Kings Harbor Multicare Cente
2000 East Gunhill Road, Bronx, NY 10469 · For profit - Corporation · 720 certified beds · (718) 320-0400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 | 10.8% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.4% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.5% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 13.5% | 19.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.1% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.4% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 3.3% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 6.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 19.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.1% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.5% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.8% | 20.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.1% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.82 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.87 | 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.
45.3% 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 350 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.8% 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 345 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 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 45.3%CMS range 39.9–51.1 | 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 | 7.5%CMS range 5.7–9.8 | 10.7% | Oct 2022–Sep 2024 | better than 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 | 43.8% | 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 | 34.8% | 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 | 46.4% | 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 | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 99.1% | 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 | 0.4% | 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 | 1.8% | 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 | 8.8%CMS range 6.8–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.61 | 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
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · D2026-04-06 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 survey the facility failed to ensure that a resident was free from physical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptom. This was evident for one (1) of two (2) residents (Resident #642) reviewed for Physical Restraints out of 39 total sampled residents. Specifically, Resident #642 was observed, on multiple occasions, in bed with two (2) upper half side rails raised on both sides. The siderail assessments were incomplete, the physician order documented use of a one (1) half side rail as an enabler, there was no documentation of the medical necessity for use of the side rails, and Resident #642 was not able to lower the bed rails voluntarily.The findings include:The facility policy titled Side Rails, last reviewed on 06/2025, stated that it is the policy of the facility to provide residents with side rails in a manner that promotes resident safety and dignity based 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 before2026-04-06 · 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 Number of residents sampled: 3Number of residents cited: 1Based on record review and interviews conducted during the survey the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the state agency. This was evident for one (1) of three (3) residents (Resident #273) reviewed for Accidents out of total 39 sampled residents. Specifically, the facility did not report Resident #273's incident of unknown origin, resulting in a nasal fracture, to the New York State Department of Health. The findings include: The facility's policy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-06 · 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 Number of residents sampled: 3Number of residents cited: 1Based on record review and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident for one (1) of three (3) residents (Resident #696) reviewed for Hospitalization out of 39 sampled residents. Specifically, Resident #696 had a change of condition and Urinalysis/Polymerase Chain Reaction testing (method to detect and identify pathogens (things that cause disease) was ordered on 02/09/2026 and results were not received until 02/19/2026 which confirmed that Resident #696 had a urinary tract infection. In addition, there was no documented evidence that the Medical Doctor and Resident #696's representative were notified when Resident #696 refused to provide a urine sample.The findings include:The facility's policy and procedure titled Resident Change in Condition effective date 03/2026 documented that it is facility's policy to establish a standardized process…
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 before2026-03-05 · 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
Based on record reviews, and interviews conducted during a survey, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice. This was evident in one (1) of three (3) residents sampled (Resident #1). Specifically, facility's investigation dated 02/17/2026 at 5:04 PM, documented Resident #1 vomited undigested foods and there was no documented evidence that Resident #1's vital signs were done, or the Registered Nurse Supervisor #1 or the medical doctor were notified that Resident #1 vomited after dinner.The findings are:The facility's policy titled Notification of Changes dated 12/2024, documented it is the policy of the facility to immediately inform the resident, consults with resident's physician, and if known, notify the resident's legal representative or an interested family member when there is an accident or incident involving the resident, upon significant change in status or condition, or regarding changes in resident's rights. The members of the interdisciplinary team should address any changes 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 · D2024-12-23 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff observation, interviews and record review conducted during an abbreviated survey (NY00333408), the facility did not ensure that pain management was provided to a resident who required such services consistent with professional standards of practice. This was evident in one out three residents (Residents #1) sampled. Specifically, Resident #1 reported to Certified Nursing Assistant #1 on 02/09/2024 at 10:10 AM that they were unable to stand and that they had pain. Resident #1 was transferred, by Licensed Practical Nurse #1 and Certified Nursing Assistant #1, before being assessed by Registered Nurse Supervisor #1 and before pain medication was administered. Resident #1 was transferred to the hospital on [DATE] and was diagnosed with an acute Pelvic fracture. There was no documented evidence of pain assessment or that pain medication was administered on 02/09/2024 prior to Resident #1 being transferred to the hospital. The findings include: The facility Policy and Procedure title Pain Assessment,…
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 · D2024-12-09 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Record reviews and interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 9 (Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #493, and Resident #572) of 9 Minimum Data Set submissions reviewed for Resident Assessments were not submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. The findings are: The facility's policy and procedure titled Minimum Data Set 3.0 Submission revised 1/2024 documented it is the policy of [NAME] Harbor Multicare Center to ensure timely submission of all Minimum Data Sets to Centers for Medicare and Medicaid Services via Internet Quality Improvement and Evaluation System. Resident #10's quarterly Minimum Data Set 3.0 with assessment reference date of…
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 before2024-12-09 · 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 interviews and record review conducted during the Recertification/Complaint survey (NY00349608) from 12/02/2024 to 12/09/2024, the facility did not ensure all alleged violations involving resident to resident physical abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 2 (Resident # 193 and # 325) of 5 residents reviewed for Abuse out of sample size 38 residents. Specifically, the facility did not report Resident # 325 hit Resident # 193 on the right shoulder with a grabber to the New York State Department of Health within 2 hours after the allegation was made The findings are: The facility policy titled Abuse - Prohibition Protocol, Types of Abuse, Response/Reporting with effective date 10/97 and last revision date 5/23, documented in the section Response/Reporting under abuse that the persons observing an incident of resident abuse or suspecting resident abuse must attempt to stop the abuse and must immediately…
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 · D2024-09-18 · 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 observations, interviews, and record review during the Abbreviated Survey (NY 00351995), the facility failed to protect residents' rights to be free from physical abuse by nursing home staff. This was evident in one out of six residents (Resident #1) reviewed for abuse. Specifically, on 08/20/2024 at approximately 4:45 PM, Certified Nursing Assistant #2 reported to Registered Nurse Supervisor #1 that at 6:53 AM, Certified Nursing Assistant #2 assisted Certified Nursing Assistant #1, in the care of Resident #1. During care, Resident #1 held on tightly to Certified Nursing Assistant #1's hand, sinking their fingers into Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 raised their hand and with a deliberate, forceful slap to Resident #1's face between their forehead and eyes. The findings are: The Facility's Policy and Procedure titled Combative Resident with revision date 08/2023, documented it is the policy of the facility to maintain the safety of residents and staff during resident combative behavior/outburst. Any physical or verbal behavior/outburst…
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 · D2024-09-18 · 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 interviews conducted during the abbreviated survey (NY00341680) on 08/27/2024-08/29/2024, the facility failed to ensure the resident was free of significant medication errors. This was evident for one out of five sampled residents (Resident #2). Specifically, on 05/08/2024 at approximately 10:50 PM, Registered Nurse # 1 administered 24 units of insulin Lantus (long-acting insulin) to Resident #2, who was not on insulin therapy. The Medical Doctor was made aware and immediately ordered dextrose 5 % and 0.45 % sodium chloride intravenous solution to be infused at 70 ml/hour for 24 hours. Fingerstick Blood Sugar and vital signs (blood pressure, pulse, and temperature), monitor every four hours for 24 hours. The findings are: The facility Policy and Procedure titled, Administration of Insulin Injection and Preparation with revision date 01/2018, documented it is the facility policy to administer insulin preparations safely and appropriately. The nurse responsibility included. Review medication order, identify resident, explain procedures, and follow the rights…
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 · E2023-05-04 · 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 observation, record review, and interview conducted during the Recertification and Complaint (NY00312479) survey from 04/27/23 to 05/04/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet resident needs. This was evident for 3 (Residents #193, #513, and #936) of 41 total sampled residents. Specifically, 1) a CCP related to abuse prevention was not developed for Resident #193 following a substantiated abuse allegation, 2) a CCP related to dialysis treatment was not developed for Resident #513 who receives dialysis, and 3) a CCP related to fractures was not developed for Resident #936 following a left rib fracture. The findings are: The facility policy titled CCP last revised 4/2022 documented the CCP should be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the plan of care when there is a new problem that requires that discipline to intervene. The care plan will be revised to reflect 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.
Show the remaining 7 citations
- Potential for harm · D2023-05-04 · 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 interviews and record review conducted during an abbreviated survey (NY00307515), the facility did not ensure that all alleged violation of abuse, including injuries of unknown source, were thoroughly investigated. This was evident in 1 (Resident #936) of 41 sampled residents. Specifically, Resident #936 was found to have multiple left rib fractures of unknown origin without evidence of an investigation to rule out abuse. The findings are: The facility policy titled Investigations dated 2/2022 documented all injuries of unknown origin will be investigated to determine abuse or mistreatment. Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. The Medical Doctor (MD) Note dated 11/17/2022 documented Resident #936 had volume depletion, was positive for cough, the MD ordered a chest x-ray, and the resident was started on Levaquin for pneumonia. The Radiology…
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 · D2023-05-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00311511) survey from 04/27/23 to 05/04/23, the facility did not ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene. This was evident for 1 (Resident #402) of 6 residents reviewed for ADLs out of 41 total sampled residents. Specifically, Resident #402 was not provided with incontinent care after having a bowel movement. The findings are: The facility policy titled Toileting last revised 04/18 documented all residents are brought to the toilet regardless of continence status, unless physically or medically contraindicated. Resident #402 had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #402 was cognitively intact, always incontinent of bowel, and required 1 person to assist with transfers and toilet use. On 05/01/23 at 12:02 PM, 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 before2023-05-04 · 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 record review and interviews conducted during the recertification and abbreviated survey (#NY00308148) from 4/27/23 to 5/4/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evidenced for 1 (Resident #475) of 41 total sampled residents. Specifically, Resident #475 was not assessed after a a family member reported swelling and discoloration to their right hand. The findings are: Resident # 475 had diagnoses of dementia and renal failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #475's cognition was severely impaired. On 04/28/23 at 10:52 AM, an interview was conducted with NOK #2. NOK #2 stated that they noticed Resident # 475's right hand and knuckles were swollen during visitation, but they were not notified about the swelling and what happened to the hand. The nurse told them that nothing happened to the resident's hand. The Aspen Complaint Tracking System (ACTS) intake dated 1/6/23…
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 · D2020-09-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews conducted during the recertification survey, the facility did not ensure that a resident's dignity was maintained. Specifically, a resident with a urinary catheter was observed on multiple occasions to have no dignity bag covering the attached urine bag. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 38 residents (Resident # 444). The findings are: The facility policy and procedure titled Catheter Care Protocol dated 6/2018 documented that when the resident is in bed, assure the Foley bag is hanging off the bed, not on the floor/not visible. If the bag is visible, use a privacy bag. Resident # 444 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, Malignant Neoplasm of unspecified Kidney and Gross Hematuria. The Quarterly Minimum Data Set (MDS) 3.0 dated 8/4/20 documented that the resident had intact cognition, needed extensive assistance of one person for bed mobility, toilet use, and personal hygiene and 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 · D2020-09-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review conducted during the Recertification and Abbreviated Survey, the facility did not ensure that advanced directives were reviewed periodically with resident representative. Specifically, there was no documented evidence advance directives had been discussed with the resident's representative. This was evident for 1 of 4 residents reviewed for Advance Directives (Resident #237). The findings are: The facility policy and procedure tiled Advance Directives revised 4/2018 documented the facility shall discuss/review the Advance Directive with resident, designated representative and CCP Team upon admission, annually, quarterly and at a change in the resident's condition warranting a review. Resident #237 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Dementia with behavioral disturbance, Delusional Disorder and Adult Failure to Thrive. The MDS also documented the resident had severe cognitive impairment. Social Services MDS Progress Note dated…
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 · D2020-09-30 · 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 observations, record reviews, and interviews during the Re-certification survey, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, the Foley catheter drainage bag and tubing were observed touching the floor in a resident's room. This was observed on multiple occasions during the survey. This was evident for 1 of 4 residents reviewed for Urinary Catheter or UTI out of a sample of 38 residents. (Resident #444) The findings are: The facility policy and procedure titled Catheter Care Protocol dated 6/18 documented that when the resident is in bed, assure the Foley bag is hanging off the bed, not on the floor/not visible. Resident # 444 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, Malignant Neoplasm of unspecified Kidney and Gross Hematuria. The Quarterly Minimum Data Set (MDS) 3.0 dated 8/4/20 documented that the resident had intact cognition, needed…
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 · C2020-09-30 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews conducted during the Recertification survey, the facility did not ensure that daily nursing staffing data was appropriately posted. Specifically, (1) the nurse staffing data form posted did not document the actual hours worked by the licensed & unlicensed nursing staff that were directly responsible for resident care per the shift that worked, (2) the data posting was not in a prominent place readily accessible to residents and visitors and (3) On 9/28/20 there was no staffing data posted in the Manor building a separate building from the Main building. This was observed in the Main and the Manor building. The findings are: On 9/28/20 and 9/29/20 at approximately 9:30 AM, the nursing data form was posted in a glass encasement in the Main building lobby approximately 20 feet from the elevators in a side hall area next to the admission office. The data was not posted in a prominent manner and was not readily accessible to residents and visitors. In addition, staffing data form posted did not document the actual hours worked by the licensed and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ESTATE OF BELLA DAVIS | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/03/2015 |
| TENENBAUM, JUDITH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/12/1994 |
| TENENBAUM, MATITYAHU | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 06/12/1994 |
| TYBERG, ISRAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/12/1994 |
| TYBERG, MIRIAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/12/1994 |
| DAVIS, MILES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 33% | since 07/03/2015 |
| LICHSTEIN, YOEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2025 |
| ZIMMERMAN, RALPH | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 12/01/1997 |
| GUPTA, SHIKTA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2025 |
| WEINBERGER, BENJAMIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2025 |
CMS files one row per role, so the 18 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 $2.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 335644. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-09, 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.