The Pavilion at Queens for Rehabilitation & Nursin
36-17 Parsons Boulevard, Flushing, NY 11354 · For profit - Partnership · 302 certified beds · (718) 961-4300 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 29% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.2% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.2% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 29.8% | 19.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.1% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.6% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.8% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.6% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.1% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.1% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.8% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.1% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.7% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.9% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.62 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.06 | 1.36 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 302 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 80.7% 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 238 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.8%CMS range 54.3–66.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.4–12.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 80.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 74.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 68.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 5.4–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.41 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 302 beds and averages 295.3 residents a day — about 98% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.87 on weekdays — 17% thinner on weekends. RN hours go from 0.94 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · F2024-11-20 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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
Based on record review and interviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024 , the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility was not able to provide a policy related to facility staffing. The Payroll Based Journal Staffing Data Report for the 3rd quarter of 2024 (04/01/2024 - 06/30/2024) documented that excessively low weekend staffing was triggered. The Facility Assessment last updated in 10/2024 documented a facility capacity of 302 residents with a weekend staffing plan by shift distributed as follows: Day shift: 2 Registered Nurse Supervisors 2nd floor: 4 Licensed Practical Nurses and 6 Certified Nursing Assistants 3rd floor : 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, interviews, and record review conducted during the Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure food was served and dishware was handled in accordance with professional standards for food service safety. Specifically, 1). numerous kitchen staff were observed not wearing beard restraints while preparing and assembling food, and 2). the Food Service Director did not wash their hands after contact with a garbage can while checking food temperatures on the tray line. This was evident during the Kitchen Observation task. The findings are: The facility policy titled Food Safety and Sanitation dated 3/25/2024 documented hair restraints are required and should cover all hair on the head, beard nets are required when facial hair is visible. Employees will wash their hands before start of work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes and touching face, hair, other people or surfaces or items with potential for contamination. The facility policy titled Employee Sanitary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review conducted during the recertification survey from on 11/13/24 to 11/20/24, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 3 (Unit 8, Unit 5, and Unit 4) of 9 resident units. Specifically, Unit 8 and Unit 5 were observed with multiple wheelchairs embedded and heavily layered with dirt and debris and Unit 4 was observed with dirty, dusty heating system. The facility policy and procedure titled Resident Environment dated 01/02/2023 documented that it is the policy of the facility to provide a safe clean comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible. The findings are: 1. On 11/13/24 at 10:37 AM, and on 11/14/24 at 11:54 AM, the following was observed in the 8th floor Dining Room Area: a. Resident #19 was observed sitting in a high back wheel chair, with metal wheelchair frame and spokes layered with encrusted dirt, debris, and dried food particles. b. Resident #135 was observed sitting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-20 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) a housekeeper did not don the required personal protective equipment when cleaning the room of a resident on contact and droplet precautions, (2) Certified Nursing Assistant (Certified Nursing Assistant #8) was assisting multiple residents to perform hand hygiene in the dining room and did not clean their hands in between residents, and 3) nurses (Licensed Practcal Nurse #3, Registered Nurse #4 and Licensed Practical Nurse #2 did not perform hand hygiene appropriately during tasks or clean blood pressure cuffs between residents. This was evident during Infection Control, Dining Observation and Medication Administration tasks. The findings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 1 (Resident #76) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required. The findings are: The facility policy titled Serving of Notice of Medicare Non-Coverage and Advanced Beneficiary Notice revised 10/30/2024, documented that it is the policy of this facility to serve Advance Beneficiary Notice and Notice of Non-Medicare Coverage within 48 hours before providing a service that Medicare will likely to deny coverage. Resident #76 was discharged from Medicare Part A services on 08/22/2024 with 71 days remaining. The Notice of Medicare Non-Coverage form…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification conducted from 11/13/2024 to 11/20/2024, the facility did not ensure a person-centered Comprehensive Care Plan was developed and implemented to address the resident's needs. This was evident for 1 (Resident #150) of 5 residents reviewed for Unnecessary Medication out of 38 total sampled residents. Specifically, a Comprehensive Care Plan related to Resident #150's use of anticoagulant medication was not developed and implemented. The findings are: The facility policy on Comprehensive Care Plan effective on 1/2020 and last reviewed 6/2024 documented the interdisciplinary team will utilize the Comprehensive Person-Centered Care Planning process to address resident strengths, needs and or problems as identified on the admission discharge summary as well as other professional assessment and orders from the physician, dietary team, therapy, social services and PASARR and MDS. The policy also documented that a Person-Centered Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the Recertification survey between 11/13/2024 and 11/20/2024, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the episodic, comprehensive, and quarterly review assessments. This was evident for 1 (Resident #109) of 5 resident reviewed for Unnecessary Medications and 1 (Resident #145) of 3 Residents reviewed for Pain Management out of 38 sampled residents. Specifically, 1) the Comprehensive Care Plan for Psychotropic Medications were not updated and revised for Resident #109, and 2). the Comprehensive Care Plan for Pain Management was not reviewed and revised for Resident #145. The findings are: The facility policy and procedure titled Care Plan dated 01/2020, last revised 06/2024, documented that the Comprehensive Person-Centered Care Plan will be periodically reviewed and revised by a team of qualified persons after each assessment. 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.
- Potential for harm · D2024-11-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during the recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure drugs and biologicals were labeled in accordance with professional standards of practice. This was evident on 2 (Unit 5 and Unit 3) of 8 resident units. Specifically, 1). an opened and undated individual vial of insulin and eye drops was observed on the medication cart in the 5th Floor medication cart, and 2). A vial of insulin was not discarded 28 days after opening and open vials of insulin and a vial of eye drops did not contain dates of when the medication was opened on the label was observed on one of the 3rd Floor medication cart. This was evident for the Medication Storage and Labeling task. The findings are: The facility policy and procedure titled Medication Storage effective 1/10/2024 documented medications must be stored in accordance with manufacturer specifications and secured in locked areas in compliance with State and Federal requirements and accepted professional standards of practice. Storage areas may 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.
- Potential for harm · D2024-11-20 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 11/13/2024 to 11/20/2024, the facility did not ensure menus were followed. This was evident for 4 residents (Resident # 70, Resident # 77, Resident #156, and Resident #201) observed during the Dining Observation task. Specifically, food items were omitted or substituted, and residents were not informed of the changes. The findings include: The policy and procedure titled Food Preferences effective 8/14/2024 documented information will be gathered upon admission to obtain residents preferences, allergies, intolerances, cultural preferences, and diet history. Food preferences will be updated periodically as needed or upon reassessment. Menus are provided as per resident request for meal selections. The policy and procedure titled Dining Room Service reviewed on 8/21/2024 documented that staff should check the residents name and diet on the meal ticket to verify that the meal is served to the correct resident and check items on the plate/tray to assure accuracy for food preferences and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 record review and interviews conducted during a Recertification and Complaint survey (NY00347992) from 11/13/2024 to 11/20/2024 the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident for 1 (Resident #177) of 1 residents reviewed for Notification of Change out of 38 sampled residents. Specifically, a Nurse's Progress Note dated 07/05/2024 documented that Resident #177 was noted with a bruise on their nose and the charge nurse and supervisor were informed, however family was not informed about the bruise until 3 days later on 07/08/2024. The findings are: The facility policy titled Notification of Changes for Residents revised 03/04/2024 documented that the facility shall promptly notify the resident and/or designated representative and physician of changes in the resident's condition in order to obtain orders for appropriate treatment and monitoring, promote resident's right to make choices about treatment and care preferences and to keep…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · Fcited before2022-11-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification survey 11/7/22 to 11/15/22, the facility did not ensure that food was stored, prepared, distribute and served in accordance with professional standards for food service safety. Specifically, an unopened container of expired cottage cheese was noted in the refrigerator. This was evident during the initial tour and follow up tour conducted during the Kitchen facility task. The findings are: The facility policy and procedure titled General Food Preparation and Handling reviewed 11/2022 documented under Food Storage item (a). Foods will be received, checked, and stored properly as soon as they are delivered. The policy did not contain any information for checking the delivered foods for the use by, best by or manufacturer expiration dates upon delivery to the facility. On 11/07/2022 from 10:10 AM to 10:30 AM, the initial tour of the kitchen was conducted with the Cook. One sealed 5-pound plastic container of 4% milk minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a Recertification survey from 11/7/22 to 11/15/22, the facility did not ensure residents' rooms were maintained in a clean, comfortable, and homelike environment. Specifically, two rooms on the second floor were noted with enteral feeding poles with dried cream brown colored stain and oxygen ventilator unit tank base stand and oxygen tank straps were noted to have gray colored dust buildup. This was evident for 1 out of 7 floors observed for the Environment. The findings are: The facility policy and procedure titled Terminal Cleaning Policy revised September 2022 documented that maintaining a high standard of hygiene is essential in preventing the spread of infection in a nursing home setting. Clean and disinfect all reusable equipment as per cleaning and decontamination of the environment and patient equipment procedure and manufacturers instruction and remove from the room. Under the Controlling CDI Environmental Services Environmental Services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-15 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review conducted during a Recertification survey from 11/7/22 to 11/15/22, the facility did not ensure that a portion of the Minimum Data Assessment (MDS) accurately reflected the resident's status. Specifically, the behavioral symptoms of a resident who refused medications daily were not captured on the Minimum Data Set (MDS). This was evident for 1 of 2 residents reviewed for Activities of Daily Living (ADL) out of 38 sampled residents. (Resident # 64). The findings are: The facility policy and procedure titled Minimum Data Set revised 9/1/2022 documented: all members of the Interdisciplinary Care (IDCP) Team participate in completion of their assigned MDS section (s). The facility policy further documented all MDS 3.0 assessments are scheduled, completed, and transmitted according to the Resident Assessment Instrument (RAI) guidelines. The facility policy contained no reference to accuracy of the MDS assessments. Resident #64 was admitted with diagnoses that included Heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification survey from 11/07/22 to 11/15/22, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 of 2 residents reviewed for Mobility out of 38 sampled residents. (Resident #151) Specifically, Resident #151 was observed on multiple occasions without a right handroll in accordance with a physician's order. The findings are: The facility policy titled Orthotic Management dated January 2022, documented that it is the responsibility of the nurse to schedule the orthosis wear time in the Certified Nursing Assistant Accountability when they pick up the orthotic order. Resident #151 was admitted to the facility with diagnoses that include Cerebrovascular Accident and Non-Alzheimer's Dementia. On 11/08/22 at 12:38 PM, Resident #151 was observed with a hand roll (gauze roll) in resident's lap. On 11/10/22 at 10:01 AM, Resident #151 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.
- Potential for harm · Fcited before2020-01-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and staff interviews during the re-certification survey, the facility did not store food properly to prevent foodborne illness. Specifically, (1) raw tilapia fish was observed stored above pre-cooked corned beef on a multi-tiered metal rack in the walk in refrigerator, (2) raw frozen tilapia fish was observed stored above pre-cooked frozen onion rings and potato pancakes, and frozen vegetables in the walk in freezer, and (3) raw sole fish rolled with scallops and crab meat was observed stored over pre-cooked frozen vegetable lasagna in the walk in freezer. This was evident for the Kitchen reviewed during the Kitchen facility task. The finding is: The Food Storage Policy and Procedure, revised on 4/10/19, documented the following: Procedure #13 Refrigerated Food Storage, line E. documented cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. Procedure #14 Frozen Food Storage line F. documented meat,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-11-20 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024, the facility did not ensure that the Nurse Staffing Information was posted appropriately. Specifically, there has been no posting in the appropriate required form of the daily nurse staffing information and was not posted in a prominent area which was readily accessible to residents and visitors. The finding is: The facility policy and procedure titled Posted Nurse Staffing Information dated 10/10/2021 with a review date of 01/15/2024 documented that the facility will ensure that the Nursing Staffing Information is posted daily at the beginning of each shift in a prominent place where it is accessible to residents and visitors. During observations conducted on 11/13/2024, the State Surveyor was unable to locate the posting of the daily nurse staffing levels for each shift or any signage instructing residents or visitors where it was located. On 11/14/2024, a posting was observed on wall next to the side of the elevator, however, the form did not include the current daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-11-20 · tag F0814 — failed to dispose of garbage properly — widespreadDispose 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 interview conducted during a Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure that garbage or refuse was disposed of properly. Specifically, the recycling trash bin was observed open with recycling trash items in bags or unbagged above the recycling bin rim. This was observed during the Kitchen Observation task. The findings are: The facility policy and procedure revised 11/8/2024 documented to establish clear guidelines for the proper segregation, collection, storage, and disposal of all waste generated within the facility, ensuring compliance with all applicable local, State, and federation regulation, while prioritizing resident and staff safety and environmental protection. General waste must be placed in the standard trash bags and disposed of in designated trash receptacles. Trash bags must be securely tied and disposed of according to the facilities trash collection schedule. The policy also documented that for recycling reusable materials like paper, plastic, and aluminum that can be processed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WEITS, AVRAHAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10% | since 11/03/2015 |
| EDELSTEIN, JOEL | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 02/01/2017 |
| FREUND, ISRAEL | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 02/01/2017 |
| FUCHS, BERNARD | Individual | DIRECT OWNERSHIP INTEREST | — | since 11/03/2015 |
| FUCHS, GERALD | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 02/01/2017 |
| FUCHS, TOVA | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 02/01/2017 |
| BUTCHMA, OLAF | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2026 |
| VARAS, EMILY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $17.7M paid to related parties — landlords or management companies under common ownership — equal to about 29% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335804. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-20, 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.