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Rockaway Care Center

353 Beach 48th Street, Far Rockaway, NY 11691 · For profit - Individual · 228 certified beds · (718) 471-5000 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609) — most recent Dec 20251 immediate-jeopardy citation$135,193 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $135,193 in federal fines (most recent 2025-04-25)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
238 Beach 20th St · (718) 327-2555 · Call to confirm hours
Pharmacy
342 Beach 54th St · (718) 634-5890 · Call to confirm hours
Grocery
Sandra 0.1 mi
325 Beach 46th St · (612) 451-6317 · Call to confirm hours
Park
3-85 B 45 St · Typically dawn to dusk
Place of worship
49-15 Rockaway Beach Blvd · (718) 337-5080

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 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 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 increased5.3%14.1%15.4%better
Long-stay residents who lose too much weight6.4%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.5%0.9%better
Long-stay residents with a urinary tract infection0.3%1.3%2.0%better
Long-stay residents with depressive symptoms16.5%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.9%0.2%0.1%worse
Long-stay residents with falls causing major injury0.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened6.6%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.4%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine96.2%95.3%95.3%typical
Long-stay residents with pressure ulcers8.3%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control14.2%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.6%13.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.1%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine62.4%78.8%79.4%worse
Short-stay residents rehospitalized after admission22.5%20.6%22.6%typical
Short-stay residents with an outpatient ER visit16.2%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.211.701.67better
Long-stay outpatient ER visits per 1,000 resident days3.011.361.80worse

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.

12.8%U.S. median 10.7%
Went back to hospital
35.5%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 35.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 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 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 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 SNF12.8%CMS range 9.0–16.510.7%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 discharge35.5%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 discharge25.8%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 discharge32.3%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 identified100.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 stay6.1%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 worsened0.0%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 hospitalization9.0%CMS range 5.4–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.291.02Oct 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

0.77
RN hours/ resident / day
0.43
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.14
Total nurse hours/ resident / day
0.59
RN hoursweekends
45.1%
Total nursing turnover
53.8%
RN turnover

How full it usually is: this home is certified for 228 beds and averages 211.1 residents a day — about 93% occupied, or roughly 17 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 2.83 hrs/resident/day on weekends vs 3.26 on weekdays — 13% thinner on weekends. RN hours go from 0.84 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.

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

Inspection trend

13
deficiencies at the latest standard inspection (2025-12-10)
7
at the previous standard inspection (2023-07-27)

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.

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · J2025-04-25 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during an abbreviated survey (NY00376954), the facility failed to ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. This was evident in 1 out of 10 residents (Resident #1) sampled for behavioral health. Specifically, from [DATE] through [DATE], Resident #1 who had a diagnosis of Huntington's Chorea Disease (a neurological disorder that causes nerve cells in the brain to break down and die, leading to uncontrolled movements, cognitive decline, and personality changes) exhibited and verbalized suicidal ideation with increased agitation and behavioral disturbances. On [DATE], [DATE], and [DATE], Resident #1 was observed by the facility's nursing staff attempting to open their room window and the windows in other resident rooms, successfully removing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-12-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during an abbreviated survey (459982), the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was evident in one (1) of 12 residents (Resident #1) sampled for elopement. Specifically, Resident #1 left the building on 02/17/2025 at 4:03 PM after being buzzed out the exit door in the lobby by Security Guard #1. Facility staff did not become aware that Resident #1 was not in the building until 5:35 PM. On 02/18/2025 at 1:20 AM, the hospital notified Nursing Supervisor #2 that Resident #1 was in the hospital. A review of the hospital Discharge summary dated [DATE] revealed Resident #1 was admitted to the hospital with diagnoses of encephalopathy (any disease or disorder that affects brain function or structure) secondary to hypothermia (core body temperature drops below 95 degrees Fahrenheit), and acute kidney injury. This resulted in actual harm to Resident #1 that was not Immediate…

    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 · F2025-12-10 · tag F0756 — failed to review each resident's drug regimen — widespread
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled: 5Number of residents cited: 5 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. This was evident for five (5) of (5) residents (Resident #4, #10, #7, #6, and #221) reviewed for Unnecessary Medications out of 41 sampled residents. Specifically, there was no documented evidence in the clinical records of Residents #4, #10, #7, #6, and #221 that monthly Medication Regimen Reviews were completed. The findings include but are not limited to: The facility policy titled 'Medication Regimen Review' dated 12/31/2023 stated the Consultant Pharmacist will perform Medication Regimen Reviews for each resident at least monthly and for all newly admitted residents. The policy also stated the Consulting Pharmacist will document in the resident's medical record that the monthly Drug Regimen Review and whether there are any recommendations in the electronic medical record. 1.Resident #4 was admitted to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-10 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification conducted from 09/24/2025 to 10/01/2025, the facility did not ensure sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). Residents reported the facility was short staffed with Certified Nursing Assistants, especially on weekends both days and nights, which resulted in a lack of timely staff response to call bells and delays in performing Activities of Daily Living and personal care. 2). The facility Payroll Based Journal for Quarter 3 (April 1 - June 30) also revealed an excessively low weekend staffing, and 3). Review of the actual staffing schedules dated from 04/01/2025 to 06/30/2025 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment.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 · E2025-12-10 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record reviews conducted during the Recertification survey, the facility did not ensure a performance review of every nurse aide was completed at least once every 12 months, and regular in-service education was based on the outcome of these reviews. This was evident during a review of Sufficient and Competent Nursing Staffing task. Specifically, six (6) of six (6) Certified Nursing Assistant personnel files contained no evidence of yearly performance evaluations and in-services based on the results of performance evaluations. The findings are:The facility policy and procedure titled 'Staffing, Hiring, Application Process and Training' last reviewed 02/06/2024, stated it is the policy of the facility to assure there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the needs safely and in a manner that promotes each residents rights, physical, mental and psychosocial well- being. 24 hour qualified staffing will be provided and staff replaced based on evaluation and review. Annual performance reviews…

    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 · E2025-12-10 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 the medication error rate was less than 5 percent. This was evident for 2 of 32 medications observed during the Medication Administration task. Specifically, Resident #180 was given the wrong dose of Lopressor 25 mg tablets and, Zyprexa 35 mg was also administered at the wrong time. This resulted in a medication error rate of 6.5%.The findings are:The facility policy titled 'Medication Administration' dated 9/20/2021 stated each resident will be provided with medication administration as ordered by the primary medical doctor. The policy also stated Licensed Nurses will have a medication competency done yearly as needed to ensure compliance with safe medication administration.A Medication Administration competency dated 8/18/25 for Registered Nurse #3 documented general guidelines which includes compares each medication label to medication administration record, ensures each order is correct for: medication, strength, route and time prior to pouring…

    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 · E2025-12-10 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure garbage and refuse were disposed of properly. Specifically, the garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests. The findings are:The facility's policy and procedure titled 'Handling, Transporting and Disposing of Trash' reviewed 9/24/2025 stated trash must be stored in refuse containers that are seamless and constructed of easily cleanable material equipped with a tight-fitting lid.On 09/26/2025 at 12:19 PM, Dietary Worker #1 was observed taking garbage from the kitchen to the garbage disposal area located outside of the building. The compactor was observed without a door and exposed piled garbage bags. Multiple flies were observed on the garbage bags and around the opening of the compactor. A door was detached and observed next to the compactor.On 09/29/2025 at 10:45 AM, the compactor was observed again without a door and with door on the ground next to it. Multiple flies were noted on the garbage…

    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 · E2025-12-10 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review conducted during the Recertification survey, the facility did not ensure the facility-wide assessment was updated to include and address the total resident population and resources that were necessary to care for those residents. This was evident during a review of Sufficient and Competent Nursing Staffing. Specifically, 1). the Facility Assessment did not identify or address care for ventilator dependent residents in the total population of services offered including respiratory therapist personnel required to meet that populations daily staffing needs, and 2). on-site hemodialysis treatment was listed as a service provided and the facility did not have a certified dialysis unit.The findings are:The facility policy and procedure titled 'Facility Assessment' last reviewed 07/15/2025, stated the facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including night and weekends) and emergencies. The policy also…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-10 · 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

    Number of residents sampled: 7Number of residents cited: 1 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure infection control practices and procedures were maintained. This was observed during medication administration for one (1) of seven (7) residents (Resident #187) observed. Specifically, Enhanced Barrier Precautions were not used when Registered Nurse #5 administered medications to Resident #187 via the gastrostomy tube.The findings are:The facility's policy titled Enhanced Barrier Precautions with a review date of 12/12/2023, stated it is the policy of this facility to adhere to the Centers for Disease Control and Prevention guidelines as related to Enhanced Barrier Precautions in order to prevent the transmission of multidrug-resistant organisms amongst residents and healthcare workers. The policy also stated the facility will implement enhanced barrier precautions during high-contact resident care with examples of high-contact resident care activities to include device care or use - central line,…

    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 · E2025-12-10 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during the Recertification survey, the facility did not ensure a building elevator was maintained in a safe working condition. This was observed in one (1) of three (3) elevators (Elevator #2) observed. Specifically, Elevator #2 was broken and out of service for over 10 months, causing delays and restricting resident movement around the facility, including attending medical appointments. The findings are: Observations conducted from 09/24/2025 to 10/01/2025 between the hours of 10:00 AM and 3:00 PM revealed Elevator #2 was not in good working condition. A security staff was positioned inside Elevator #2 to move passengers from floor to floor and the unit staff were observed paging the front door security staff to send Elevator #2 to various units when needed. Facility is a six floored building with 3 elevators located near the lobby. There were 2 passenger elevators (Elevator #1 and #2, and Elevator #3 was designated as a service elevator and used primarily for transporting goods, equipment, and staff only. On 09/26/2025…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-10 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled: 2Number of residents cited: 1 Based on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced dignity. This was evident for one (1) of two (2) residents (Resident #12) reviewed for Catheter out of a sample of 41 residents. Specifically, Resident #12's foley catheter drainage bag and tubing were not covered with a privacy bag.The findings are:The facility policy titled 'Indwelling Foley Catheters' last reviewed 09/02/2022 stated a drainage bag cover should be utilized to maintain resident dignity.The facility policy titled 'Resident Right to Privacy and Dignity', last reviewed 01/2025 stated that residents are treated in a dignified manner and their privacy rights are upheld as outlined in the Resident [NAME] of rights.Resident #12 was admitted to the facility with diagnoses which include Obstructive uropathy, Seizure Disorder, and Acute kidney failure.The admission Minimum Data Set (an assessment tool) dated 08/06/2025 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 · Dcited before2025-12-10 · 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

    Number of residents sampled: 2Number of residents cited: 1 Based on observations, record reviews, and interviews conducted during the Recertification and abbreviated survey (460002), the facility did not ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. This was evident for one (1) of two (2) residents (Resident #9) reviewed for Physical Restraints out of 41 sampled residents. Specifically, Resident #9 was observed by facility staff in their bed restless and agitated while on a mechanical ventilator, with each hand inside a pillowcase wrapped with tape around their wrists. The findings are: The facility policy titled 'Restraints' dated 07/08/25 stated it is the policy of the facility to promote and maintain residents' highest practicable well-being in a restraint free environment and only utilize a physical restraint in a circumstance in which the resident has medical symptoms that may warrant the use of a restraint. The facility policy also stated 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-12-10 · 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

    Based on record review and interviews conducted during the Abbreviated (459971) and Recertification survey, the facility did not ensure 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, mental and psychosocial needs. This was evident for one (1) of two (2) residents (Resident #223) reviewed for Hospitalization out of 41 sampled residents. Specifically, there was no comprehensive care plan developed for tracheostomy care for Resident #223.The findings are:The facility policy and procedure titled 'Comprehensive Care Planning', last reviewed 10/16/2023, stated each resident will have a comprehensive person-centered care plan developed that is in compliance with Federal and State regulations. The facility will establish an interdisciplinary team care planning process to ensure resident care and treatment is planned appropriately for the resident's needs and condition, impairment, disability or disease process in a timely, systematic and comprehensive manner.…

    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 · D2025-12-10 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews conducted during the Recertification survey, the facility did not ensure that the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for one (1) of two (2) residents (Resident #9) reviewed for Physical Restraint out of 41 sampled residents. Specifically, there was no documented evidence bilateral hand mittens for Resident #9 were released every two-hours as per Physician's order. The findings are: The facility policy titled 'Restraints' dated 07/08/25 stated it is the policy of the facility to promote and maintain residents' highest practicable well-being in a restraint free environment and only utilize a physical restraint in a circumstance in which the resident has medical symptoms that may warrant the use of a restraint. The facility policy also stated staff would monitor and document the use of physical restraint on resident's medical records as indicated by the Interdisciplinary team. Resident #9 had diagnoses which included Acute…

    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 · D2025-12-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during the Abbreviated (459994) and Recertification survey, the facility did not ensure the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for one (1) of two (2) residents (Resident #229) reviewed for Hydration out of a total of 41 sampled Residents. Specifically, a Comprehensive Metabolic Panel laboratory test was ordered for Resident #229 on 04/09/2025, there was no documented evidence that blood test was performed. The findings are: The facility policy titled 'Laboratory and Diagnostic Test' reviewed 04/01/2025, stated it is the policy of the facility that all diagnostic interventions will be provided as ordered by the physician. The physician/designee will identify, and order laboratory testing based on the resident's monitoring needs. The license nursing staff will process test requisitions. The laboratory providers will report test to the facility. The results of diagnostic testing will be reviewed by the nursing and medical staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 2Number of residents cited: 1 Based on observation, record review, and interviews during the Recertification survey, the facility did not ensure the resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident for one (1) of two (2) residents (Resident #225) reviewed for Hydration out of 41 total sampled residents. Specifically, Resident #225, who had a physician's order for thickened liquid, was observed drinking coffee and water without a thickener.The findings are:The facility's policy titled 'Aspiration Precautions' reviewed on 5/31/23 stated it is the policy of this facility to identify residents who are at potential risk for aspiration and to implement interventions that will prevent aspiration and easily alert staff of who those residents are. The policy also stated the resident's meal tickets will be updated by the Food Service Director/Dietitian to indicate the diet texture, thicken…

    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 · D2025-12-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure residents who needed respiratory care were provided care that was consistent with professional standards of practice. This was evident for one (1) of two (2) residents (Resident #78) reviewed for Respiratory Care out of a total sample of 41 residents. Specifically, Resident #78 was observed with an undated oxygen nasal cannula and an undated nebulizer mask and tubing. The findings are:The facility policy titled 'Oxygen Therapy' reviewed on 07/30/2021 stated residents will be provided with oxygen therapy as ordered by the Medical Doctor. When a resident uses oxygen on an as needed basis, the tubing will be labeled and placed in a zip locked bag until needed for use. When a resident has nasal cannula tubing for the concentrator, and a 2nd for use the oxygen tank, the tubing not in use must be secured in a plastic bag (dated and changed weekly). The 11-7 nurse will change and date all oxygen delivery equipment on Sunday.Resident #78 was admitted to the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-10 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a Quality Assurance and Performance Improvement program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents. Specifically, 1.) the facility had pattern deficiencies in the areas of Resident Rights, Sufficient Nursing Staff, Pharmacy Services, Administration, Infection Control and Physical Environment, and 2). There were repeated deficiencies from the last survey conducted from 07/20/2023 through 07/27/2023. (Refer to F604 and F880)The findings are:The facility's Quality Assurance and Performance Improvement Plan with a revision date of 07/08/25 documented the plan was designed to provide guidance in assessing and improving overall quality of care and quality of resident life. Focus areas will include all systems that affect resident and family satisfaction, quality of services and care provided, and all areas that affect the quality of people living and working in 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · 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

    Based on observations, record review, and interviews during an abbreviated survey (NY00360059), the facility did not ensure that a resident care plan was reviewed and revised by the interdisciplinary team. This was evident in one (1) out of ten (10) residents (Resident #2) sampled. Specifically, on 11/11/2024 Resident #2 alleged Certified Nursing Assistant #5 hit them on their head and pushed them to the ground on the evening of 11/10/2024. The facility investigated the allegation and concluded that the abuse allegation was inconclusive. Resident #2's care plan was not reviewed and revised to reflect the allegation of abuse and it's outcome. The findings include: The facility's Policy and Procedure titled Comprehensive Care Planning dated 03/10/2025, documented the facility utilizes an interdisciplinary team to provide an individualized comprehensive resident assessment and care planning process in order to maximize and maintain every resident's functional potential and quality of life. The care plan is revised when appropriate to reflect the resident's current needs based on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during an abbreviated survey, (NY00376954), the facility failed to ensure that the physician reviewed the resident's total program of care, including medications, at each visit. This was evident in one (1) out of ten (10) residents (Resident #1) sampled for quality of care. Specifically, Resident #1 who exhibited increased agitation with behavioral disturbances secondary to Huntington's Disease, verbalized suicidal ideation from [DATE] to [DATE]. Resident #1 was transferred to the hospital emergency department on [DATE], [DATE], and [DATE]. A Patient Visit Information (Hospital Discharge Summary) from the hospital emergency department dated [DATE], documented as recommended on [DATE], Abilify 20 milligram to be decreased to 10 milligram daily due to the risk of akathisia restlessness, and agitation. There was no documented evidence that a physician reviewed the hospital emergency room discharge summary and recommendation. There were no physician's…

    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 before2023-07-27 · 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 7/19/2023 to 7/27/2023, the facility did not ensure a resident remained free of physical restraints. This was evidenced for Resident #88 reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #88 was observed with bilateral 1/2 SR in place and unable to independently use or release the SRs. The findings are: The facility's policy titled Side Rail Usage last reviewed 10/1/22 dated 10/1/2022 documented partial SR will only be used by a resident to assist with his or her bed mobility and will not interfere with the resident's ability to egress from the bed surface. The Rehab Therapist will complete the Rehab SR assessment found in the electronic medical record (EMR). Resident #88 had diagnoses of seizures and Cerebral Vascular Accident (CVA). The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #88 was moderately cognitively impaired, totally dependent on 2 people for…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · 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 interviews and record review conducted during the Recertification and Complaint Survey (NY00303837) from 07/19/2023 to 07/27/2023, the facility did not ensure all alleged violations involving abuse were reported immediately to the New York State Department of Health (NYSDOH), but not later than 2 hours after the alleged occurrence. This was evident for 2 (Resident # 153 and # 100) of 4 residents reviewed for Abuse out of 38 total sampled residents. Specifically, an altercation involving Resident #153 and # 100 was not reported to the NYSDOH within 2 hours of occurrence. The findings are: The facility policy titled Abuse Prevention dated 9/19/2022 documented the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source and misappropriation of resident property and report the results to all investigations to all the proper authorities within prescribed timeframes. Alleged violations involving abuse, neglect, exploitation…

    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 · D2023-07-27 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification and Abbreviated (NY0029797) survey, the facility did not ensure correct installation and maintenance of bed rails. This was evident for 1 (Resident #33) of 5 residents reviewed for Accidents out of 38 total sampled residents. Specifically, Resident #33 had bilateral half upper side rails (SR) in place without an assessment for risk of entrapment and proper installation and Resident #33 fell from the bed while attempting to use the SRs. The findings are: The facility policy titled SR Use dated 10/1/2022 documented the resident will be assessed for functional status on admission, readmission and quarterly. Partial SR will only be used by a resident to assist with his or her bed mobility. The initial assessment of SR will be completed by the Interdisciplinary team (IDT) including nursing, rehab, and social service. The resident or significant other will be notified and educated about the SR. The maintenance worker will conduct…

    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 · D2023-07-27 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification survey from 07/19/2023 to 7/27/2023, the facility did not ensure each resident received food that accommodated resident's allergies and preferences. This was evident for 1 (Resident #2) of 38 total sampled residents. Specifically, Resident #2 preferred not to consume milk and was observed with milk served on their meal tray. The findings are: The facility's policy titled Tray Line Food Service dated 07/09/2023 documented ensure that the staff are providing residents' food preferences. The Food Supervisor will be responsible for double checking the tray accuracy prior to the food truck leaving the kitchen. Resident #2 had diagnoses of multiple sclerosis and bladder cancer. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #2 had moderate cognitive impairments and required the limited assistance of 1 for eating. On 07/24/2023 at 12:46 PM, Resident # 2 observed with their lunch meal tray 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 from 7/19/2023 to 7/27/2023, the facility did not ensure safe food storage was practiced. This was evident during observation of the Kitchen. Specifically, 48 cans of expired beans were observed in the emergency food storage area. The findings are: The facility policy titled 3 Day Emergency Food Supply dated 1/10/2019 documented monthly inventory checks are done to ensure that emergency supply is adequate in meeting needs of all residents with regards to diet ordered and applicable supplies. The Dietary Inventory of Emergency Food Supply form documented food items must be counted and expiration date of the items must be documented. Check all food items on a regular basis for expiration date. During the initial tour of the kitchen and emergency food storage area storage on 7/25/2023 at 11:00 AM, 48 cans of beans with use date of June 2023 (lot # EST199W) were on the shelf in the emergency food supply area. On 7/25/2023 at 11:30 AM, the Food Service Director was interviewed and stated 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 · D2023-07-27 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 interviews conducted during the recertification survey from 7/19/2023 to 7/27/2023, the facility did not ensure a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day, and a provision that the facility immediately notifies hospice about a need to transfer the resident from the facility for any condition. This was evident for Resident #55 reviewed for Hospice out of 38 total sampled residents. Specifically, there was no documented evidence the facility communicated with Hospice when Resident #55 was transferred to the hospital. The finding is: The facility policy titled Hospice Care dated 2/2018 documented the following the facility will ensure a communication process with hospice, including how the communication will be documented between the facility and the hospice care provider, to ensure that the need of the residents is…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-27 · 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 and interview conducted during the Recertification survey from 07/19/2023 to 07/27/2023, the facility did not ensure infection prevention and control practices were maintained. This was evident for 1 (Resident #111) of 6 residents investigated 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 observation. The findings are: The facility policy titled Treatment Policy dated 07/10/2023 documented after cleansing and drying the wound, discard gloves, wash hands, and apply clean gloves. Resident #111 had diagnoses of right elbow pressure ulcer and respiratory failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #111 was severely cognitively impaired and had a stage 4 pressure ulcer. On 07/27/2023 at 09:31 AM, a wound care observation of Resident #111 was conducted with RN #3 performing the wound care. RN #3 washed their hands and donned gloves, then…

    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 · D2021-07-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview during the Recertification survey, the facility did not ensure that residents received services that accommodated the resident's needs and preferences. Specifically, the call bell buttons were not kept within the reach of the residents. This was evident for 6 of 9 residents reviewed for Accommodation of Needs in the Environment facility Task (Residents #8, 84, 120, 157, 185 and 186). The findings included but are not limited to: 1) Resident #84 was admitted with diagnoses which include Schizoaffective Disorder, Diabetes Mellitus, and Hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The resident required limited assistance of one person when performing Activities of Daily Living (ADLs). On 07/06/21 at 12:31 PM, resident #84 was observed in bed, alert and awake. The call bell button was found on the floor, approximately 4 feet away from the resident. On 07/06/21 at 02:43 PM, a follow-up observation…

    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 · D2021-07-12 · 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 during the Recertification survey, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately to reflect the resident's status. Specifically, a resident who was placed on a wander guard device since [DATE] was not coded for having a wander guard device. This was evident for 1 of 37 sampled residents reviewed for MDS assessment (Resident #68). The finding is: Resident #68 was admitted to the facility with diagnoses which include Hypertension and Schizophrenia. The most recent Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had severely impaired cognition. Resident #68 required the limited assistance of one person for Activities of Daily Living (ADLs). On [DATE] at 11:09 AM, Resident #68 was observed in the hallway with a Wander guard device on the left wrist. On [DATE] at 12: 05 PM, Resident #68 was observed in the room with a Wander Guard device on the left wrist. The Registered Nurse (RN#3) was also present…

    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 before2021-07-12 · 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 staff interview and record review conducted during a the Recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address a resident's concerns. Specifically, care plans were not developed to address the care needs of oxygen therapy, nebulizer treatment, CPAP use, inslin use, and anticoagulant therapy. This was evident for 2 of 37 sampled residents (Resident #46 and Resident #66). The findings are: The policy and procedure titled Comprehensive Care Plan dated 3/2017 documented that each discipline involved in the Comprehensive assessment and care planning will develop a proposed plan of care which includes measurable objectives, interventions and timetables to evaluate the effectiveness or lack of effectiveness of the interventions. 1) Resident #46 was admitted to facility with diagnoses which include Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), and Anxiety Disorder. The quarterly…

    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 · D2021-07-12 · 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 interviews during the recertification survey, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers. Specifically, a resident with orders to apply bilateral heel pads when in bed and in the wheelchair was observed not wearing the heel pads during multiple observations. This was evident for 1 of 2 residents reviewed for Pressure Ulcer (Resident #9). The finding is: The facility's Policy and Procedure dated 4/12/2012, titled Adaptive Equipment Policy documented It is the policy of this facility that assistive/adaptive equipment is issued after resident's evaluation by the licensed rehabilitation therapist. The nursing department and the rehabilitation department will monitor care and proper use of adaptive device. Nursing will document the use of these devices on Certified Nursing Assistance (CNA)accountability record. The CNAs are accountable to ensure presence and proper functioning of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-12 · 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 during the recertification survey, 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. Specifically, Oxygen tubing, nebulizer tubing, and nebulizer masks were observed on multiple occasions touching the floor, uncovered, and improperly stored. This was evident for 3 of 6 residents reviewed for Respiratory Care (Resident #46, #118, #438) out of an investigative sample of 37 residents. The findings are: The undated facility policy titled Oxygen Tubing documented the following under the section titled procedure: 1. During hourly rounds oxygen tubing will be checked to ensure it not touching the floor. 2. Excess tubing will be secure to prevent it from touching the floor. 3. Oxygen tubing noted touching the floor will be cleaned with EPA registered germicidal wipes or replace and 4. Cognitively…

    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

“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

$135,193 in federal fines across 1 penalty.

  • $135,193 — penalty dated 2025-04-25

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
MELNICKE, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/24/2008
STERLING NATIONAL BANKOrganization5% OR GREATER MORTGAGE INTERESTsince 05/26/2017
JAFFA, ROSALIEIndividualW-2 MANAGING EMPLOYEEsince 02/11/2018
SIRKIS, AVROMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/30/2018

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$27.6M
Net patient revenuemost recent cost report
-0.5%
Operating marginrevenue minus expenses
$1.7M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 63%Medicare 4%Other / private 33%

This home reported $1.7M 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

$375per resident / day
operating cost
$11,394per month
≈ monthly operating cost
$373per 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 335571. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-10, 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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