Briarcliff Manor Center For Rehab And Nursing Care
620 Sleepy Hollow Road, Briarcliff Manor, NY 10510 · For profit - Partnership · 120 certified beds · (914) 941-5100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, 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 (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $97,282 in federal fines (most recent 2025-06-20)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 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
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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 | 4 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 1 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 | 10.9% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.6% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.2% | 1.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 84.0% | 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 | 2.4% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.3% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.7% | 13.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 95.4% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.7% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 0.9% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.1% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.1% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 17.7% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.0% | 9.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.89 | 1.70 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.81 | 1.36 | 1.80 | typical |
‡ 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.
59.9% 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 269 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.2% 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 157 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 59.9%CMS range 53.4–64.5 | 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 | 9.6%CMS range 7.0–13.0 | 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 | 66.2% | 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 | 68.2% | 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 | 67.5% | 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 | 92.5% | 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 | 88.8% | 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 | 94.1% | 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 | 0.0% | 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 | 4.2% | 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 | 8.9%CMS range 6.2–11.8 | 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 120 beds and averages 110.7 residents a day — about 92% occupied, or roughly 9 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 3.13 hrs/resident/day on weekends vs 3.27 on weekdays — 4% thinner on weekends. RN hours go from 0.53 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 unchanged from the previous inspection. 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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2023-09-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review during an abbreviated survey (NY00324542), the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #1 and Resident #2) reviewed for anti-seizure medications. Specifically, Resident #1 had a physician's order for Vimpat (controlled antiseizure medication) 200 milligrams (mg) 1 tab every 12 hours at 9AM and 9PM daily, and over three days in 08/2023 and four days in 09/2023. A total of 12 doses of Vimpat were not administered to Resident #1. Resident #2 had a physician's order for Keppra (anti-seizure medication) 1000 mg 1 tab every 12 hours at 9AM and 9PM daily, and over six dates a total of 7 doses of Keppra were not administered to Resident #2. Subsequently, Resident #1 suffered a seizure on 9/17/23 at 3:45 PM and was transferred to the hospital. This resulted in actual harm for Resident #1 which was Immediate Jeopardy and Substandard Quality of care with the likelihood of risk for harm to the health and safety…
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 · G2025-06-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during the abbreviated survey (NY00383393), the facility did not ensure a resident remained free from physical abuse. This was evident for one (1) (Resident #1) of four (4) total sampled residents. Specifically, Resident #1 reported they were hit in their groin by Certified Nurse Aide #3 on 6/11/2025 at approximately 1:30 AM. This resulted in psychosocial harm that did not rise to level of Immediate Jeopardy. The findings are: The facility policy titled Abuse Prevention & Reporting, dated 1/3/2025, documented any employee involved in abuse will be disciplined appropriately. Resident #1 had diagnoses of hydrocephalus (fluid on the brain) and major depressive disorder. The Minimum Data Set 3.0 assessment (an assessment tool) dated 5/16/2025 documented Resident #1 presented with mild cognitive impairment with a Brief Interview for Mental Status score of 14 out of 15. The Comprehensive Care Plan related to victimization, initiated 5/10/2025 and last reviewed on 6/16/2025, documented Resident #1 would verbalize feeling safe.…
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 before2025-03-12 · 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 during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure residents had the right to a dignified experience for 1 of 4 residents (Resident #24) reviewed for dignity. Specifically, Resident #24 was observed multiple times after meals with food/crumbs on their chin and their gown. The findings include: Resident #24 had diagnoses including cerebral infarction (stroke), hemiplegia affecting left non dominant side, and dementia. A Resident Care Plan dated 3/30/21 titled Activities of Daily Living documented the resident required a one person assist with bathing, partial/moderate assistance for upper body dressing, and supervision or touching assistance for eating and personal /general hygiene. The Quarterly Minimum Data Set (an assessment tool) dated 12/26/24 documented Resident #24 had moderate cognitive impairment, upper and lower extremity impairment on one side and required supervision/touching assistance with eating and hygiene. During an observation on 3/05/25 at 10:35 AM, Resident #24 was observed 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 · D2025-03-12 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, and interviews conducted during a recertification survey from 03/05/2025 to 03/12/2025, the facility did not ensure that the residents' advance directives were accurate for 1 (Resident # 82) of 24 residents reviewed. Specifically, Resident #82's Medical Orders for Life Sustaining Treatment form was changed from Do Not Resuscitate (allow a natural death if the heart stops beating or resident stops breathing) to Full Code (perform Cardio-Pulmonary Resuscitation) and the physician orders and facility identifiers (system used to alert staff the resident's code status) were not updated to reflect the resident's wishes. The findings include: The facility policy, Advanced Directives, with a 12/13/2024 review date, documented the individual's wishes on advance directives will be identified and honored by the facility. All Do Not Resuscitate orders must align with the corresponding Medical Orders for Life Sustaining Treatment documentation to maintain accuracy in the resident's care preferences. A Do Not Resuscitate alert will be placed in the resident'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 · D2025-03-12 · 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 conducted from 3/5/25 to 3/12/25, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, room C-19-B had broken window clips, room C-9-B had a broken radiator cover, a window shade that was stained, and black scuff marks on the wall between the window and resident dresser, room A-17 had a faulty window unit and faulty sealed Packaged Terminal Air Conditioner unit which allowed cold outside air to enter the room. The findings include: The facility policy titled Maintenance/Engineering policy dated 7/24/24 documented provide a safe, functional and effective environment for residents, staff and all individuals who provide care to residents and all individuals who visit the facility. During an observation on 03/06/25 at 12:08 PM of room C-19-B, a hand-written sign was observed on the lower left side of the window stating Do not open this window. A piece of the broken window opening latch was observed on the windowsill. During an observation on 03/06/25 at…
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 · D2025-03-12 · 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 observations, interviews and record reviews conducted during a recertification survey from 3/5/25 to 3/12/25 it was determined that for 1 of 1 residents (Resident #10) reviewed for skin conditions the facility did not ensure that injuries of unknown origin were reported to the state agency. Specifically, the state department was not notified after the 3/4/25 Accident/Incident Report documented Resident #10 was observed with discoloration that suddenly appeared on the right side of the resident's face. The findings include: Resident #10 was admitted with diagnoses including Congestive Heart Failure, Non-Alzheimer's Dementia, and Seizure Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 had severely impaired cognition, required partial to moderate assist for bed mobility and transfer; it further documented and had no falls. The 2/18/25 Accident/Incident report documented the resident was being given care by the certified nurse aide when the resident 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.
- Potential for harm · Dcited before2025-03-12 · 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 interview conducted during the recertification survey from 3/5/25-3/12/25, the facility did not ensure each Resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 2 (Residents #52 and #57) of 3 Residents reviewed for Activities of a Daily Living. Specifically, Resident #52 and #57 who required dependent assistance with Activities of Daily Living, were observed during multiple observations with fingernails that were long and ungroomed. The findings include: The facility policy titled Activities of Daily Living, reviewed 7/28/24, documented: It is the policy of this center to provide activity of daily living care to all Residents based on assessment of needs. 1) Resident #52 was admitted [DATE]. Diagnoses included quadriplegia, abnormalities of gait and mobility, and major depressive disorder. The Annual Minimum Data Set (a resident assessment tool) dated 1/2/25 documented Resident #52…
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 · D2025-03-12 · 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 observation, interview, and record review during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure appropriate care was provided in accordance with professional standards of practice for 1 of 1 residents (Resident #10) reviewed for Skin Conditions. Specifically, on 2/18/25 the registered nurse was not made aware, and there was no documented evidence that a registered nurse assessment was conducted after Resident #10 was hit in the face with the bed control while cares were being provided by Certified Nurse Aide #7. The findings include: Resident #10 was admitted to the facility with diagnoses including Congestive Heart Failure, Non-Alzheimer's Dementia, and Seizure Disorder. The 2/18/25 Accident/Incident Report documented Resident #10 was being given care by the Certified Nurse Aide when the resident was playing/fidgeting with the bed controls, and it suddenly swung into the resident's face. It further documented a nurse was notified and no injury was noted. Resident #10…
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 · D2025-03-12 · 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, record review and interviews conducted during the Recertification survey from 3/5/2025 to 3/12/25, the facility did not ensure that 1 of 2 residents (Resident #34) reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice. Specifically, Resident #34, had a physician's order for oxygen to be administered via nasal cannula at 3 liters per minute, and was observed multiple times with the oxygen rate not consistent with the physicians' order. Additionally, there was no signage present indicating oxygen was being utilized in Resident #34's room. The findings include: The facility policy titled Oxygen Administration last revised on 10/29/24 documented to verify that there is a physician's order; place an oxygen in use sign on the outside of the room entrance door; and turn on the oxygen on at the prescribed rate. Resident #34 had diagnoses including shortness of breath, depression, acute and chronic respiratory infarction. The Quarterly Minimum Data Set (a resident assessment tool) dated 12/19/24 documented…
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 before2025-03-12 · tag F0725 — failed to have enough nursing staff — isolatedProvide 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
Based on interview, and record review conducted during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure that sufficient staff was available to meet the needs of all residents on 30 days reviewed. Specifically, actual staffing levels were below minimum levels on the following dates (2/2/2/25, 2/3/25, 2/4/25, 2/8/25, 2/9/25, 2/10/25, 2/12/25, 2/16/25, 2/17/25, 2/24/25, 2/25/25, 3/1/25, and 3/3/25). The findings include: The Minimum Par Levels for Nursing Sheets documented the 7AM -3PM shift for unit A should have at least 4 Certified Nurse Aides, Unit B should have at least 3 Certified Nurse Aides, and unit C should have at least 3 Certified Nurse Aides, the 3PM-11PM shift for unit A should have at least 3 Certified Nurse Aides, unit B should have at 3 Certified Nurse Aides, and unit C should have at least 2 Certified Nurse Aides, and the 11PM-7AM shift for unit A, unit B and unit C should have at least 2 Certified Nurse Aides. The February 2025 daily staffing sheets documented 2/2/25 11AM - 7PM 1 Certified Nurse Aides on Unit B when the minimum requirement…
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 · D2025-03-12 · 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 interview and record review during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure that 5 of 5 randomly selected Certified Nurse Aides (Certified Nurse Aides #17, 18, 19, 20 and 21) received at least 12 hours per year of in-service education. Specifically, Certified Nurse Aides #17, 18, 19, 20, and 21 received only 10 of the 12-hours mandatory in-service training. The findings include: During an interview on 3/11/25 at 3:33 PM, the Director of Nursing was requested to provide the training records of 5 Certified Nurse Aides. Certified Nurse Aide #17 was hired 3/15/23 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. Certified Nurse Aide #18 was hired 8/5/14 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. Certified Nurse Aide #19 was hired 3/17/09 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. Certified Nurse Aide #20 was hired 10/24/23 and received 10…
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 · D2025-03-12 · 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 interviews during the recertification survey conducted 03/05/25-03/12/25, the facility did not ensure each resident was offered pneumococcal immunizations and education regarding the benefits and potential side effects of the immunizations for 2 of 5 residents (Residents #1, #24) reviewed. Specifically, there was no documented evidence that Resident's #1 and #24 were offered, declined, or received education regarding the pneumococcal immunization. The findings include: The facility policy titled Pneumococcal vaccinations (last reviewed 7/3/24) 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 #1 had diagnoses including cerebral palsy, osteoporosis, and heart disease. The Quarterly Minimum Data Set (a resident assessment tool) dated 1/2/25 documented Resident #1 had intact cognition. There was no…
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 21 citations
- Potential for harm · D2025-03-12 · 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 conducted during recertification and abbreviated survey (NY00365960) from 03/05/2025 to 03/12/2025, the facility did not ensure that the resident's care plan was reviewed and revised timely for 1 of 2 residents (Resident #164) reviewed for falls. Specifically, Resident #164's care plan was not reviewed or updated to reflect new interventions after a medical assessment on 11/29/24 and a fall on 12/2/24. The findings include: Resident #164 was admitted to the facility with diagnoses including intracranial injury, benign prostatic hyperplasia, and weakness. The admission assessment dated [DATE] documented Resident #164 had three or more falls in the last three months and had balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, and jerking or unstable when making turns resulting in a Fall Risk Assessment score of 21 (High Risk for falls). The 11/26/24 Care Plan Report documented risk…
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 before2025-03-12 · 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
Based on observation, record review, and interview conducted during the recertification and abbreviated survey (NY00365646) from 3/5/24 to 3/12/24, it was determined the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #165) reviewed for accidents. Specifically, a two (2) person assist was not provided as per care plan resulting in Resident #165 rolling to the floor from the bed and sustaining a laceration/abrasion to their forehead, bridge of nose, and left hip. The findings include: Resident #165 was admitted to the facility with diagnoses including hypotension, pneumonia, and malnutrition. The November 2024 Certified Nurse Aide Instructions documented resident required one- person physical assistance for bed mobility and bathing. The Activities of Daily Living Care Plan with a revision date of 11/28/24 documented dependent for bathing and required 2-person physical assist for bathing and bed mobility, half side rails to be used as enablers for bed mobility. The December 2024 Certified Nurse Aide Instructions…
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 · D2025-01-17 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 (#NY00344591), the facility did not ensure the residents' right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. This was evidence for 1 (Resident #1) of 3 reviewed. Specifically, the facility changed Resident #1's rooms without providing the residents with advanced written notification. The findings are: The facility Policy entitled Room Change Policy and Procedure last reviewed 12/20/24, documented that the social worker will 2. Give the resident, designated representative/family member notification prior to changing their room. 7. Will document room changes and transfers in the resident's medical record. This Policy does not reflect that the resident has the right to receive written notification before being transferred to another room. Resident #1 was admitted with diagnoses that included Aftercare following joint replacement surgery, obesity, essential…
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 before2024-04-19 · 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 observation, interview, and record review during an abbreviated survey (NY00335256) conducted on 4/5/24, the facility did not ensure the environment remained as free of accident hazards as possible for 1of 3 residents reviewed for accidents. Specifically, the certified nursing assistant providing caring to Resident #1 did not request the assistance of another staff member during transfers from the toilet to the wheelchair to ensure safety. Resident #1 fell to the floor. No injuries documented upon assessment post fall. Findings include: The Resident #1 was admitted with the following diagnoses including nontraumatic intracerebral hemorrhage, Hypertension, Type 2 Diabetes, and peripheral vascular disease. The Minimum Data Set (an assessment tool) dated 3/8/24, revealed the resident had severely impaired cognition, had an impairment on one side of the body for the upper and lower extremities, required substantial/maximum assistance with toileting, transfers, and bathing. Review of the certified nurse aide…
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 · Ecited before2024-02-02 · 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
Based on observation, interviews and record review conducted during the recertification and abbreviated survey (00325156) from 1/28/24 to 2/2/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during confidential interviews and the group meeting (Resident Council) a of lack of staff to respond to call bells and provide assistance with activities of daily living; 2) multiple nursing staff members reported a lack of sufficient staffing; and 3) analysis of the actual staffing schedule showed that on multiple occasions during the month of January 2024, the facility was below the minimum levels documented on the Facility Assessment. Findings include: During a Resident Council meeting on 1/30/24 at 10:11 AM, most of the 10 residents complained that when administration left in the evening, the aides did not care about them. They reported the staff did not respond to call bells and one resident stated they tested the call bell system and it took 2 hours for 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 · E2024-02-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the recertification survey from 1/28/24-2/2/24, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, the metal shelves in a deep freezer that stores food was peeling, there was unlabeled and undated roast beef in a large metal pan located in the walk in refrigerator, there was 20 pounds of undated ground beef in the walk in freezer, the metal shelves in the reach in refrigerator had brownish crusty peelings where desserts, juices, and sandwiches were stored, a metal container in the reach in refrigerator containing mixed fruit was not completely covered, the cook on the tray line was not wearing a beard covering, one food service staff did not follow safe food handling practices while recording food temperatures, dishware was not clean and dry, 1 of 2 nourishment refrigerators were not maintained at safe temperatures for food safety, and 2 of 2…
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 · E2024-02-02 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview during the recertification survey from 1/28/24 - 2/2/24, the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, there was garbage on the ground surrounding the compactor, and the area was not maintained in a sanitary condition to prevent harborage and feeding of pest. Findings include: The facility policy titled Garbage Disposal dated 11/1/18 documented all facility garbage will be handled in the same manner through use of trash compactor. Garbage should never be overfilled and must always have an appropriate fitting cover. All garbage will be place into the trash compactor for disposal. During an observation on 01/30/24 at 02:38 PM garbage was observed on the ground surrounding (front, sides, and back of) the garbage compactor. There were clear plastic cups and utensils, one coca cola can, an empty 4 ounce chocolate ice cream container, multiple 4 ounce empty juice cups, multiple pairs of used blue and clear gloves, straws, plastic cellophane wrap and bags, ripped cardboard, Wendy'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 · Ecited before2024-02-02 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the recertification survey from 1/28/24 to 2/2/24, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1., The facility 'COVID positive resident line list' documented the date of the first COVID positive resident (Resident #100) inaccurately, and 2. Physician orders for transmission based precaution-contact/droplet precaution were not obtained timely for five residents (Resident #215, #216, #92, #218, #18) with 2/1/24 positive COVID test results. The findings are: The facility policy, 'It is the policy of this facility to identify and manage individuals with suspected or confirmed SARS COVID 19 infection. The Transmission Based Precautions for COVID-19- contact and droplet precautions. 1. The 1/31/24 nurses note for Resident #100 documented COVID swab result positive. The COVID positive resident line list documented that…
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 before2024-02-02 · 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 during the recertification survey from 1/28/24 to 2/2/24, the facility did not ensure that care was provided in a manner that maintained dignity for 1 of 2 residents (Resident #78) reviewed for dignity. Specifically, Resident #78's urinary catheter drainage bag was not concealed to prevent direct observation by others. The findings are: The facility policy, 'Indwelling Urinary Catheter Care' last reviewed 12/28/23 documented that the facility would provide catheter care to all residents with indwelling urinary catheters, and that for dignity purposes all residents would have a privacy bag or use a leg bag. Resident #78 had diagnoses which included neurogenic bladder, quadriplegia, and injury to the spinal cord. The 9/6/23 care plan titled Activities of Daily Living documented: provide dependent assistance with bathing, bed mobility, dressing, toilet use, transfers. The 9/6/23 care plan titled Elimination documented neurogenic bladder. Interventions included foley catheter care as ordered. The 12/4/23 physician order documented…
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 · D2024-02-02 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 from 1/28/24-2/2/24, the facility did not ensure they provided the appropriate liability and appeal notices to Medicare beneficiaries at the termination of Medicare coverage. This was evident for 3 (Resident #5, #64, #91) of 3 residents reviewed for beneficiary protection notification rights. Specifically, Resident #5 was discharged from the facility to home and did not receive a written Notice of Medicare Non-Coverage for Medicare Part A as required. And the facility was unable to provide documented evidence that Residents #64, and #91 or their representatives received the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required. Findings include: The facility policy titled Notice of Non-Medicare Coverage dated 6/12/18 documented the Notice of Non-Medicare Coverage must be delivered at least two calendar days before Medicare covered services end or the second…
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 · D2024-02-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification and abbreviated surveys (NY00299405, NY00332134, and NY00332265) from 1/28/24 to 2/2/24 the facility did not thoroughly investigate all allegation of abuse for 2 out of 3 residents (Resident #267 and Resident #273), reviewed for abuse. Specifically, on 1/24/24 the facility reported to the New York State Department of Health that Resident #273's family member threatened to call the New York State Department of Health to say Resident #273 was sexually assaulted, however on 1/25/24 the facility sent Resident #273 to the hospital for an allegation of sexual abuse and the facility did not notify the New York State Department of Health and did not complete a thorough investigation or suspend the accused during the investigation. Statements were not obtained from all witnesses including the alleged perpetrator and the alleged perpetrator continued to work while the investigation was ongoing. 2) The facility reported an allegation of staff to resident…
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 before2024-02-02 · 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
Based on observation, interview, and record review during a Recertification survey from 1/28/24 to 2/2/24, the facility did not ensure the environment remained as free of accident hazards as possible for 1 (Resident #365) of 4 residents reviewed for accidents. Specifically, the cable wire in the Resident #365's room was not secured, encased, and out the resident walkway to prevent accidents. Findings include: Review of the facility policy and procedure titled Accidents, Assessments, Preventions and Interventions dated 7/1/10 and last reviewed on 12/18/23, documented the purpose was to ensure that all residents were properly assessed, and appropriate interventions were put in place to prevent falls, and that nursing staff was to check that the room was clutter free in walkway and to remove any obstacles. Resident #365 had diagnoses including chronic obstructive pulmonary disease, emphysema, and schizoaffective disorder-bipolar type. The Minimum Data Set (an assessment tool) dated 1/11/24, revealed the resident had severely impaired cognition, required moderate assistance with eating…
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 · D2024-02-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 interview and record review during the recertification and abbreviated (NY00324842) surveys conducted 1/28/2024-2/2/2024, the facility did not ensure a resident was provided with adequate fluids to maintain proper hydration and health for 1 of 5 residents (Resident #272) reviewed for nutrition/hydration. Specifically, Resident #272, was not administered intravenous fluids as ordered. Findings include: Resident # 272 was admitted to the facility on [DATE] with diagnoses including cancer, malnutrition and dehydration. The admission Minimum Data Set ( an assessment tool) dated 9/14/2023 documented the resident's cognition was moderately impaired and the resident required limited assistance with eating. Nurse Practitioner #2's progress note dated 9/21/2023, documented the resident was seen lying in bed for follow up on poor oral intake and questionable dehydration. The resident complained of dry mouth and ate about 25% of breakfast and lunch and reported poor fluid intake. The plan was intravenous (IV)…
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 · D2024-02-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review during the recertification and abbreviated surveys (NY00331117) from 1/28/24 to 2/2/24, the facility did not ensure that medical records were maintained, complete and accurately documented for each resident in accordance with accepted professional standards and practices. Specifically, nursing staff documented in the Treatment Administration Record on one occasion 'intact' and on three occasions 'skin intact' between two dates that the wound doctor had documented an open wound, and on one occasion on the same date the resident went for a consult to evaluate the open wound. This was evident for 1 of 8 residents (Resident # 269) reviewed for Pressure Ulcers. The finding is: Resident #269 was admitted with diagnoses including surgical wound post laminectomy, spinal stenosis, and vascular dementia. The 11/9/23 admission Minimum Data Set (an assessment tool) documented Resident #269 had severely impaired cognition, and had a surgical wound present on admission. The 11/13/23 wound consult note documented mid lower back is a partial thickness surgical…
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 · D2023-09-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 interviews and record review during an abbreviated survey (NY00324542), the facility did not provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 5 residents (Resident #1 and Resident #2) reviewed for pharmaceutical services. Specifically, Resident #1 had a physician's order for Vimpat (controlled antiseizure medication) 200 milligrams (mg) 1 tab every 12 hours at 9AM and 9PM daily, and over three days in 08/2023 and four days in 09/2023 a total of 12 doses of Vimpat were not administered to Resident #1. Resident #2 had a physician's order for Keppra (anti-seizure medication) 1000 mg 1 tab every 12 hours at 9AM and 9PM daily, and over six dates a total of 7 doses of Keppra were not administered to Resident #2. Subsequently, Resident #1 suffered a seizure on 9/17/2023 at 3:45PM and was transferred to the hospital. . The findings include: The facility policy…
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 · E2020-11-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 observations, record reviews and interviews conducted during a Recertification Survey, it could not be ensured that the facility developed and/or followed a plan of care with measurable goals, timeframes and interventions for 2 of 6 residents (Residents #74 and #92) reviewed for Pressure Ulcers, 1 of 5 residents reviewed (Resident #89) for Unnecessary Medications and 1 of 1 resident (Resident #58) reviewed for Activities of Daily Living (ADLs). Specifically, 1) heel booties and/or offloading of feet was not provided for Resident #74, 2) heel booties were not applied for Resident #92, 3) care plans including diagnoses and medications were not developed for Resident #89, and 4) staff did not provide mouth cares as per the ADL plan of care for Resident #58. The findings are: Review of the facility Policy and Procedure dated 4/2/2020 related to Comprehensive Care Planning showed that the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable…
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 · E2020-11-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 observation, interview and record review conducted during a recertification survey the facility did not ensure that 2 of 6 residents (#74 and #92) reviewed for pressure ulcer was provided the appropriate care to promote healing of an existing pressure ulcer. Specifically, for resident #74 [NAME] feet were not off loaded at all times as per physician order and heel float devices were not applied as per the plan of care and 2) for resident #92 heel booties were not applied as per physician orders. The findings are: Review of a 7/14/2020 facility Policy and Procedure showed that all residents will be assessed for potential or development of decubitus ulcers or skin conditions. All residents who have an actual break in skin will have an appropriate plan of care developed to promote optimal skin integrity. 1. Review of the Annual Minimum Data Set (MDS; a resident assessment tool) dated 10/3/2020 showed that Resident #74 was admitted to the facility on [DATE] with diagnoses including but not limited 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 · Ecited before2020-11-10 · tag F0880 — failed to prevent and control infections — patternProvide 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 observations, record reviews and interviews conducted during the Recertification Survey, it could not be ensured that the facility maintained infection prevention and control to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) for 1 of 1 resident (Resident #74) reviewed for Urinary Catheter, staff did not ensure a foley catheter bag and tubing were placed to prevent contamination, 2) laundry was not handled and transported to prevent contamination and 3) staff did not perform hand hygiene after contact with potentially contaminated surfaces. The findings are: 1. Review of an untitled 3/5/2018, last revised 6/15/2020 facility Policy and Procedure documented that the facility has procedures to prevent catheter associated Urinary Tract Infections and included a directive for keeping the catheter tubing and drainage bag off the floor. Resident #74 was admitted to the facility on [DATE] with diagnoses…
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 before2020-11-10 · 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, record reviews and interviews conducted during the Recertification Survey, it could not be ensured that the facility provided necessary services to maintain good oral hygiene for 1 of 1 resident (Resident #58) reviewed for Oral Hygiene. Specifically, Resident #58 was observed to have substantial residue on her tongue during several observations. The finding is: 1. Review of Resident #58's 2/27/2020 MDS showed that Resident #58 was admitted on [DATE] with diagnoses including Gastric Hemorrhage, Ulcerative Colitis with Rectal Bleeding, Malnutrition and Other Artificial Openings of the Gastrointestinal Tract. The MDS also showed that Resident #58 was moderately cognitively impaired and required a gastrostomy tube to sustain life. Furthermore, the MDS showed that Resident #58 requires extensive assistance of 1 staff for eating and personal hygiene. Review of the Quarterly MDS dated [DATE] showed that the resident's need for assistance with ADLs has remained unchanged. Resident #58's 2/20/2020…
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 · Bcited before2020-11-10 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews during a Recertification Survey, it could not be ensured that the facility provided residents with a dignified dining experience. Specifically, staff were observed feeding residents while standing and the residents were seated. The finding is: Review of the facility Policy and Procedure revised on 1/6/2020 showed that the facility is committed to assuring the rights and protection of its residents to be treated with respect, dignity and self-determination. 1. Review of the 8/19/2020 Minimum Data Set (MDS; a resident assessment tool) showed that Resident #79 was admitted on [DATE] with diagnoses including Bipolar Disorder, Metabolic Encephalopathy and Chronic Kidney Disease. Further review of the MDS showed that Resident #79 is moderately cognitively impaired, requires extensive assistance of 1 person for bed mobility, transfers, toilet use and personal hygiene. Resident #79 requires physical assistance of one person for eating. During observation on 11/5/2020…
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 · B2020-11-10 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each 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 observations, interviews and record reviews during the Recertification Survey, it could not be confirmed that the facility ensured that the call bell system was accessible for 4 of 8 residents reviewed for Environment. Specifically, the facility did not ensure that Residents #40, #46, #47 and #74 either had a call bell and/or that the residents' call bell was within reach. The findings are: Review of an untitled facility Policy and Procedure dated 2/12/2020 described that call bells for each resident will be provided; a call bell next to the bed and always available. Furthermore, a manual call bell will be provided for each resident in the event their electronic call bell is not functioning. 1. Resident # 40 was readmitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia and Psychotic Disorder. The 10/21/20 Quarterly Minimum Data Set (MDS; a resident assessment tool) indicated that Resident #40 was severely cognitively impaired. Several observations from…
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
$97,282 in federal fines across 2 penalties.
- $37,076 — penalty dated 2025-06-20
- $60,206 — penalty dated 2023-09-29
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 EXCELSIOR CARE GROUP — 33 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 | 1 of 5 | 2.5 | -1.5 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.3 | -1.3 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 32 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| BERKOWITZ, CHESKEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | 13% | since 07/12/2019 |
| LEIFER, JOEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | 25% | since 07/12/2019 |
| PLATSCHEK, RICHARD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | 25% | since 07/12/2019 |
| ZUPNICK, JOEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | 38% | since 07/12/2019 |
| STEINBERG, MOSHE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/12/2019 |
| STERN, SAMUEL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/12/2019 |
| EXCELSIOR CARE GROUP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/21/2019 |
| APPELBAUM, YAKOV | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/06/2024 |
| OLONILUA, PATRICIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/09/2024 |
| SAXENA, AMIT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2021 |
CMS files one row per role, so the 25 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 $3.2M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 335005. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-12, 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.