facility policy for Administering Medications dated 4/20/21 documented during administration of medications, the medication cart is to be kept closed and locked when out of sight of the medication nurse. During an observation on 1/2/24 at 02:50 PM on the S1 unit the medication cart was unlocked. At the time of observation the medication cart was unattended by the nurse. During an interview on 1/2/24 at 2:55 PM Staff #13 (Licensed Practical Nurse) stated the cart was unlocked when they walked away to give medications to another resident. Staff #13 stated it was a bad choice because they might have been detained for a long period of time and anyone in the hallway could have…
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 before2023-12-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 conducted during a complaint survey (#NY00290874), it could not be ensured that the facility developed a person-centered care plan that included measurable objectives, time frames and interventions in order to maintain the residents ' safety for 1 of 1 resident reviewed for physical abuse. Specifically, no comprehensive care plan was found in the record to address the risk for abuse for the resident who had been identified as displaying behaviors, had mood scores indicating moderate or moderately severe depression, brief interview for mental status scores indicating moderately impaired cognition, diagnoses of progressive neurological condition, anxiety, and depression, and functional limitations in activities of daily living. The findings are: The Resident was admitted with diagnoses including progressive neurological conditions, paraplegia, anxiety disorder, and major depressive disorder. The admission Minimum Data Set (MDS: an assessment tool) dated 11/29/2021…
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 before2023-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an abbreviated survey (NY00316307), the facility did not ensure that a resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident #1) reviewed for accidents. Specifically, Resident #1 had multiple incidents of falls in the facility and the interventions in place to prevent falls was not reevaluated to prevent subsequent falls. Fall risk assessments were not updated after falls. On [DATE], Resident #1 fell and refractured their left hip which was repaired on [DATE]. Facility X-Ray findings documented Resident #1 sustained an acute markedly midshaft displaced fracture of the left mid femur. Resident #1 was discharged to the emergency room for higher level of care. The Findings are: Review of facility policy on Accidents and Incidents revised on [DATE] documented that the facility will ensure that the residents environment remains as free from accident hazards as is possible while providing adequate…
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 before2020-02-28 · 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 observation, interview, and record review conducted during a recertification survey, the facility did not ensure that care was provided in a manner to maintain dignity for 1 of 1 resident (Resident # 87) reviewed for urinary catheter. Specifically, the resident's urinary drainage bag and tubing were not concealed to prevent direct observation by other residents and visitors. The Findings are: Resident #87 had diagnoses and conditions not limited to Schizophrenia, Urinary Retention, and Benign Prostatic Hyperplasia (BPH). According to the 11/29/2019 Annual Minimum Data Set (MDS; an assessment tool), the resident had moderate impaired cognition and used a urinary catheter for urine output. A Suprapubic Foley Catheter Care Plan updated 1/1/2020 had goals, not limited to maintaining the resident's dignity. Interventions included to ensure that the urinary drainage bag is always covered and to provide privacy and dignity at all times. The resident was observed in bed on 2/24/2020 at 11:11AM, 2/25/2020 at 9:56AM, and 2/25/2020 at 11:13AM. On all occasions, the resident's urinary…
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 before2020-02-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 that care plan interventions were implemented for resident #123. Specifically, a positioning device identified in the care plan was not provided to the resident on a consistent basis. This was evident for 1 of 2 residents reviewed for position/mobility. The findings are: Resident #123 was admitted to the facility with diagnoses including Coronary Artery Disease, Diabetes Mellitus, Hyperlipidemia, Dementia, Psychotic Disorder, Dysphagia and Muscle Weakness. The Minimum Data Set (MDS; an assessment tool) significant change assessment dated [DATE] indicated that the resident required extensive assistance of one person for bed mobility and eating, extensive assistance of two for transfers and total assistance of one for toileting. Surface to surface transfer (transfer between bed and chair or wheelchair) was coded 2 - not steady, only able to stabilize with human assistance. The plan for Activities of Daily Living (ADLs) initiated 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 · D2020-02-28 · 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
Based on observations, interviews and record reviews conducted during a recertification survey, it was determined that for one (Resident #55) of two residents reviewed for respiratory care, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice, and the comprehensive person-centered care plan. Specifically, the resident was being administered oxygen at a liter flow greater, and at a frequency greater than the current physician's order. The findings are: Resident #55 was admitted to the facility with diagnoses including but not limited to Diabetes Mellitus, Barrett's Esophagus, and Hypertension. The 12/3/2019 Quarterly MDS revealed that Resident #55 was cognitively intact and received oxygen therapy. Review of the 2/2020 Physician's Orders included oxygen via nasal cannula (n/c) at 2 LPM (Liters Per Minute) as needed (PRN). Review of the February 2020 Treatment Administration Record (TAR) revealed that the PRN oxygen order had no signatures reflecting physician's approval for the use of 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 before2020-02-28 · 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 observations, interview and record review during the most recent recertification, the facility did not ensure that medications were secured in a locked storage area. Specifically, a medication cup with 4 pills was observed on a resident's bed not under direct supervision of authorized staff. The findings are: Resident #79 was admitted to the facility with diagnoses including but not limited to Hypertension, Neurogenic Bladder and Multiple Sclerosis. The 10/22/19 Annual Minimum Data Set (MDS; an assessment tool) showed that Resident #79 was cognitively intact. An observation on 2/25/2020 at 9:05 AM revealed that Resident #79 was in his room eating breakfast while a medication cup containing 4 pills was resting on top of the resident's bed. During interview on 2/25/2020 at 9:07AM with Resident #79, he shared that the nurses leave medications at the bedside all the time. An interview was conducted on 2/25/2020 at 9:08AM with the Licensed Practical Nurse (LPN #2) who stated that she left the medication with Resident #79 because she needed to use the rest room. When asked what…
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 before2020-02-28 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview during the recent recertification survey, the facility did not ensure that food items brought in for residents from the outside were labeled and dated appropriately and discarded within the required time frame. This was evident for 2 of 4 resident units. The findings are: The North 1 and South 2 unit refrigerators were observed on 2/28/2020 at 3:10 PM. The following was noted: North 1 unit refrigerator: Two sandwiches in the refrigerator were undated. The LPN present stated that the sandwiches were brought in by family members for residents and that the families forget to put dates on the food. He further stated that the night staff is responsible for monitoring the food in the refrigerator. South 2 unit refrigerator A plastic container of a tan, soft substance was dated 2/24 (4 days old). There was a container of cottage cheese that had been opened but not dated when opened. The CNA did not know when the container had been opened and stated she would bring it up with the family when they come in. The CNA present stated that the policy is to throw…
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 · D2020-02-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the most recent re-certification survey, the facility did not ensure that care was provided in a manner to minimize the spread of infection. This was evident during the care of 1 resident (Resident #128) reviewed for transmission based infection and for 1 of 3 residents (Resident #390) reviewed for pressure sores. Specifically, 1) a certified nurse aide did not implement the use of personal protective equipment (PPE) while providing care to Resident #128 on contact precautions for Clostridium (C.) difficile; and 2) a Licensed Practical Nurse (LPN #1) did not follow proper procedure in hand hygiene and prevention of cross contamination during a wound care procedure. The findings are: 1. Resident #128 was admitted to the facility on [DATE] with the diagnosis of Schizophrenia. At the time of admission the resident was positive for C. difficile. A laboratory report dated 2/9/20 revealed that the resident tested negatively for C. difficile and per…
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
$44,500 in federal fines across 1 penalty.
- $44,500 — penalty dated 2024-01-11
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SAPPHIRE CARE GROUP — 8 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 | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 7 homes this chain runs (chain average 2.6★, 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 |
|---|---|---|---|---|
| ABRAMCZYK, MACHLA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 04/26/2017 |
| FARKOWITZ, ESTHER | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 04/26/2017 |
| PLATSCHEK, RICHARD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 33% | since 04/26/2017 |
| SCHUCK, ROBERT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 13% | since 04/26/2017 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M 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 335750. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-14, 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.