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The Monarch at Brooklyn Rehabilitation and Nursing

135 Linden Boulevard, Brooklyn, NY 11226 · For profit - Limited Liability company · 200 certified beds · (718) 693-6060 Medicare & Medicaid certified

Call the home — (718) 693-6060 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jul 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2503 Church Ave · (718) 928-7575 · Call to confirm hours
Pharmacy
2606 Church Ave · (718) 282-5504 · Call to confirm hours
Grocery
2186 Bedford Ave · (718) 940-4081 · Call to confirm hours
Park
(718) 408-6190 · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.5%14.1%15.4%better
Long-stay residents who lose too much weight7.9%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection1.9%1.3%2.0%typical
Long-stay residents with depressive symptoms4.0%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury1.4%3.1%3.3%better
Long-stay residents whose ability to walk worsened10.9%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication1.4%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine87.9%95.3%95.3%typical
Long-stay residents with pressure ulcers6.0%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control13.6%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table2.7%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine58.3%78.8%79.4%worse
Short-stay residents rehospitalized after admission18.6%20.6%22.6%better
Short-stay residents with an outpatient ER visit3.7%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.561.701.67typical
Long-stay outpatient ER visits per 1,000 resident days0.921.361.80better

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.

41.8% 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 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.8%U.S. median 51.5%
Got home and stayed home
9.0%U.S. median 10.7%
Went back to hospital
64.2%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 64.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 162 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.8%CMS range 32.8–51.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.0%CMS range 5.8–13.510.7%Oct 2022–Sep 2024no 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 discharge64.2%56.6%Oct 2024–Sep 2025CMS 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 discharge56.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge62.4%50.0%Oct 2024–Sep 2025CMS 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 identified96.7%98.7%Oct 2024–Sep 2025CMS 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 setting98.6%100.0%Oct 2024–Sep 2025CMS 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 discharge94.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.7%CMS range 5.8–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.491.02Oct 2022–Sep 2024CMS 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

0.62
RN hours/ resident / day
0.39
LPN hours/ resident / day
1.83
Aide hours/ resident / day
2.84
Total nurse hours/ resident / day
0.47
RN hoursweekends
44.1%
Total nursing turnover
52.5%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 192.6 residents a day — about 96% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.84 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.60 hrs/resident/day on weekends vs 2.94 on weekdays — 11% thinner on weekends. RN hours go from 0.68 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2025-08-14)
10
at the previous standard inspection (2023-09-15)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Dcited before2025-08-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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, the facility failed to maintain a resident's right to a safe, clean, comfortable homelike environment. This was evident in one (1) (Unit 4) of 5 units observed. Specifically, the unit hallway, dayroom, and pantry room were observed with dark, brown-colored stains on the floor. The floor edges were observed with old, yellow-colored grease-like stains. A heavy strong old odor was also noted. The findings include: The facility was not able to present a policy related to the deficiency. On 08/07/2025 at 10:15 AM, during observation in Unit 4, the floors in the hallway in front of the nursing station and in front of the elevator, entrance by the dayroom, and the pantry were observed with dirt, dark stains, and with old, yellow-colored grease-like stain. A heavy strong odor was also noted. There were 26 residents in the day room at the time of this observation. On 08/07/2025 10:59 AM, an interview was conducted with Licensed Practical Nurse #3. They stated that the hallway, at the front of the elevator, and towards the day room 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 interviews conducted during the Recertification survey from 08/07/2025 to 08/14/2025, the facility did not ensure that residents' Comprehensive Care Plans were reviewed and revised after each assessment. This was evident for one (1) (Resident #8) of five (5) residents reviewed for Unnecessary Medications. Specifically, there was no documented evidence that the Comprehensive Care Plans for Anticoagulation Therapy and Psychoactive Drug Use were reviewed and revised after the last quarterly Minimum Data Set assessment was completed.The findings include: The facility policy and procedure titled Comprehensive Care Plans dated 05/25/2025 stated 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 interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly Minimum…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the Recertification and Abbreviated Survey (Incident 673700) the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for one (1) (Resident #203) of two (2) residents reviewed for wandering and elopement out of 35 total sampled residents. Specifically, on 09/01/2024, Resident #203, who was severely impaired in cognition and had a wander alert device (a device that alerts staff when the resident is exiting the building), left the building undetected through the front door at 11:25 AM. Resident #203 was located by the facility staff approximately 300 feet from the facility and returned to the facility at 1:11 PM. The findings include:The policy and procedure titled Wandering and Elopement Risk with a last revised date of 05/20/2025 defined elopement as an occurrence when a resident leaves the premises or safe area without authorization and/or any necessary supervision to do so. The policy documented if a resident is identified as at risk for wandering, elopement, or other…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-03 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during an abbreviated survey (incident 673540), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) out of five (5) residents (Resident #3) sampled for abuse. Specifically, on 07/10/2024 at 9:00 PM, Resident #3's family reported to Registered Nurse Supervisor #2 that on 07/10/2024 at around 5:45 PM, Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 interviews conducted during the Recertification survey from 09/10/2023 to 09/15/2023, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during review of the kitchen facility task. Specifically, (1) staff were not wearing hair nets in the kitchen. (2) A staff member's personal bag was on the kitchen counter next to the meat slicer. (3) Food in the freezer was stored too close to the ceiling. (4) Food stored in the refrigerator was not covered and labeled. The findings are: Facility policy and procedure titled Date for Marking Food Safety dated 7/18/2023 documents the facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control safety for food. Facility policy and procedure titled Emergency Food Supply dated 7/18/2023 documents it is the policy of this facility to establish procedures to ensure that food is available for residents, staff, and volunteers in the case of an emergency. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 interviews and record reviews conducted during a Recertification Survey on 09/10/2023 to 09/15/2023, it was determined that for one (Resident #55) of seven residents, the facility did not ensure Resident # 55's property was safeguarded and free from loss or theft. Specifically, personal items which included 4-night gowns went missing. The facility did not investigate or complete a timely and thorough investigation of the missing property. Review of the facility policy and procedure titled, Resident Property documents the facility will maintain a safe environment for patient/resident property and will properly investigate all allegations of lost/missing or misappropriated property. The findings are: On 09/11/23 at 11:58 AM Resident #55 reported 4-night gowns missing for over a period of 3 weeks. Resident #55 stated that a room change was done and there were laundry bins in the bathroom that had the 4-night gowns, and the clothing went to the laundry and has not seen the clothing since. Resident #55 reported to the CNA the clothing was missing and was told they will check 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews during the recertification survey, the facility did not ensure that nursing staff implemented the interventions of a resident's comprehensive care plan (CCP). This was evident for 1 of 7 residents reviewed for Pressure Ulcer (Resident #25) out of a total sample of 38 residents. Specifically, Resident #25 did not have heel booties applied at all times as per the CCP for Pressure Ulcer prevention. The findings are: The Facility's Policy and procedure titled Skin and Wound Management issued on 2/07/2017 documented that it is the policy of the facility to maintain intact skin and to prevent avoidable pressure ulcer injury. Some of the limited measures that will be utilized to prevent skin breakdown include turning positioning, pressure relieving mattress, incontinence management, skin barrier, heel booties, heel offloading, wheelchair cushion and other positioning device, adequate nutrition and resident/family education. Resident #25 was admitted with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 the Recertification survey of 9/10/23 - 9/15/23, the facility did not ensure that the comprehensive care plans (CCPs)were reviewed and/or revised after each assessment and as needed to reflect changes in the resident needs. This was evident for 1 (Resident #60) of 8 residents reviewed for Activities of Daily Living (ADL) and 1 (Resident #46) of 5 residents reviewed for Unnecessary medications, out of an investigative sample of 38 residents. Specifically, (1) the Diabetes Mellitus CCP for Resident #46 was not reviewed and revised quarterly and after an episode of hypoglycemia. (2) the Dysfunctional coping or interaction CCP for Resident #60 was not reviewed and/or revised quarterly. The findings are: The facility policy and procedure titled Comprehensive Care Plan, effective date, and last review date of 5/15/23, documents each resident will have an individualized interdisciplinary plan of care in place. The comprehensive care plan will be reviewed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-15 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review conducted during a Recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure residents received proper treatment and assistive devices to maintain vision abilities. This was evident for Resident #52 and #103 reviewed for Communication. Specifically, 1) Resident #52 did not have a follow up consultation with the Ophthalmologist as recommended, and 2) Resident #103 did not have a recommended consultation with the Optometrist for glasses. The findings are: The policy titled Physician Services documented the attending physician is responsible for supervising follow-up visits. 1) Resident #52 had diagnoses of coronary artery disease and hypertension. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #52 was cognitively intact, had adequate vision, and wore corrective lenses. The Comprehensive Care Plan (CCP) related to sensory deficit initiated 1/5/2023 and last reviewed 7/26/2023 documented Resident #52 will use glasses 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, during the recertification survey, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. This was evident for 1 of 7 residents reviewed for Pressure Ulcer (Resident #25). Specifically, during multiple observations, Resident #25 was observed without heel booties in place as ordered. The findings are: The Facility's Policy and procedure titled Skin and Wound Management issued on 2/07/2017 documented that it is the policy of the facility to maintain intact skin and to prevent avoidable pressure ulcer injury. Some of the limited measures that will be utilized to prevent skin breakdown include turning positioning, pressure relieving mattress, incontinence management, skin barrier, heel booties, heel offloading, wheelchair cushion and other positioning device, adequate nutrition and resident/family education. Resident #25 was admitted with diagnoses which include Dementia,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2023-09-15 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during the recertification survey conducted 9/10/2023 to 9/15/2023, the facility did not ensure a system was established to record the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. This was evident for 1 (6th Floor) of 5 medication carts. Specifically, the 6th Floor medication cart Narcotics Log (NL) was incomplete and did not match the narcotics medication count in 2 blister packs. The findings are: The facility policy titled Control Substance Handling dated 5/15/2023 documented upon removal of a controlled substance from the packaging for administration, doses removed shall be documented on the NL On 09/13/2023 at 02:44 PM, the 6th Floor medication cart was observed with the following blister packs of narcotics medication: 4 pills of Pregabalin 1mg for Resident #47 25 pills of Clonazepam .5mg for Resident #75 The NL dated 9/13/2023 documented the following: 5 pills of Pregabalin 1mg for Resident #47 26 pills of Clonazepam .5mg for Resident #75 On 9/13/2023 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards. This was evident for 1 (6th Floor) of 5 floors. Specifically, an expired influenza vaccine vial was observed in the 6th Floor medication room. The findings are: The facility policy titled Medication Storage dated 5/15/2023 documented medication rooms are routinely inspected for outdated medications. These medications are destroyed in accordance with facility policy. The facility policy titled Destruction of Unused Drugs dated 05/15/2023 documented expired drugs shall be disposed of in accordance with state laws and regulations. Unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. On 09/13/2023 at 02:57 PM, a 2022-2023 Quadrivalent influenza vaccine vial .5 mL with an expiration date of 6/30/2023 was observed in the 6th Floor medication room refrigerator. On 9/13/2023 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-15 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose 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 conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure garbage and refuse was properly disposed. This was evident during the Kitchen facility task. 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. The findings are: The facility's policy and procedure titled Disposal of Garbage and Refuse dated 7/18/2023 documents the facility shall properly dispose of kitchen garbage and refuse. Dumpsters shall be emptied according to the facility contract. Garbage shall not accumulate or be left outside the dumpster. On 09/14/2023 at 01:05 PM an observation was made of the garbage dumpster area. Observed the trash compactor to be closed and locked, noted large flies and insects flying near the compactor. Garbage was observed scattered on the ground within the compactor area. Located near the garbage compactor additional observations made, noted laundry bins stored with dirty…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey from 9/10/2023 to 9/15/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #120) of 38 total sampled residents. Specifically, Registered Nurse (RN) #1 did not practice hand hygiene and glove changes and Licensed Practical Nurse (LPN) #5 did not properly handle sterile gauze during wound care for Resident #120. The findings are: The facility policy titled Hand Hygiene dated 5/15/2023 documented all staff will perform proper hand hygiene procedures to prevent the spread of infection. Resident #120 had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #120 was severely cognitively impaired and had unhealed stage IV pressure ulcer. On 9/13/2023 at 08:46 AM, LPN #5 and RN #1 were observed preparing to provide right ischium and sacral wound care to Resident #120. LPN #5 opened 3 packets 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-01-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 Recertification survey, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, potentially hazardous foods were not maintained at an acceptable temperature to prevent foodborne illness. This was evident during the Kitchen Observation task and 1 of units observed for Dining Observation task (2nd floor). The findings are: The facility policy and procedure titled Food Preparation and Handling reviewed 04/30/2016 documented to provide meals prepared using methods and techniques designed to preserve maximum nutritive value, enhanced flavor and be free of injurious organisms and substances. All meats will be heated to a safe minimum internal temperature. Final cooking temperatures. Monitor the foods internal temperature for 15 seconds. Foods should reach the following internal temperatures: poultry and stuffed foods - 165 degrees F, Ground meat, ground fish, and eggs held for service at least…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-01-03 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1) Oxygen tubing was observed touching the floor on three occasions. 2) A staff member was observed entering a room with signage of contact droplet precautions without wearing the appropriate Personal Protective Equipment (PPE). 3) There was no water management plan for Legionella with required components including but not limited to a) a facility-specific environmental risk assessment, b) a site-specific water management plan, or c) a sampling plan was in place. This was evident for 3 out of 37 residents (Residents # 95, #485 and #494 reviewed in the investigation sample. The findings are. The facility policy Infection Control dated 3/17/2020 documented transmission-based precautions and standard precautions to prevent the spread of infection and maintain the least restrictive precautions for residents based on their clinical…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-03 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during the Recertification/Complaint Survey (NY 00258651 & NY 00 267928) from 12/27/2021 to 1/3/2022, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1) no CCP was developed and implemented for residents with skin break and 2) no CCP was developed for resident on oxygen therapy. This was evident for 3 out of 7 residents reviewed for Pressure Ulcer/Injury (Resident # 391, # 341, and # 540), and 1 out of 1 resident reviewed for Respiratory Care (Resident # 95) out of a sample of 39 residents. The findings are: The facility's policy Multidisciplinary Comprehensive Care Plan reviewed 7/2/2018 documented this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residents…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-03 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews during the Recertification/Complaint Survey from 12/27/2021 to 1/3/2022, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag and tubing were left uncovered and exposed to public view. This was evident for 1 of 3 resident reviewed for Dignity (Resident #70) . The findings are: The facility's policy titled Resident Rights with effective date 8/2017 documented the facility is committed to assuring that all services meet high standards and that staff is respectful of individual needs, privacy and dignity. It is also documented under Resident Rights that the resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of facility. Resident #70 was admitted to the facility with diagnoses that included Retention of urine, unspecified; Malignant neoplasm of prostate; and Major depressive…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 interview conducted during a Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. Specifically, the patient tubs on the 2nd and 3rd floor were noted with stains on the bathtub that were discolored with pink and rust colored in the bathtub around the drain and leading down the wall from the tub handles. This was evident for 2 of 5 resident floors observed for the Environment (Floors 2 and 3). The findings are: The facility did not have a policy and procedure related to cleaning of the tubs. 1) On 12/30/2021 at 09:24 AM, the 3rd floor tub room was observed. There was a black colored stain in the middle of the tub seat. There was a lap belt with black spots on it, and the tub had brown rust stains and red spots in the area underneath the faucet and the bottom of the tub. On 12/31/2021 at 02:52PM, the 3rd floor tub room was observed again. The stains from the first observation were still present. There was water dripping from the pipe, and a scrub brush and vinyl glove were inside 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-03 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 from 12/27/2021 to 1/03/2022, the facility did not ensure an ongoing program of activities was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident based on the comprehensive assessment and care plan. Specifically, a resident was observed for extended periods of time not participating in meaningful activities. This was evident for 1 of 1 residents reviewed for Activities out of 37 sampled residents (Resident # 112). The finding is: The facility Policy and Procedure tilted Activities with reviewed on 10/13/2021 documented this facility to provide an ongoing program to support residents in their choice activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests and support the physical, mental 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-03 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 interview, observation and record review, the facility did not ensure that needed services, care and equipment was provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition. Specifically, a resident was observed on multiple occasions not wearing a palm guard as per Physician's order to improve resident's contractures. This was evident for 1 of 4 residents reviewed for Position/Mobility out of a sample of 38 residents. (Resident #29) The findings are: The facility policy titled Nursing Rehabilitation dated 09/10/17 and reviewed on 04/14/19, documented that the facility will provide the necessary care and services based on the comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences to maintain or improve the resident's ability to perform ADLs and to prevent decline unless its avoidable. Resident #29 was admitted to the facility with diagnoses that included…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-08-14 · tag F0641 — pattern
    Ensure 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 interview, the facility failed to ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident for 2 (Resident #12 and #188) of 35 total sampled residents. Specifically, 1.) Resident #188's Minimum Data Set assessment did not accurately reflect their fall history; 2.) Resident #12's Minimum Data Set assessment documented they had diagnosis of Post Traumatic Stress Disorder. There was no documented evidence that the resident had this diagnosis. The findings include: The facility policy and procedure titled Minimum Data Set Accuracy dated 5/20/2025 documented that it is the policy of the facility that any person completing a portion of the Minimum Data Set (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 1.) Resident #188 had diagnoses of Anoxic Brain Injury, Seizure, Depression and Asthma. A comprehensive care plan for falls was initiated for Resident #188 on 07/09/2024 and was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARERITE CENTERS — 34 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.6+1.4 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 33 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Bethany Center For Rehabilitation And Healing LLCNashville, TN 1 of 5Quality Center For Rehabilitation And Healing LLCLebanon, TN 2 of 5Nashville Center For Rehabilitation And Healing LlNashville, TN 2 of 5Sans Souci Rehabilitation And Nursing CenterYonkers, NY 2 of 5The Grove At Valhalla Rehab And Nursing CenterValhalla, NY 2 of 5The Paramount At Somers Rehab And Nursing CenterSomers, NY 2 of 5Waters Edge at Port Jefferson for Rehabilitation aPort Jefferson, NY 3 of 5Coral Reef Subacute Care Center LLCMiami, FL 3 of 5Encore At Boca Raton Rehabilitation And Nursing CeBoca Raton, FL 3 of 5Glengariff Health Care CenterGlen Cove, NY 3 of 5Green Hills Center For Rehabilitation And HealingNashville, TN 3 of 5Pearl At Fort Lauderdale Rehabilitation And NursinFort Lauderdale, FL 3 of 5Savoy At Fort Lauderdale Rehabilitation And NursinFort Lauderdale, FL 3 of 5The Emerald Peek Rehabilitation And Nursing CenterPeekskill, NY 3 of 5The Grand Pavilion For Rehab & Nursing at RockvillRockville Centre, NY 3 of 5The Willows At Ramapo Rehab And Nursing CenterSuffern, NY 3 of 5Trevecca Center For Rehabilitation And Healing LLCNashville, TN 4 of 5Chatham Hills Subacute Care CenterChatham, NJ 4 of 5Creekside Center For Rehabilitation And HealingMadison, TN 4 of 5Gallatin Center For Rehabilitation And HealingGallatin, TN 4 of 5Legacy At Boca Raton Rehabilitation And Nursing CeBoca Raton, FL 4 of 5Manchester Center For Rehabilitation And Healing LManchester, TN 4 of 5St James Rehabilitation & Healthcare CenterSt James, NY 5 of 5Cortlandt HealthcareCortlandt Manor, NY 5 of 5Lebanon Center For Rehabilitation And Healing, LLCLebanon, TN 5 of 5Luxor Nursing & Rehabilitation at Mills PondSt James, NY 5 of 5Palmetto Subacute Care CenterMiami, FL 5 of 5Sayville Nursing And Rehabilitation CenterSayville, NY 5 of 5The Chateau At Brooklyn Rehabilitation and NursingBrooklyn, NY 5 of 5The Enclave At Rye Rehab And Nursing CtrPort Chester, NY 5 of 5The Hamlet Rehabilitation and Healthcare Center atNesconset, NY 5 of 5The Phoenix Rehabilitation and Nursing CenterBrooklyn, NY 5 of 5The RiversideNew York, NY

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
JHSL 135 OPCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/01/2021
ZELMAN, ELIEZERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/01/2021
HOFFMAN, ELKYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 07/01/2021
MCLEAN-DAVIS, WINSOMEIndividualW-2 MANAGING EMPLOYEEsince 07/01/2021

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$29.3M
Net patient revenuemost recent cost report
-7.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 59%Medicare 16%Other / private 25%

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

$463per resident / day
operating cost
$14,086per month
≈ monthly operating cost
$431per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

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 335560. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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