Concord Nursing and Rehabilitation Center
300 Madison Street, Brooklyn, NY 11216 · Non profit - Corporation · 140 certified beds · (718) 636-7500 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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 (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 | 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 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.8% | 14.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.6% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 38.2% | 19.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.2% | 0.2% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 1.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.6% | 12.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 8.6% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.7% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.5% | 19.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.6% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.7% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 17.6% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.2% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.03 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.29 | 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.
33.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 33.9%CMS range 22.9–48.5 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.6%CMS range 7.5–18.2 | 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 | 58.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 48.8% | 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 | 51.2% | 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 | 94.4% | 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 | 91.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.49 | 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 140 beds and averages 137.8 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.545 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.01 hrs/resident/day on weekends vs 3.41 on weekdays — 12% thinner on weekends. RN hours go from 0.61 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · E2026-03-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility did not ensure that a resident's right to a safe, clean, comfortable, and homelike environment was maintained. This was evident on all resident units (Unit 2, 3 and 4). Specifically, rooms were not cleaned, hallways and day rooms were observed discolored with dark-brown color stains, days rooms and hallways were observed with cracked floor tiles, and days rooms also were observed with greasy dark stains in the corners. Findings are The facility policy titled, Maintenance Services, with a current effective date of 05/28/2025, documented that the facility provides maintenance services to the facility, grounds, and equipment in accordance with current standards of practice and State and Federal regulations. Functions of maintenance personnel may include, but are not limited to, maintaining the building in good repair and free from hazards. The facility policy titled, Cleaning and Disinfection of Environmental Surfaces, last revised on 04/16/2025,…
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 · E2026-03-13 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, review of the weekend staffing and the Payroll Based Journal Staffing Data Report dated [NAME] 1st, 2025 to September 30th, 2025, was evident for low weekend staffing. The findings include, but are not limited to: The Payroll Based Journal Staffing Data Report for Quarter four (4) of 2025 dated July 1st to September 30th documented that submitted weekend staffing data was excessively low. The Facility assessment dated [DATE] documented the following Units' levels/capacity: fourth (4th) floor: 45 residents, third (3rd) floor: 45 residents, second (2nd) floor: 33 residents, and the ventilator unit: 17 residents. The Facility's undated document titled, Concord Nursing and Rehabilitation Center, documented PAR…
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 · E2026-03-13 · 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
Based on observations, record review and staff interview, the facility failed to ensure that food was stored, prepared, and distributed, and that expired food in the walk-in freezer/refrigerator and the unit pantry were discarded in accordance with professional standards for food service safety. This was evident during the kitchen and unit pantry observation tasks. Specifically, food items were observed in the refrigerators with green, grey, black, and white fuzzy substances on them and expired food items were observed in the unit pantry resident refrigerator. The findings are: A facility policy and procedure titled, Food Storage, last revised 05/10/2024, documented that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contamination. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. On 03/10/2026 at 10:00 AM, a tour of the facility kitchen was conducted with the Food Service Director. As per the Food…
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 · E2026-03-13 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility did not ensure building elevators were maintained in safe working conditions. This was evident for (2) of three (3) elevators (Elevator #2 and #3) observed. Specifically, Elevators #2 and #3 were observed broken and was reported to be out of services for over several months, causing delays and restricting residents' movement around the facility, including delay of food services to the units. The findings include: Observations conducted from 03/08/2026 to 03/13/2026 between the hours of 10:00AM and 3:00PM included attention to the 2 passenger elevators (Elevator #1 and #2) and 1 service elevator (Elevator #3). Not Working signage had been posted on elevators #2 and #3. Despite the signage, Elevator #2 was observed being used. It was noted that Elevator #2 would skip Floor #3. On 03/10/26 at 11: 19 AM, during the resident council meeting, Resident #65 stated that the two elevators, #2 and #3 have been broken down for several months and that they have mentioned it on several occasions at several previous resident council…
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 before2026-03-13 · 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, the facility did not ensure that a resident was free from physical restraints for purposes of discipline or convenience that are not required to treat the resident's medical symptoms, and did not ensure the evaluation of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This was evident for one (1) of three (3) residents investigated for Restraints out of 27 total sampled residents. Specifically, Resident #117 was observed wearing a hand mitten restraint on multiple occasions without a physician's order, resident or representative consent, or documentation reflecting ongoing re-evaluation for the need of the hand mitten restraint. The findings are: The facility policy titled, Physical Restraint Use, last revised 12/02/2024, documented that the facility promotes a restraint free environment and supports the resident's right to be free from physical restraints imposed for the purposes 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 · D2026-03-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs was completed and implemented for each resident. This was evident in 1 of 3 residents reviewed for Restraints out of 27 total sampled residents. Specifically, Resident #102 was observed to utilize a Wander Guard elopement prevention device without a corresponding Comprehensive Care Plan in place. The findings are: The facility policy titled, Care Plans - Comprehensive, last reviewed 08/02/2024, documented that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment, and the interdisciplinary team…
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 before2026-03-13 · 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
Based on record review and staff interviews, the facility did not ensure that the resident Comprehensive Care Plan was reviewed and revised for one (1) (Resident #6) of eight (8) residents reviewed for Accidents out of 27 sampled residents. Specifically, there was no documented evidence that the Comprehensive Care Plan for Falls was reviewed and revised after the last quarterly Minimum Data Set assessment was completed and after the resident had a fall with injury. The findings are: The facility policy and procedure titled, Care Plans Comprehensive, last reviewed 8/2/2024, states that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functionable needs is developed for each resident. The policy also stated that the Care Planning Interdisciplinary team is responsible for reviewing and updating the care plan during significant change, readmission, and at least quarterly with the scheduled Minimum Data Set. Resident #6 was admitted with diagnoses which include, but are 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 · D2026-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility did not ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice. This was evident for 1 (Resident #23) out of 8 residents reviewed for Respiratory Care out of 27 sampled residents. Specifically, Resident #23 was observed using oxygen via undated nasal cannula at a rate of 4 liters per minute when the Physician's Order was written for oxygen to be received at a rate of 2 liters per minute. The findings are: The facility's policy titled, Oxygen Therapy Administration, last reviewed 09/17/2025, documented to initiate flow of oxygen following manufacturer instructions for use, based on the type of device, and at the prescribed flow rate. Resident #23 had diagnoses that included Congestive Heart Failure, Sepsis, Cardiogenic Shock The Annual Minimum Data Set assessment dated [DATE] documented that Resident #23 has severe cognitive impairment and received oxygen therapy while residing…
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 before2026-03-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments consistent with state or federal requirements and professional standards of practice. This was evident for 1 (4th Floor) of 4 units. Specifically, a large bag containing discontinued medications with multiple blister packs was observed on top of a desk at the 4th floor nurses' station. Additionally, stock medications were stored on the 4th floor nurses' station cabinet and were not locked. The findings are: A facility policy titled, Medication Storage, dated 05/2025, documented that it is the policy of the facility that all medications delivered to the facility are stored according to the federal and state guidelines. The policy documented that over-the-counter medications may be stored in the medication carts or a locked cabinet within the nursing station. On 03/13/26 at 12:01 PM, on unit 4, a large clear plastic bag was observed on top of a desk at the 4th floor nurses' station. The clear plastic bag had several blisters containing…
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 · D2026-03-13 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the observations and interviews, the facility did not ensure garbage was disposed of and refused properly. Specifically, waste, debris, and trash were not properly contained in closed dumpsters, and the garbage dumpster area was not maintained to prevent potential feeding and harborage for pests. This was observed during the Kitchen facility task. The findings are: The facility's policy and procedure titled, Garbage-Food and Refuse Disposal, last revised 12/2020, documents food-related garbage and refuse are disposed of in accordance with current state laws. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. Storage areas will be kept clean at all times and shall not constitute a nuisance. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Housekeeping personnel will empty garbage and refuse containers daily and will clean the containers daily on the outside. On 03/10/2026 at 11:40 AM, an observation was made with the Director…
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 13 citations
- Potential for harm · D2025-12-01 · 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 interviews conducted during an abbreviated survey (652565), the facility failed to ensure that a resident, identified as an elopement risk, received adequate supervision to prevent elopement from the facility. This was evident for one (1) of five (5) residents (Resident #2) sampled. Specifically, on 11/29/2024 at 12:24 AM, Resident #2, who had severely impaired cognition, identified at risk for elopement, and was wearing a wander alert device, exited the facility building undetected by staff. Facility staff became aware Resident #2 was not in the building when Police Officers return the resident to the facility at 12:40 AM on 11/29/2024. Facility staff did not respond appropriately to an activated door alarm on Resident #2's unit. The findings include:The facility's 'Security Guards' policy and procedure dated 08/2019 documented the facility utilizes security guards to protect and provide safety to its residents and staff. Security guards are responsible for patrolling the nursing home's entrances and building, reporting all emergencies 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 · E2024-07-26 · 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 observation, record review, and interview conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure infection prevention and control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) A resident's urinary drainage bag was observed on the floor on multiple occasions. This was evident for 1 (Resident #27) of 2 residents reviewed for Urinary Catheter out of 29 sampled residents. 2.) Registered Nurse #2 did not perform hand hygiene between glove changes during gastrostomy dressing change. This was evident for 1 (Resident #80) of 4 residents observed for the nutrition investigation. 3.) The facility did not have a facility-specific water management plan for Legionella with mandatory components including but not limited to identifying acceptable pathogen levels. This was evident during the Water Management Plan review for…
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 before2024-07-26 · 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
Based on observations, record review, and interview conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure that residents remained free from physical restraint. This was evident in 1 (Resident #106) of 1 resident reviewed for Restraints out of 29 total sampled residents. Specifically, Resident #106 was observed with a mitten on the right hand. There was no documented evidence of appropriate assessment and care planning prior to the application of right hand mitten. Additionally, there was no documented monitoring provided while the right hand mitten was applied. The findings are: The facility's policy titled Restraint Use with a last revised date of 12/2023 documented that the facility will promote a restraint-free environment in accordance with State and Federal regulations. When the use of restraints is indicated, the least restrictive alternative for the least amount of time will be used and ongoing evaluation for the need of restraint will be documented. Resident #106 had diagnoses of Other Specified Disorders of Brain, Vascular…
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 before2024-07-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. This was evident in 1 (4th floor) of 3 units. Specifically, on 07/24/2024 at 10:57 AM, Resident #14's medication were left unattended on top of the medication cart. The findings are: The facility's policy titled Medication Storage with a revised date of 09/2023 documented that the facility will store medications in a manner that maintains the integrity of the product, ensures the safety of the residents, and in accordance with Department of Health guidelines. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. Resident #14 had diagnoses of Essential Hypertension, Epilepsy, Gastroesophageal Reflux Disease 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 before2024-07-12 · 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 interviews conducted during an abbreviated survey (NY00347659), the facility did not ensure care plans were reviewed and revised by the interdisciplinary team. This was evident for 1 out of 4 residents (Resident #1) sampled. Specifically, Resident #1's toes, on their left lower extremity, was observed with discolorations on 06/21/2024. The Medical Doctor was notified and ordered an Arterial Doppler Study on 06/21/2024. Review of Resident #1's Comprehensive Care Plans, revealed that the risk for Impaired Skin Integrity care plan was not updated to reflect on the discolorations to Resident #1's left toes. The findings are: The facility Policy and Procedure titled, Care Plans- Comprehensive, revised on 10/2023 documented that a comprehensive person-centered care plan that includes measurable objectives, timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy also states that assessments of residents are…
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 before2024-07-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during an abbreviated survey (NY00347659), the facility did not ensure that a resident medical record accurately reflected on the resident current condition. This was evident in 1 out 4 residents (Resident #1) sampled. Specifically, Resident #1's representative reported on 06/22/2024 at 5:00 pm that Resident #1's toes on the left lower extremity had discolorations. According to an interview with Primary Medical Doctor #1 on 07/10/2024 at 12:10 pm, they were in the facility and was notified of the discolorations on 06/21/2024. Primary Medical Doctor #1 stated that they assessed Resident #1 but did not document their assessment in Resident #1's medical record on 06/21/2024. The findings are: A Policy and Procedure titled Charting and Documentation last reviewed on 06/2023 states that all services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. Resident #1 has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-08 · 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 observations, record review and interviews conducted during the recertification survey from 6/1/2022 to 6/8/2022, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised after each assessment, including both the compehensive and quarterly reviewed assessments. This was evident for 1 (Resident #87) of 3 residents reviewed for pressure ulcers (PU). Specifically, the CCPs related to Resident #87's PUs were not reviewed and revised after each assessment to reflect changes in the condition of the wounds. The findings are: The facility policy titled, Care Plans-Comprehensive dated 10/2021 documented CCPs are revised when resident's condition changes or at least quarterly in accordance with the Minimum Data Set 3.0 (MDS) assessment. Resident #87 had diagnosis of chronic respiratory failure with hypoxia and ventilator dependence. The MDS dated [DATE] documented the Resident #87 was severely cognitively impaired, was at risk for PUs, had two stage 3 wounds, and had one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, interviews, and record review during the recertification survey from 6/1/22 to 6/8/22, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #41) of 3 residents reviewed for limited range of motion. Specifically, Resident #41, a resident with bilateral hand contractures, was observed on multiple occasions without gauze rolls to bilateral hands as per Medical Doctor Order (MDO). The findings are: The facility policy titled Splints, Prosthetics and Orthotics dated 10/12/21 documented to promote quality care, the facility uses appropriate techniques and devices for splints, prosthetics and orthotics. Resident #41 had diagnoses of dementia, cerebral infarction, and quadriplegia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #41 had moderately impaired cognition. The resident was not provided with splinting devices. On 6/02/2022…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 6/1/22 to 6/8/22, the facility did not ensure a resident's medical records were complete. This was evidenced by 1 (Resident #72) of 5 residents reviewed for unnecessary medication. Specifically, there was no documented evidence in the Medication Administration Record (MAR) Resident #72 received their hypertensive medication as per Medical Doctor Order (MDO) on multiple occasions. The findings are: The facility policy titled Medication Administration dated 12/2021 documented medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. If a drug is withheld, refused or given at another time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug 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.
- No harm found · C2026-03-13 · tag F0636 — widespreadAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility did not ensure that a comprehensive assessment of a resident was conducted in accordance with the required timeframes. This was evident for 15 (Resident #s 94, 17, 11, 41, 64, 140, 13, 17, 26, 37, 92, 46, 122, 103, 75) of 16 residents reviewed during the Resident Assessment Facility Task. Specifically, the admission and Annual assessments were not completed within 14 days of the Assessment Reference Date. The findings include but are not limited to: The facility policy titled, Minimum Data Set 3.0, last reviewed 01/2019, documented it is the policy of the facility to follow the guidelines of the most current State specific Resident Assessment Instrument manual correctly and effectively according to the Centers for Medicare and Medicare Services. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the Minimum Data Set assessment with a target date of 11/01/2025 for Resident #94 was completed late, more than 14 days after the Assessment Reference Date. The Centers for…
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 · C2026-03-13 · tag F0638 — widespreadAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility did not ensure timely completion of each resident's quarterly review assessments. This was evident for 16 (Residents 140, 143, 64, 13, 17, 26, 37,46, 94, 41, 92,122,11,103, 93, and 75) of 16 residents reviewed during the Resident Assessment Facility Task. Specifically, the residents' Quarterly Minimum Data Set assessments were not completed within 14 days of the Assessment Reference Date. The findings include, but are not limited to: The facility policy titled, Minimum Data Set Assessment 3.0, last reviewed 08/2019, documented it is the policy of this facility to follow the guidelines of the State specific Resident Assessment Instrument manual correctly and effectively according to centers for Medicare and Medicaid Services. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented Resident #140's Quarterly Minimum Data Set Assessment with an Assessment Reference Date of 02/03/2026 was completed with an assessment date more than 14 days after the reference date. The Centers…
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 · C2026-03-13 · tag F0640 — widespreadEncode 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
Based on record review and interviews, the facility did not ensure Minimum Data Set Assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident for 16 (Residents #s 92, 37, 93, 17, 143, 13, 94, 26, 46, 64, 122, 11, 103, 75, 140, and 41) out of 16 residents reviewed for Resident Assessment Facility Task Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings include, but are not limited to: The facility policy titled, Minimum Data Set 3.0, last reviewed 8/2019, documented it is the policy of the facility to follow the guidelines of the most current State specific Resident Assessment Instrument manual correctly and effectively according to the Centers for Medicare and Medicaid Services. The Quarterly Minimum Data Set assessment for Resident #92 with an Assessment Reference target date of 11/01/2025 was submitted to the Centers for Medicare and Medicaid on 11/24/2025 as evidenced on the Centers for…
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 · C2024-07-26 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during the Recertification Survey from 07/21/2024 to 07/26/2024, the facility did not ensure that notice of the availability of the survey results was posted in areas of the facility that are prominent and accessible to the public. Specifically, the notice in the lobby of where to locate the survey results was posted in an area that was not accessible to the public; and there were no posted notices in resident units advising the residents, family members, or legal representatives of the survey results location. The findings are: The facility's policy titled Survey Results with a revised date of 12/2023 documented that survey results must be readily accessible for viewing. Resident, visitors, etc. should not be required to ask to see the results. During multiple observations on 07/21/2024, at 9:00 AM, the notice of survey result availability was posted in the lobby entrance of the main building that was not in view of residents or visitors. The notice was located next to the security desk, behind a standing sign.…
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 | Since |
|---|---|---|---|
| PHILLIPS, SAMUEL | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 01/01/2016 |
| GADDY, CRAIG | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2016 |
| PILGRIM, DEIDRE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2016 |
| WILTSHIRE, ALBERT | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2016 |
| BUTLER, ERICA | Individual | CORPORATE OFFICER | since 01/01/2016 |
CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 335538. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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.