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Haven Manor Health Care Center, LLC

1441 Gateway Boulevard, Far Rockaway, NY 11691 · For profit - Corporation · 240 certified beds · (718) 471-1500 Medicare & Medicaid certified

Call the home — (718) 471-1500 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609, F0610) — most recent Jan 2026Resident-funds citation (F0570)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0570)
  • 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
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5-29 Beach 20th St · (718) 327-7307 · Call to confirm hours
Pharmacy
1909 Cornaga Ave · (718) 327-7027 · Call to confirm hours
Grocery
18-16 Everdell Ave
Park
M S 530.3 mi
10-45 Nameoke St · (718) 327-3723 · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 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 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
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 increased13.5%14.1%15.4%better
Long-stay residents who lose too much weight2.6%5.8%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.5%0.9%better
Long-stay residents with a urinary tract infection1.6%1.3%2.0%better
Long-stay residents with depressive symptoms19.1%19.5%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained3.0%0.2%0.1%worse
Long-stay residents with falls causing major injury1.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened9.4%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.6%13.2%18.9%worse
Long-stay residents given the seasonal flu vaccine97.3%95.3%95.3%typical
Long-stay residents with pressure ulcers3.3%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control12.3%19.5%21.2%better
Short-stay residents rehospitalized after admission24.4%20.6%22.6%typical
Short-stay residents with an outpatient ER visit6.3%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.751.701.67worse
Long-stay outpatient ER visits per 1,000 resident days1.831.361.80typical

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.

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.

10.4%U.S. median 10.7%
Went back to hospital
69.0%U.S. median 56.6%
Met the expected recovery
0.09U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 69.0% 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 42 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.3–14.610.7%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 discharge69.0%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 discharge52.4%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 discharge52.4%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 identified98.5%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 setting100.0%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 dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%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 worsened4.6%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 hospitalization8.0%CMS range 4.3–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 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

0.36
RN hours/ resident / day
0.44
LPN hours/ resident / day
0.87
Aide hours/ resident / day
1.67
Total nurse hours/ resident / day
0.24
RN hoursweekends
27.3%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 240 beds and averages 214.0 residents a day — about 89% occupied, or roughly 26 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 1.67 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.87 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 1.37 hrs/resident/day on weekends vs 1.79 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.41 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below the national median of 45%.

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

Inspection trend

12
deficiencies at the latest standard inspection (2026-01-23)
9
at the previous standard inspection (2023-11-15)

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.

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Ecited before2026-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain the residents' right to a safe, clean, and comfortable environment. This was evident on the 6th Floor. Specifically, observation on the 6th Floor include but is not limited to stained ceiling tiles in some of residents' rooms, radiators were rusted and the base had cracks, window blinds had stains, bedside tables were dirty. The findings are:The facility's policy and procedure titled Maintenance Services with a reviewed date 01/2026 documented the Environmental Services Department is responsible for managing the maintenance function in the most cost-effective manner possible while maximizing the useful life of equipment, rooms, and properties while striving to provide the best service to our residents.Observations were conducted from 01/15/2025 at 10:00 AM to 01/23/2026 at 12:30 PM and the following were observed on the 6th Floor:1. The hallway ceiling was observed with brown colored stains.2. room [ROOM NUMBER] had cracked tile…

    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 before2026-01-23 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 observation, record review, and interview conducted during the Recertification Survey from 01/15/2026 to 01/23/2026, the facility did not ensure residents had a right to make choices regarding aspects of their life for two (2) of two (2) residents out of 38 residents reviewed for smoking. Specifically, the facility did not allow the residents to go out and smoke and did not offer a smoking cessation program for Resident # 103 and Resident #102, who were known smokers at the time of admission. The findings are:The policy and procedure titled 'Safe Smoking Program' reviewed 01/26 documented the facility will permit smoking in a designated area, at a designated time for those residents who choose to smoke while ensuring the safety of all other residents, staff and visitors. Residents who desire or request assistance with smoking cessation will be assisted through the Activities, Nursing and Social Service Departments. The policy also documented that smoking will be permitted only in the designated patio…

    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 · D2026-01-23 · tag F0582 — isolated
    Give 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

    Number of residents sampled: 3Number of residents cited: 1 Based on record review and interviews, the facility did not ensure that a resident or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for one (1) resident (Resident #216) of three (3) residents reviewed for Beneficiary Notification. Specifically, there is no documented evidence that the Notice of Medicare Non-Coverage form was mailed to Resident #216's designated representative on the same day the telephone notification was made.The findings are:The facility provided no policy and procedure on the delivery of the Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice.Resident #216 was discharged from skilled services on 01/14/2026 with 93 benefit days of Medicare Part A remaining and remained in the facility. The Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice were completed. The Notice of Medicare Non-Coverage documented Resident # 216's representative 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure residents' rights to privacy and confidentiality were maintained. This was evident for one (1) (2nd Floor) of two (2) units observed for medication administration. Specifically, Licensed Practical Nurse #3 walked away from the medication cart without locking the laptop computer exposing Resident #136's medical record. The findings include: The facility's policy titled Resident Privacy, Confidentiality, and Resident Records with a last reviewed date of 01/2026 documented that the facility will protect each resident's right to privacy and will maintain confidentiality and security of all residents' records. On 01/16/2026 at 9:30 AM, during medication pass observation on the 2nd Floor unit, Licensed Practical Nurse #3 left the medication cart with the computer laptop open and walked towards room [ROOM NUMBER]. The computer screen displayed Resident #136's medical record. There were two (2) housekeeping staff in the hallway directly…

    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 before2026-01-23 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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 interview, the facility failed to ensure residents were free from any physical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident for two (2) residents (Resident #143 and Resident #141) of three (3) residents investigated for Physical Restraint. Specifically, 1). Resident #143 was observed wearing a seat belt in wheelchair and Resident #143 stated they did not know how to remove the seat belt, and staff had to remove it. 2). Resident #141 was observed with a lap seat belt affixed while seated in a wheelchair on multiple occasions. Resident #141 was not able to remove the seat belt on their own.The findings are: The facility policy titled 'Restraints' dated last reviewed 1/2026 stated it is the facility's policy to promote and encourage a restraint- free environment. All residents have the right to be free from physical and chemical restraints imposed for the purposes of discipline 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure that a copy of the discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This was evident for one (1) of one (1) resident (Resident #214) reviewed for Discharge. Specifically, there was no documented evidence that a copy of Resident #214's discharge notice was sent to the Office of the State Long-Term Care Ombudsman.The findings are:The facility's policy and procedure titled Discharge Planning with a revision date of 09/2025 documented that when a resident's discharge plan has been determined, a Notice of Discharge is prepared, and a copy of the notice will be sent to the Long-Term Care Ombudsman, and a copy is retained by the facility in the resident record.Resident #214 was admitted to the facility on [DATE] with diagnosis including Kidney Failure, DM, Metabolic Encephalopathy, and borderline personality disorder.The discharge Minimum Data Set assessment dated [DATE] documented…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · 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 observation, record review, and interviews, the facility failed to ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for two (2) of 4 (four) (Residents #141 and #143) residents observed for restraints. Specifically, Residents #141 and #143 was observed on multiple occasions wearing seatbelts. There was no care plan developed for both residents to address ongoing use of restraints.Cross Reference F-tag 604: Right to be Free from Physical Restraints The findings include: The facility's policy titled Comprehensive Care Plan with a last reviewed date of 01/2026 documented that it is the facility purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable, and based on resident needs. The policy further documented the Comprehensive Care Plan should include…

    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 · D2026-01-23 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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, the facility failed to ensure that a resident who was administered enteral tube feedings received the appropriate treatment and services to prevent complications. This was evident in two (2) of two (2) (Residents #10 and #12) residents reviewed for tube feeding out of 38 total sampled residents. Specifically, Residents #10 and #12's enteral tube feeding formula and water bag were not labeled with the resident's name, the date and start time of the administration.The findings include:The facility's policy and procedure titled Enteral Feedings with a last revised date of 01/2026 documented that the formula containers will be labeled with resident's name, date, rate and time container was started. 1. Resident #10 was admitted with diagnoses that included Anemia, Parkinson's Disease, Malnutrition, Gastrostomy status.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #10 had severe impairment in cognition and required total dependence 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · 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, record review, and interview, the facility did not ensure that medication and biologicals drugs were labeled in accordance with currently accepted professional principles on the Medication Cart on the 4th floor. Specifically, Residents #119 and #186's eye drops did not have the resident's name on the vial. This was evident for one (1) (4th Floor) of five (5) units reviewed for Medication Storage. The findings are:The facility's Policy titled Label/Store Drugs and biologicals dated last review January 2026 documented all medications and the biologicals must remain in original Pharmacy labeled packaging, unless administered per authorized dispensing practice. The policy further documented the required elements as applicable include the resident name if resident -specific, medication name, strength, dosage form, directions for use, prescriber name, date dispensed, expiration date, Pharmacy name and Prescription number, On 01/20/2026 at 9:08 AM, during the medication storage facility task the fourth (4th) floor medication cart was examined with Licensed Practical…

    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 · Dcited before2026-01-23 · 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

    Based on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for one (1) of three (3)(Licensed Practical Nurse #3) nurses observed during medication administration. Specifically, Licensed Practical Nurse #3 failed to sanitize the sphygmomanometer (an equipment used to take blood pressure) and the blood pressure cuff before and after use and in between residents. The findings include: The facility's policy titled Reprocessing of Reusable Resident Medical Equipment with a last reviewed date of 01/2026 documented equipment or items in the resident environment likely to have been contaminated with infections fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agent example wearing gloves for handling soiled equipment, and properly clean and disinfect or sterilize reusable equipment. The policy…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2026-01-23 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 provide a safe and comfortable environment for the staff. This was evident during physical environment observation in the laundry room on the basement and the 6th Floor nurses' station.The findings include: The facility's policy and procedure titled Maintenance Services with a reviewed date 01/2026 documented the Environmental Services Department is responsible for managing the maintenance function in the most cost-effective manner possible while maximizing the useful life of equipment, rooms, and properties while striving to provide the best service to our residents.1. On 01/16/2026 at 9:41 AM, during observation in the laundry room at the basement, the back of washing machines #3 and #4 was rusted and the gray colored panels were loose and disconnected from the machine. 2. On 01/16/2026 at 12:19 PM, the nurses' station on the 6th Floor was observed with mismatched floor tiles, there was a brown colored substance on the wall under the desk, and the desk was chipped. On 1/23/2026 at 12:10 PM, the Maintenance…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-10 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during the abbreviated survey (#2650673), the facility did not ensure each resident's right to privacy and confidentiality. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, photographs of Resident #1's body and private space were taken without the resident's or designated representative's written consent. The findings include:The facility policy and procedure titled 'Photographs, video surveillance and audio recordings' dated 01/2022 documented the facility is committed to ensuring that the rights of the residents to safe and secure environment, privacy, confidentiality and dignity are maintained. The policy also stated to support accurate assessment and timely clinical decisions-making, authorized healthcare providers may take photographs or video during emergency situations when necessary to document the condition of a resident. Resident #1 was admitted with diagnosis including Non-Alzheimer's Dementia and Acute kidney failure.The Minimum Data Set (a resident assessment tool) dated 09/17/2025…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-04 · 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 (NY00333004), the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than two hours after the allegation of abuse was made, to the State Survey Agency (New York State Department of Health). This was evident in two out of four residents sampled (Residents #1 and #2). Specifically, on 02/04/24 at 1:00 am, Resident #1 informed the front desk Receptionist that Resident #2 climbed into their bed and took advantage of them. On 02/06/24 at 9:30 am, the facility reported the allegation to the New York State Department of Health, two days after the incident occurred. The findings include: The facility Policy and Procedure titled Abuse Prevention and Reporting Policy with a revised date of 04/13/23, documented that all alleged violations must be reported immediately but no later than 2 hours if the alleged violation involves abuse. The facility's Accident/Incident Report 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-15 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 11/8/2023 to 11/15/2023, the facility did not ensure the Director of Nursing (DNS) served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. This was evident for 1 (Unit 5) of 5 Units. Specifically, the DNS was observed working as a charge nurse and administered medication to residents. The findings are: The facility policy titled Competent Nursing Staff dated 1/1/2023 documented the facility will have sufficient nursing staff to provide nursing services. The facility census at the time of survey entrance on 11/8/2023 at 9:00 AM was 219 out of 240 available beds. On 11/14/2023 at 08:47 AM, the DNS was observed administering medication to a resident on Unit 5. On 11/15/2023 at 09:39 AM, the DNS was observed on Unit 5 administering medication to residents. The DNS was interviewed at the time of the observation and stated they need to attend to the residents' needs because the medication nurse scheduled to work did not come in and 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during a Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure a safe, clean, comfortable, and homelike environment was provided to residents. This was evident for 1 (Unit 2) of 5 resident units. Specifically, rusty bedframes were observed being used for Resident #372 and #152. The findings are: The facility policy titled Resident Right - Safe/Clean/Comfortable/Homelike Environment dated 11/15/2023 documented Maintenance staff were responsible for conducting environmental rounds per defined schedule of all units and other areas to identify building issues that require repair. All staff were responsible to report issues related to cleanliness and equipment. The Director of Maintenance follows up with the Administrator for any issues not addressed in a timely manner. On 11/13/2023 at 02:54 PM, observations of the Unit 2 were conducted and Resident #372 and Resident #152 were observed with rusty bedframes. On 11/14/2023 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-15 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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 observations, interview, and record review conducted during the Recertification Survey from 11/08/2023 to 11/15/2023, the facility did not ensure that residents remained free of physical restraints. This was evidenced for 2 (Resident #197, Resident #141) of 6 reviewed for Physical Restraints out of 38 total sampled residents. Specifically, 1) Resident #197 was observed with bilateral upper 1/2 siderails (SR) in place without assessment or Medical Doctor Order (MDO), and 2) Resident #141 was observed with bilateral 1/2 siderails (SR) in place without a restraint assessment or Medical Doctor Order (MDO). The findings are: The facility policy titled Restraints dated 11/13/2023 documented a physical restraint is any physical or mechanical device that the individual cannot remove easily which restricts freedom of movement, for example, side rails. The facility policy titled Side/Bed Rail dated 1/2023 documented the use of side rails is only permissible if they are used to treat a resident's medical symptoms…

    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 · Dcited before2023-11-15 · tag F0641 — isolated
    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 record review and interview conducted during the recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure accuracy of resident assessments. This was evident for 2 (Resident #110 and Resident #184) of 38 total sampled residents. Specifically, 1) the Minimum Data Set 3.0 (MDS) assessment for Resident #110 did not accurately reflect the resident's diagnoses, and 2) the MDS assessment for Resident #184 did not include the resident's use of a Wander Alert Device (WAD). The findings are: An undated facility policy titled Resident Assessment - MDS documented an accurate assessment of residents will be completed. 1). Resident #110 was diagnosed with schizophrenia and depression. The MDS assessments dated 7/27/2023 and 10/25/2023 documented Resident #110 was severely cognitively impaired. The MDS assessments did not document Resident #110 was diagnosed with schizophrenia, bipolar disorder, or depression. The Comprehensive Care Plan (CCP) related to psychotropic drug use initiated…

    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 · D2023-11-15 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 from 11/08/2023 to 11/15/2023, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility. This was evident for 1 (Resident #472) of 38 total sampled residents. Specifically, Resident #472 did not have a Preadmission Screening and Resident Review (PASARR) completed prior to their admission to the facility. The findings are: The facility policy titled admission Screening Procedures dated 1/2022 documented the Screen was reviewed to determine if the could meet the applicant's needs. Resident #472 was admitted to the facility on [DATE] with diagnoses of osteoarthritis and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #472 was severely cognitively impaired. There was no documented evidence that a PASARR was completed for Resident #472 prior to their admission to the facility. On 11/15/2023 at 02:59 PM,…

    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 · D2023-11-15 · 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 observation, record review, and interviews conducted during the Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure comprehensive care plans (CCP) were reviewed and revised after each assessment. This was evident for 1 (Resident #110) of 38 total sampled residents. Specifically, the CCPs related to Activities of Daily Living (ADL) and psychotropic drug use were not reviewed and revised upon quarterly Minimum Data Set 3.0 (MDS) assessment. The findings are: An undated facility policy titled CCP documented goals, objectives, and interventions are reviewed and/or revised by the Interdisciplinary Team (IDT) at least quarterly and after each scheduled MDS assessment. Resident #110 had diagnoses of non-Alzheimer's dementia and diabetes mellitus. The MDS assessment dated [DATE] documented Resident #110 was severely cognitively impaired, required limited assistance for dressing, toilet use and personal hygiene, and required supervision for eating. The 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-15 · 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, record review, and interview conducted during the recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure residents received proper treatment and services to maintain vision abilities. This was evident for 1 (Resident #143) resident of 38 total sampled residents. Specifically, Resident #143 did not receive a Ophthalmology consult in accordance with Medical Doctor Order (MDO). The findings are: The facility policy titled Consultation In-House and Outside Appointment dated 1/1/2023 documented all consultations ordered by the attending physicians will be completed for residents in a timely manner. Resident #143 had diagnoses of hypertension and hyperlipidemia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #143 was cognitively intact and had impaired vision. On 11/08/2023 at 10:49 AM, Resident #143 was interviewed and stated they were almost blind in their left eye, was supposed to have a follow up with the eye doctor, and was promised they…

    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 · D2023-11-15 · 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, record review, and interview conducted during the Recertification survey from 11/08/2023 to 11/15/2023, the facility did not ensure an account of all controlled drugs was maintained as per standard of practice. This was evident for 1 (Unit 6) of 5 Units. Specifically reconciliation of narcotics was performed by 1 Licensed Practical Nurse (LPN). The findings are: The facility policy titled Medication Administration dated 03/2021 documented controlled substances count will be conducted by two (2) nurses (on-coming and outgoing) each shift. On 11/10/2023 at 03:12 PM, LPN #6 was observed counting narcotics on Unit 6 alone and without a second nurse present. On 11/10/2023 at 03:13 PM, LPN #6 was interviewed and stated 2 nurses were supposed to count the narcotics at shift change. LPN #1 from the outgoing shift left the unit already and LPN #6 did not inform the Registered Nurse (RN) Supervisor. On 11/13/2023 at 02:15 PM, LPN #1 was interviewed and stated they had a personal emergency and was unable to remain on the unit to reconcile the narcotics with LPN #6. LPN #1…

    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 · Dcited before2023-11-15 · 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, record review, and interview conducted during the Recertification survey from 11/08/2023 to 11/15/2023, the facility did not ensure infection prevention and control practices were maintained. This was evident for 1 (Resident #152) of 3 residents reviewed for Pressure Ulcer/Injury, out of 38 total sampled residents. Specifically, the Registered Nurse (RN) failed to practice hand hygiene and glove changes during wound care. The findings are: The facility's policy titled Dressing (Aseptic), revised on 1/21, documented that staff will perform wound and pressure ulcer dressing procedures according to aseptic (clean) technique, purpose is to promote rapid healing through aseptic method of applying the prescribed treatments. The policy also documented to apply clean gloves and cleanse wound using even strokes, remove gloves, wash hands and don clean gloves, and apply medication/treatment as ordered and secure the dressing. Resident #152 was admitted to the facility with diagnoses 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 · F2021-08-19 · tag F0570 — widespread
    Assure the security of all personal funds of residents deposited with the facility.
    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 during the Recertification survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds was purchased. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 165 of 172 residents who maintained personal funds accounts at the facility and was evident during the Personal Funds Facility Task. The findings are: The Facility Policy titled Resident Banking - Management of Personal Funds established 12/2010 documented- the Chief Financial Officer/designee will maintain a system that assures a full and complete separate accounting, according to generally accepted accounting principles, or each resident's personal funds entrusted to the facility on the resident's behalf . The policy did not containing reference to possession of a surety bond and how this would be managed. 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 · E2021-08-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the Recertification Survey, the facility did not ensure that resident received appropriate care and services for catheter care. Specifically, two residents with suprapubic indwelling catheters did not have their catheters changed as ordered. This was evident for 2 of 3 reviewed for Urinary Catheters or Urinary Tract Infections (UTI) out of a sample of 36 residents, (Resident #73 and Resident #94) The findings are: The facility's Policy and Procedure on Care of Resident with Indwelling Catheter revision date 1/2021 documented that indwelling catheters should only be inserted when necessary for the following residents resident has acute urinary retention or bladder outlet obstruction. The policy also documented indwelling catheters should not be changed routinely exceptions include physician order to change catheter. 1. Resident #73 was admitted to the facility with diagnoses that included Unspecified Dementia without behavioral disturbance,…

    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 · Ecited before2021-08-19 · tag F0880 — failed to prevent and control infections — pattern
    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, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1). a Housekeeping Aide (HA) did not perform hand hygiene after handling bed linen in resident rooms and before handling clean linen and after removing gloves, and 2). a Licensed Practical Nurse was observed during medication observations using the same tissue to instill eye drops to both eyes of a resident. The findings are: The facility policy titled Hand Washing Guidelines, revised 01/2021, documented all personnel wash their hands appropriately in accordance with current standards of practice and CDC guidelines. To reduce the risk of nosocomial infections by decreasing the risk of transmission of pathogenic microorganisms to residents and other persons with 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-19 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 observation, interviews, and record reviews, conducted during Recertification survey, the facility did not ensure that the residents right to self-determination to make choices are respected. Specifically, the facility smoking program was cancelled on 03/20/2020 and residents were not given the choice to smoke when small group activities resumed. This was evident for 1 out of 4 resident review for Choices (Resident # 168) The findings are: The facility's policy and procedure titled Safe Smoking Program revised in 01/2021 documented that to maintain the highest quality of life for all residents, the facility will permit smoking in the designated area at a designated time for those residents who choose to smoke. The revised policy contained no documentation that the smoking program had been canceled due to the COVID-19 pandemic. Resident # 168 was admitted to the facility with diagnoses which include Schizophrenia and Hypertension. The Minimum Data Set (MDS) dated [DATE] documented Resident # 168 had…

    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 before2021-08-19 · 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 interview and record review conducted during a recertification and complaint investigation (NY00278371) completed on 8/19/2021, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, to the State Survey Agency. Specifically, the facility did not report an incident of resident-to-resident physical abuse that occurred on 6/22/2021 to NYSDOH until 6/23/2021. This was evident for 2 of 7 residents reviewed for Abuse (Resident # 101 and Resident # 424). The finding is: The facility policy and procedure titled Abuse Reporting revised 1/2017 documented it is the facility's responsibility to report incidences to the NY DOH as per guidance in the Nursing Home Incident Reporting Manual- August 2016. It is the facilities responsibility to notify local authorities per guidance of the Elder Justice Act if reasonable suspicion of a crime against an individual who is a resident of, or receiving care form, the facility. This…

    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 · D2021-08-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and staff interviews during the recertification survey the facility did not ensure that an incident was thoroughly investigated. Specifically, the facility did not obtain staff statements from all witnesses on the previous shift for an investigation conducted regarding a resident who was transferred to the hospital for evaluation after an allegation of sexual assault. This was evident for 1 out of 7 residents reviewed for Abuse out of 36 sampled residents. (Resident #95). The finding is: The facility policy and procedure titled Abuse Reporting revised 1/2017 documented it is the facility's responsibility to report incidences to the NY DOH as per guidance in the Nursing Home Incident Reporting Manual- August 2016. The policy also documented all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation…

    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
  • No harm found · Bcited before2026-01-23 · 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 interviews, the facility failed to ensure that Minimum Data Set assessments accurately reflected the resident's status. This was evident for three (3) of 3 (three) (Residents #141, 100, and 143) reviewed for resident assessment. Specifically, 1.) Resident #141's use of restraint was not accurately documented in the Minimum Data Set assessment. 2.) Resident #100 who had a physician's order for clopidrogel (an antiplatelet drug used to prevent blood clot by preventing platelets from clumping together in the blood), was coded in the Minimum Data Set assessment as receiving anticoagulant. 3.) Resident #143's use of restraint was not accurately documented in the Minimum Data Set assessment. Cross Reference to F-tag 604: Right to be Free from Physical RestraintsThe findings include: The facility's policy titled Resident Assessment Minimum Data Set 3.0 with a last reviewed date of 01/2026 documented it is the policy of the facility to ensure a comprehensive and accurate…

    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.

Who owns this facility

Owner / managerTypeRoleShareSince
CYTRYN, ARONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF99%since 04/08/2025
CYTRYN, DAVIDIndividualDIRECT OWNERSHIP INTERESTsince 12/17/2007
BORELLO, NANCYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
SAIF, MOHAMMEDIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 04/08/2025
PIERRE, KETTLYNEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/05/2023
CANTOR TRUSTOrganizationADP OF THE SNFsince 06/03/2025
HAVEN MANOR ASSOCIATES LLCOrganizationADP OF THE SNFsince 06/03/2025
MANOR HAVEN ASSOCIATESOrganizationADP OF THE SNFsince 02/19/1974

CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$24.8M
Net patient revenuemost recent cost report
-0.8%
Operating marginrevenue minus expenses
$356K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 90%Medicare 3%Other / private 6%

About 90% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $356K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$330per resident / day
operating cost
$10,037per month
≈ monthly operating cost
$328per 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 335676. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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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