Rutland Nursing Home, Inc
585 Schenectady Avenue, Brooklyn, NY 11203 · Non profit - Corporation · 538 certified beds · (718) 604-5221 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $55,231 in federal fines (most recent 2025-06-12)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 22% of its spending goes to commonly-owned related companies
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — 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 | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 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 | 16.1% | 14.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.9% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.9% | 1.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.1% | 19.5% | 6.5% | better 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 | 0.4% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.1% | 12.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 10.8% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 72.3% | 95.3% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 10.5% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 2.4% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.1% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 29.0% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 10.5% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 1.9% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.56 | 1.70 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.52 | 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.
40.7% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.0% 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 30 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 40.7%CMS range 29.4–53.8 | 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 | 10.8%CMS range 7.3–14.9 | 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 | 40.0% | 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 | 36.7% | 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 | 33.3% | 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 | 64.2% | 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 | 66.7% | 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 | 3.8% | 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 | 8.5%CMS range 5.3–14.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 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 538 beds and averages 440.7 residents a day — about 82% occupied, or roughly 97 beds typically open. It usually has some room. 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 4.41 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.24 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.446 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 4.03 hrs/resident/day on weekends vs 4.57 on weekdays — 12% thinner on weekends. RN hours go from 1.33 to 1.02 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 22% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2026-03-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 survey, the facility failed to ensure a resident receiving enteral feeding received appropriate care and was monitored for complications related to tube feeding. This was evident for one (1) out of five (5) residents reviewed for enteral feeding (Resident #1). Specifically, on 02/20/2026, Resident #1 who received feeding and medications through a nasogastric tube (medical tube inserted through the nose into the stomach) had a change in their breathing pattern and was transferred to the hospital. Resident #1 was diagnosed with respiratory failure due to aspiration pneumonitis (an inflammation of the lung, which may lead to infection often presents rapidly with breathing difficulty, cough, and fever, requiring supportive care like oxygen) caused by a misplaced nasogastric tube in the left lung. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings include: The facility policy and procedure title Enteral Feeding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-06-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during an abbreviated survey (NY00371268), the facility failed to ensure that a resident was free from resident-to-resident abuse. This was evident for one (1) out of five (5) residents (Resident #1) sampled. Specifically, on 01/31/2025 at 2:50 PM, Licensed Practical Nurse #1 witnessed an altercation between Resident #1 and Resident #2 in the elevator at the lobby level . Licensed Practical Nurse #1 separated the residents. Resident #1 and Resident #2 were assessed by Registered Nurse Supervisor #1 and there were no injuries. The facility failed to ensure timely safety measures to prevent further abuse. On 01/31/2025 at 5:25 PM, Resident #1 complained of left side chest pain and stated that Resident #2 entered their room and hit them. Resident #1 was transferred to the emergency room for evaluation and returned to the facility on [DATE] at 7:00 AM with diagnoses of an acute fracture (break) to the left fourth rib. This resulted in actual harm 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 · Fcited before2025-07-09 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews conducted during the onsite visit for Complaint NY00384371, it was determined that the facility failed to maintain safe and comfortable temperature levels. This was evident on six (6) of the seven (7) resident floors, where 22 out of 34 rooms sampled had temperatures above the Federal and State requirements in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29 range of 71 degrees Fahrenheit to 81 degrees Fahrenheit. Specifically, on 06/23/2025, Resident #1 submitted a complaint to the New York State Department of Health that there was loss of air conditioning on the sixth floor. The temperature on the sixth floor was 86.9 degrees Fahrenheit. From 06/24/2025 through 06/25/2025, two (2) additional complaints were submitted to the New York State Department of Health regarding high temperatures throughout the facility, stating all residents were affected. The facility documented Resident #1's room and other residents' room temperatures had exceeded safe and comfortable ranges.The findings are:The facility's policy and procedure 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 · F2025-07-09 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews conducted during an Abbreviated Survey and Partial Extended Survey (NY00384371), the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 06/23/2025 to 06/25/2025, complaints were submitted to the New York State Department of Health regarding high temperatures throughout the facility. The Administrator failed to provide effective leadership and oversight to ensure that comfortable and safe temperature levels were maintained in residents' rooms and common areas in the facility.The findings are:The facility's policy and procedure on Extreme Heat Emergency dated 03/2025, documented all departments at the facility are responsible to be prepared to respond to periods of high temperature and humidity with appropriate, well, coordinated resident care. The policy further documented the plan will be activated whenever the inside temperature…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-31 · 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 interviews conducted during the onsite survey for the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that food was handled in accordance with professional standards for food service safety and staff did not ensure that infection control practices were maintained in the kitchen. This was evident during the Kitchen task. Specifically, dietary staff with visible facial hair and no beard restraints were observed assisting with food tray preparation on the tray line and removing cleaned items from the dish machine. The findings are: The facility policy titled Uniform Policy revised June 2024 stated that hair nets, beard restraints and department approved caps are required throughout all areas of the Department of Food and Nutrition. The facility policy titled Food Safety revised August 2024 stated that staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Dietary staff must wear hair restraints (hairnet, hat and or/beard restraint to prevent hair from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification via mail at the termination of Medicare Part A benefits. This was evident for 1 (Resident #129) of 3 residents reviewed for Beneficiary Notification out of 39 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made. The findings are: The facility policy titled Medicare Certification, Notice of Medicare Non Coverage/ Skilled Nursing Facility-Advanced Beneficiary Notice of Non-Coverage with an effective date of 2023 and last revision date of 2025 documents that a complete copy of the Notice of Medicare Non Coverage and Skilled Nursing Facility Advanced Beneficiary Notice of Non- Coverage are provided to beneficiaries receiving skilled services and have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification Survey and Complaint survey (NY00365250) from 03/24/2025 to 03/31/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident in 1 (7th Floor) out of 2 laundry rooms and in 19 out 38 resident rooms and shower rooms on the 7th floor observed during Environmental Task. Specifically, (1) the dryer on the 7th floor resident laundry room was noted with visible gray colored dust vents in the back, (2) multiple room fans were noted to have dusty front and back areas and dusty blades, and (3) water damage on the ceiling, broken wall tiles, and soiled curtains were observed in the bathrooms on both wings. The findings include but are not limited to: The facility policy and procedure titled Washing of Resident Laundry revised 03/16/2024 stated that the nursing home provides a washer and dryer for residents located on the 7th and 10 floors. Residents or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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, interview, and record review conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that a copy of all transfers and discharges were sent to a representative of the Office of the State Long-Term Care Ombudsman in a timely manner. This was evident for 1 (Resident #743) of 1 resident reviewed for Discharge. Specifically, Resident #743 was transferred to the hospital on [DATE] and the discharge notice was not sent to the Office of the State Long-Term Care Ombudsman until 03/25/2025. The findings are: Resident #743 had diagnoses which included Respiratory Failure and Tracheostomy. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #743 was a minor, was rarely or never understood, and required dependent-level assistance with all Activities of Daily Living. The Discharge Minimum Data Set assessment dated [DATE] documented that Resident #743 had an unplanned discharge to a short-term general hospital with a return to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-31 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure that Minimum Data Set assessments accurately reflected a resident's status. This was evident for 1 (Resident #743) of 1 resident reviewed for accuracy of assessment out of 39 total sampled residents. Specifically, Resident #743's Minimum Data Set assessments did not accurately reflect the Resident's gender. The findings are: The facility policy titled Completion of Minimum Data Set 3.0 last revised 2025 stated that the Minimum Data Set will be completed by the interdisciplinary team and the Minimum Data Set Coordinator will transcribe assessment data completed by concerned disciplines into the Minimum Data Set book. Review for accuracy prior to submission by Minimum Data Set Assessors and clinical disciplines is necessary. Resident #743 was admitted to the facility with diagnoses that included Respiratory Failure and Tracheostomy. The admission Minimum Data Set 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 · D2025-03-31 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during a Recertification Survey between 03/24/2025 and 03/31/2025, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Residents #379) of 2 residents reviewed for Care Planning out of 39 residents sampled residents. Specifically, Resident #379 and their representative were not provided with a copy of the baseline care plan. The findings are: The facility policy on Baseline Care Plan dated 11/2017, last revised 01/2025 stated that the baseline care plan will be developed within 48 hours of admission. The policy also stated Along with the baseline care plan is a summary of care plan that is provided to the resident and representative in a language that can be understood. Resident #379 was admitted to the facility with diagnoses that included Seizure Disorder, Anxiety Disorder, and Respiratory Failure. The Quarterly Minimum Data Set assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that a person-centered comprehensive care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #102) of 2 residents reviewed for Edema out of a sample of 39 residents. Specifically, a person-centered care plan was not developed and implemented for Resident #102 who had edema. The findings are: The facility policy titled Comprehensive Care Planning initiated 08/2020 and revised 01/2025 stated that an individualized, interdisciplinary Comprehensive Care Plan is developed by an interdisciplinary team representing all appropriate health care professionals as soon as possible after admission and no later than 1 week after comprehensive assessment are competed. The policy also stated that the resident's comprehensive care plan must be individualized, reflect an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the Recertification survey between 03/24/2025 and 03/31/2025, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the episodic, comprehensive, and quarterly review assessments. This was evident for 2 (Resident #376 and Resident #194) of 5 residents reviewed for Unnecessary Medications out of an investigative sample of 39 residents. Specifically, 1). The Comprehensive Care Plan for Infection/Antibiotic Use for Resident #376 was last reviewed on 02/25/2025 and was not updated to reflect use of a Peripheral Intravenous Catheter line to give intravenous antibiotics or after Resident #376 completed a course of intravenous antibiotics, and 2). The Major Depressive Disorder and the Psychotropic Drug Use Comprehensive Care Plan for Resident #194 was not reviewed or revised after each assessment. The findings are: The facility policy and procedure titled…
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 17 citations
- Potential for harm · D2025-03-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 03/24/2025 to 03/31/2025 the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain mobility and function. This was evident for 1 (Resident #120) of 2 residents reviewed for Rehab and Restorative out of a total sample of 39 residents. Specifically, Resident #120 did not receive the Nursing Rehabilitation Standing and Balance Program in March 2025 as recommended by the Rehabilitation Department. The finding is: The facility policy titled Restorative Nursing Programs implemented 01/2000 and last revised 01/2025 states it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Residents, as identified during the comprehensive assessment process will receive services from restorative aides when they are assessed to have a need 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 · D2025-03-31 · 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 conducted during the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 (Resident #17) out of 3 residents reviewed for Respiratory Care out of 39 sampled residents. Specifically, Resident #17 was observed using oxygen via an undated nasal cannula at a rate of 3 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 Administration last reviewed 01/2025 stated that oxygen is administered to residents who need it, consistent with standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in case of an emergency. Staff shall change oxygen tubing and mask/cannula weekly and as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review during the recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that recommendations in the medication regimen reviews were identified and acted upon by the attending physician. This was evident for 1 (Resident #125) of 5 residents reviewed for Unnecessary Medication out of 39 sampled residents. Specifically, four Medication Regimen Reviews which recommended that an order for psychotropic medications for a diagnosis other than an approved chronic psychiatric condition be evaluated, were not addressed. The findings are: The facility policy and procedure titled Medication Regimen Review effective 11/28/2017 and revised 10/2024 stated that the Pharmacist will document any irregularities and send copies of findings to the Physician, Director of Nursing Services, Medical Director. The policy also documented that these reports must be acted upon in a timely manner and completed forms filed in individual resident's chart. 1. The Medication Regimen Review dated 09/30/2024 documented that Resident #125 was currently receiving…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure a resident was given psychotropic medication to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #12U) of 5 residents reviewed for Unnecessary Medication out of 39 total sampled residents. Specifically,1. Resident #125 was not provided with nonpharmacological interventions to address behavior before an antipsychotic medication was restarted, and 2. Resident #125 was prescribed a psychotropic medication without an appropriate diagnosis. The findings are: The facility policy titled Free From Unnecessary Antipsychotic Drugs effective 11/28/2017 and revised 11/2/2024 stated residents are given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as documented by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the Recertification and Complaint Survey (NY00369624 and NY00354365) conducted from 03/24/2025 to 03/31/2025, the facility did not ensure residents received adequate supervision and assistance devices consistent with resident's needs, goals, and care plan to prevent accidents. This was evident for 2 (Residents #108 and #260) of 2 residents investigated for Accidents out of 39 total sampled residents. Specifically, (1) Resident #108 fell and hit the back of head causing injury to left eye orbital while being transferred to bed by 2 Certified Nursing Assistants, and 2. (2) Resident #260 who required a harness while out of the crib and in a wheelchair was removed from wheelchair with harness and placed in a Gerichair without any harness causing Resident #260 to move and fall to the floor. The findings include: 1. Resident #108 has diagnoses that included Cerebrovascular Disease (medical term for stroke, interruption in the flow of blood to cells in the brain),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-26 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 (NY00355337) the facility failed to ensure that a resident was treated with respect and dignity and cared for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. This was evident for one (1) out of six (6) residents (Resident #6) sampled. Specifically, on 09/24/2024 Licensed Practical Nurse #1 reported when they entered Resident #1's room the Resident immediately started to cry stating Certified Nursing Assistant #1 told them none of the staff members liked them. A Neuropsychology progress note by the Psychiatrist dated 09/24/2024 documented Resident #6 was upset and reported Certified Nursing Assistant #1 went off on them and told them they were the worst person. The findings are: The policy titled Promoting/Maintaining Resident Dignity 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 · Ecited before2023-10-23 · 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 observation and interview conducted during the Recertification survey 10/16/2023 to 10/23/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, 1) a dietary staff did not change contaminated gloves after disposing garbage and proceeding to handle soiled dishes which were scraped before cleaning for the tray line and no hand hygiene between changing gloves. This was observed during the Kitchen facility task. The findings are: The facility's policy and procedure dated 09/2023 titled Hand Hygiene, documented hand hygiene is the most effective method to prevent infections. Documented hand hygiene needs to performed when moving from dirty to clean and before donning gloves. The dietary department employee meeting sign in sheet date 8/4/2023 documented dietary aide received training that included hand hygiene. On 10/19/2023 at 03:51 PM - 4:26 PM, the Dietary Aide (DA) was observed transporting trash from the kitchen which was placed 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 · D2023-10-23 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview conducted during the recertification survey 10/16/2023 to 10/23/2023 and complaint NY00315981, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident on 2 of 13 units. (8 [NAME] and 10 West). Specifically, a live mouse was observed crawling in a resident's room on 8 [NAME] and in the hallway near the nursing station on the 10th floor. The facility policy and procedure titled Pest Control revised 03/2023 documented the facility is to maintain an effective pest control program that eradicates and contains common household pests and rodents that include roaches, ants, mice, and rats. The finding is: 1. On 10/18/2023 at 08:30 AM, while standing next to the nurses station on 10 [NAME] beside RN #3, a mouse was observed crawling from under the door of the staff lounge toward the documentation area located behind the nurses station. RN #3 present at the time of the mouse sighting stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-23 · 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 interview and record review conducted during the Recertification/Complaint Survey from 10/16/23 to 10/26/23, the facility did not ensure a comprehensive person-centered care plan (CCP) was reviewed and revised to address a resident's needs (NY00320501). This was evident for 1 of 3 residents (Resident #212) reviewed for Resident-to-Resident Physical Abuse out of 43 total sampled residents. Specifically, Resident #212's CCP related to at risk to be abused/abused others was not reviewed or revised after the Resident-to-Resident Physical Abuse allegation which occurred on 7/20/23. The findings are: The facility policy titled Comprehensive Care Planning with effective date August 2000 and last revised date 8/2022 documented the resident's comprehensive care plan (CCP) must be individualized and resident centered. Resident #212 had diagnoses of Acquired absence of left leg below knee, End stage renal disease, and Major Depressive Disorder. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a Recertification and Complaint survey (NY00323515) from 10/16/2023 to 10/23/2023, the facility did not ensure a resident received adequate supervision to prevent a resident from eloping. This was evident for 1 (Resident #592) of 3 residents investigated for Accidents out of an investigative sample of 43 residents. Specifically, Resident #592 left unit on 9/3/23 at approximately 10:23 AM to go to the lobby and sit in front of the building and was discovered missing at approximately 2:40 PM. The resident did not return to the unit for lunch served from 12:00 PM to 12:30 PM, and the medication nurse reported resident was not in room at 1:30 PM to receive medication. Resident was able to exit the lobby area undetected by staff by sliding under the fence on the outside of the building. The findings include: The facility policy titled Administrative/Resident care Policy & Procedure manual Prevention of resident Elopement dated last revised 9/2023 documented staff…
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 · D2023-10-20 · 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
Based on record review and interviews conducted during an Abbreviated Survey (NY 00319068), the facility failed to ensure that an alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, if the event that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause he allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency (NYSDOH). This was evident in one of the five residents reviewed for abuse (Resident #1). Specifically, on 04/26/2023 at approximately 5:00 PM, Behavioral Health Associate (BHA) #2 reported that BHA #1 grabbed their personal phone from Resident #1 hand in an aggressive way and bumped Resident #1's forehead. The incident was not reported to the New York State Department of Health (NYSDOH). The findings are: The facility's Policy and Procedure entitled Abuse with review date 07/2022, documented it is the policy of the facility that abuse allegations are reported as per Federal and State Law.…
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 · E2021-08-06 · tag F0604 — failed to not use physical restraints improperly — patternEnsure 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, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that residents were free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, Specifically, residents were observed with four side rails during multiple observations. This was evident for 3 of 3 residents reviewed for Physical Restraints out of a sample of 38 residents. (Resident #222, Resident # 296, Resident # 297). The findings include but are not limited to: The facility policy and procedure titled Restraint revised on 11/2020 documented that it is the facility policy to promote and encourage a restraint-free environment. The policy further states that all residents have the right to be free from physical restraints imposed for discipline or convivence and not required to treat the resident medical symptoms. Examples of Restraint include using side rails that keep residents from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-06 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the recertification Survey the facility did not ensure that it promoted and facilitated resident self-determination through support of resident choice. Specifically, residents bathing preferences were not honored. This was evident for 1 of 3 residents reviewed for Choices out of 38 sampled residents (Resident #45). The findings are: The facility policy titled Bathing the Resident revised in 12/2020 documented under section Shower under Documentation to Report any abnormalities observed or problems during procedure to the nurse. Document on CNA accountability record. Resident #45 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis and Heart Failure. The admission Minimum Data Set (MDS) 3.0 dated 05/05/2021 documented resident had intact cognition. The resident was totally dependent with assistance of one staff for bathing. The MDS also documented that it was very important to the resident to choose between tub bath, shower,…
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 before2021-08-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during recertification survey, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, the most recent MDS did not accurately capture that residents were receiving oxygen. This was evident for 2 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents (Resident # 41 and Resident # 222). The findings are: The October 2017 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.15, Section O: Special Treatment, Procedures, and Programs documented that the items in this section intend to identify any special treatment procedures and programs that the Resident received during the specified period. 1. Resident #222 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Renal Insufficiency. Physician Orders dated 05/23/2021 and 6/24/21 documented Oxygen…
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 before2021-08-06 · 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 staff interview conducted during the recertification, the facility did not ensure that a resident's person-centered, comprehensive care plans (CCP) were revised in a timely manner. Specifically, care plans were not revised after the quarterly assessment. This was evident for 1 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents. (Resident #41) The findings are: The facility policy titled Comprehensive Care Planning revised 1/2020, documented that it is the policy of the [NAME] Nursing Home to provide every resident with all the necessary care and services through a comprehensive, interdisciplinary systematic organized and timely plan, which promotes a culture of person -centered care. It also documented that the Interdisciplinary team members reviews the CCP periodically (not to exceed three months) and prior to the scheduled meeting. Resident #41 was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease, Asthma, and Seizure Disorder. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-08-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 staff interviews conducted during a recertification survey, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, a resident with a diagnosis of Alzheimer's Dementia was prescribed an anti-psychotic medication without documented evidence in the clinical record to support the use of psychotropic medication for the resident. This was evident for 1 of 5 residents reviewed for the Unnecessary Medication out of a sample of 38 residents. (Resident #67) The findings are: The facility policy and procedure titled Free from Unnecessary Psychotropic Drugs effective 11/28/2017 and last revised 10/2020 documented that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. The policy further documented that antipsychotic medication in persons with dementia should not be used if 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.
- No harm found · C2025-03-31 · 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 conducted during the Recertification Survey from 03/24/2025 to 03/31/2025, 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 in 5 (Residents #148, #318, #28, #102, #407) of 5 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings are: The facility's policy titled Completion Of Minimum Data Set (MDS0) 3.0 with a revised date of 2025 documented that specific information as to completion of the Minimum Data Set 3.0 (MDS) should be done according to the Resident Assessment Instrument (RAI) manual 3.0 version. 1. The Quarterly Minimum Data Set Assessment for Resident #148 with an Assessment Reference Date of 01/29/2025 was documented as submitted to the Centers for Medicare and Medicaid Services Data System on 03/20/2025. 2. The Annual Minimum Data Set Assessment 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.
“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
$55,231 in federal fines across 1 penalty.
- $55,231 — penalty dated 2025-06-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| AYALA, VICTOR | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| BULLOCK, REGINALD | Individual | CORPORATE DIRECTOR | since 01/02/2021 |
| CIUFFO, JOSEPH | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| GARCIA, LISA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 01/02/2021 |
| GREEN, RICHARD | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| KATZIN, ARYEH | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| LANZMAN, ALEXANDER | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2024 |
| MARSHALL, LEWIS | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2024 |
| MASON, HOPE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| MAWERE, JONATHAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2024 |
| NAIRNE, MICHAEL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| NELSON, HUGH | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2024 |
| REID, MAURICE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| ROSENFELD, PAUL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/02/2018 |
| ROVT, ALEXANDER | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| SCAGNELLI, MICHAEL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| SHELTON, MARK | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| SHTERN, NUSIN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| WATERMAN, ROBERT | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| WELLS, EDNA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| WHITE, HENNA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2021 |
| FIGUEROA, MICHELLE | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 01/01/2023 |
| SCOTT, SANDRA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| ONE BROOKLYN HEALTH SYSTEM, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| PARAJULI, SUNITA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| POLLACK, NEIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| CLEMENZA, ANTHONY | Individual | TRUSTEE OF THE SNF | since 01/01/2021 |
| ESSEN MEDICAL ASSOCIATES, PC | Organization | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 55 rows in the source record cover these 28 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.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $26.3M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335537. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-31, 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.