Ghent Rehabilitation & Nursing Center
1 Whittier Way, Ghent, NY 12075 · For profit - Corporation · 120 certified beds · (518) 828-0800 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 | 11.3% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.4% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 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 | 1.9% | 19.5% | 6.5% | better 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 | 6.2% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.6% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.9% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.0% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.3% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.8% | 13.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.3% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.1% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.4% | 20.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.1% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.28 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.32 | 1.36 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 109 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.4% 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 57 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 0.32 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.1%CMS range 32.5–48.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 6.0–12.7 | 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 | 75.4% | 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 | 64.9% | 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 | 64.9% | 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 | 100.0% | 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 | 85.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.3% | 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 | 1.1% | 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 | 0.0% | 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 | 8.1%CMS range 4.7–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 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 120 beds and averages 113.6 residents a day — about 95% occupied, or roughly 6 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.70 hrs/resident/day on weekends vs 3.73 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.55 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2026-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the survey, the facility failed to ensure the resident's environment remained free of accident hazards as is possible. This was identified for one (Resident #1) of 20 residents reviewed. Specifically, Resident #1 was injured from their bed's installation hardware (bolt for a bed rail, which is an adjustable metal or rigid plastic bar that attach to the bed) that protruded beyond its frame. On 05/22/2026, Resident #1 sustained a cut to their right lower leg from the hardware on the bed while Registered Nurse #1 assisted the resident into bed. Resident #1 required hospitalization and 16 staples. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings include: The facility policy and procedure titled, Resident Safety and Accident Prevention, reviewed 01/2026, documented that the facility is committed to providing a safe and supportive environment for all residents by implementing a structured, proactive accident prevention…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview during the recertification survey dated 08/28/23 through 09/01/23, the facility did not provide effective housekeeping and maintenance services for three (3) of 3 resident units and the core area. Specifically, on Unit #1, the floor was soiled with dirt in corners and next to walls in the corridors, dining rooms, nurse station, and resident room #s 101, 105, 109, 111, 118, 121, and 122; the windows were soiled with air borne debris and water stains in resident room #s 101, 105, 109, 111, and #122; the corridor wall outside the nurse aide room was soiled with drip marks, the walls were scraped in the room [ROOM NUMBER] restroom, the paint was chipped on the door frame to room [ROOM NUMBER], and wallpaper was peeling in the foyer old tub room; and the laminate on the nurse station enclosure walls was chipped. On Unit #2, the floor was soiled with dirt in corners and next to walls in the corridors, dining rooms, nurse station, and resident room #s 208, 212, 227; the windows…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-01 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview during the recertification survey conducted 8/28/2023-9/1/2023, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for 4 of five test trays. Specifically, food and beverages served to the residents on the units were served at suboptimal temperatures, unappetizing in appearance and were not palatable. This was evidenced by: Food Council done separately from Resident Council documented the following concerns: - 5/17/2023 meeting documented the following: All residents attending stated food was not as warm as they would have liked, no cold cereal was provided as stated on meal slips, milk was sour, ice cream sandwiches were soft, toast too hard, too many egg dishes for breakfast, would like more meat, facility out of sugar substitutes that need to be available for therapeutic diets, out of Nepro (liquid supplement) needed for therapeutic diets, desert presentation is poor, an alternative to cart/heating ideas 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 · Ecited before2023-09-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews during the recertification survey dated 08/28/23 through 09/01/23, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for two (2) of 3 resident unit kitchenettes and the main kitchen. Specifically, in the main kitchen, the microwave oven, can openers and holders, sheet pan racks, plate warmer, shelving, stove drip pans, roll-in refrigerator, fire extinguishers, floor behind cooking equipment, and dishwashing area floor in corners and along the walls were soiled with food particles, food drips, and/or a black build-up; the pantry restroom fixtures were soiled with human residue or soap stains; the pantry restroom floor and walls were soiled with dirt particles along the walls and in corners. In both the Unit #1 kitchenette and Unit #2 kitchenette, the microwave ovens, refrigerators, cabinets, and floors next to walls and in corners were soiled with food particles, food drips, and/or dirt. This is evidenced as follows: During observations on 08/28/23 at 10:58…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-01 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interviews during the recertification survey dated 08/28/23 through 09/01/23, the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations in one (1) of 2 kitchenettes. Specifically, in the Unit #2 kitchenette refrigerator 3 packages of deli-sliced cold cuts were labeled with a resident's name and dated 7/17, 7/22, and 8/16; one package of deli-sliced cold cuts was labeled with a resident name with a date that was not discernable; restaurant meatballs that were not labeled with the resident name or date; and restaurant pizza that was not labeled with the resident name or date. This is evidenced was evidenced by: During observations on 08/28/23 at 10:58 AM, in the Unit #2 kitchenette refrigerator 3 packages of deli-sliced cold cuts labeled with resident name) and dated 7/17, 7/22, and 8/16; one package of deli-sliced cold cuts was labeled with a resident name with a date that was not discernable; restaurant meatballs that were not labeled with the resident name or date;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews during the recertification survey and abbreviated survey (Case #NY00309535), the facility did not ensure all alleged violations involving abuse, neglect, including injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury for 2 (Resident #'s 55 and #69) of 6 residents reviewed for accidents. Specifically, for Resident #55, the facility did not ensure the New York State Department of Health (NYSDOH) was notified about an unwitnessed fall resulting in a serious injury requiring transfer to the emergency room for further treatment and for Resident #69, the facility did not ensure to report a fall resulting in a left hip fracture to the NYSDOH within 2 hours of learning of the serious bodily injury. This was evidenced by: The facility policy titled Abuse Prevention Manual, dated 8/2020, documented an alleged violation of abuse,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews during the recertification survey, the facility did not ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with profession standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences and that services are provided by a qualified professional for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function for 1 (Resident #33) of 1 resident reviewed for respiratory care. Specifically, the facility did not ensure that Resident #33 was provided with Oxygen @ 2 liters/minute via nasal cannula (NC) every shift as ordered by the physician and did not ensure the prescribed oxygen flow rate was routinely monitored by a licensed nurse per standard of practice and as documented on the resident's comprehensive care plan for Altered Respiratory Status. This was evidenced by: Resident #33 Resident #33 was admitted to the facility with diagnoses of pleural effusion,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-06-09 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interviews during the recertification survey, the facility did not ensure training was provided to their staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Specifically, the facility did not provide new employee orientation to include Abuse, Neglect and Mistreatment to 5 (CNA #1, Laundry Employee #1, Maintenance Employee #1, LPN #4 and Dietary Employee #1) employees prior to their start of work in the facility. This was evidenced by: The Policy and Procedure (P&P) titled Resident Abuse Reporting dated 08/2020 documented, All employees are required to receive upon new hire orientation and at least annually therefore, training and competencies on the abuse prevention policies and procedures. It is the responsibility of the Staff Educator to ensure the coordination of the training requirements and keep records of all employees training. During an interview on 06/03/2021 at 11:30 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-09 · 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
Based on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #'s 27, 53, and #96) of 24 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #27, the facility did not ensure a care plan was developed to address the resident's diagnosis of other seizures; for Resident #53, the facility did not ensure a care plan was developed to address the resident's diagnosis of hypothyroidism; and for Resident #96, the facility did not ensure a discharge care plan was developed to address the resident's discharge plan to return to the community. This is evidenced by: The Policy and Procedure (P&P) titled Comprehensive Care Planning dated 10/2020, documented an individualized or person-centered Comprehensive Care Plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during the recertification survey the facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure the facility policy and procedure developed for the monthly Medication Regimen Review (MRR) included time frames for the different steps in the process. This is evidenced by: Review of the facility policy titled Medication Regimen Review dated 6/2020, did not include documentation of the time frames for the steps in the MRR process. During an interview on 6/09/2021 at 12:55 PM, the Director of Nursing (DON) stated they were not aware the MRR policy did not document specific time frames for the steps of the process, and the MRR policy should include the necessary time frames for the steps of the process. During an interview on 6/09/2021 at 1:04 PM, the Regional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-09 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, food temperature thermometers were not in calibration, plumbing fixtures were not in good repair, and equipment and the floor required cleaning. This is evidenced as follows. The kitchen and unit kitchenettes were inspected on 06/03/2021 at 10:09 AM. Two of 5 food temperature thermometers were found not in calibration when tested in a standard ice-bath method as follows: 20 degrees Fahrenheit (F) and 29 F. The buffalo chopper, microwave oven, handwashing sink, and fire extinguisher in the kitchen and microwave ovens, cupboards, drawers, cabinets, refrigerator door gaskets, and floors in corners in the kitchenettes were soiled and required cleaning. The food preparation sink faucet was leaking, the drain under a preparation table was open to the kitchen environment…
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 15 citations
- Potential for harm · E2019-05-22 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
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 the recertification survey, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for 1 (Resident #18) of 1 resident reviewed for personal funds. Specifically, for Resident #18, the facility did not ensure the resident had access to personal funds on weekends and holidays. This is evidenced by: Resident #18: The resident was admitted to the facility on [DATE], with a diagnosis of cerebral palsy, diabetes and hypertension. The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make self understood. The facility's Policy and Procedure (P&P) titled Patient Personal Needs Fund (undated), documented the following objectives; to maintain an accounting system for those residents who wish to have their funds managed by the home, and to make these funds available to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-05-22 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that residents were free from physical restraints that are not required to treat medical symptoms for 2 (Resident #'s 13 and 81) of 3 residents reviewed for restraints. Specifically, for Resident #'s 13 and 81, the facility did not ensure the use of physical restraints did not inhibit a resident's freedom of movement; and for Resident #81, the facility did not ensure the resident was free from psychosocial impact (agitation) related to restraint use. This is evidenced by: Resident #13: The resident was admitted to the facility on [DATE], with diagnoses of dementia, Parkinson's Disease, and chronic kidney disease. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could sometimes understand others and could sometimes make self understood. During observations on 5/17/19 at 1:35 PM and 5/20/19 at 9:54 AM, the resident was sitting in a wheelchair. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-05-22 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the recertification survey, the facility did not ensure 1 (Resident #19) of 1 resident reviewed for hospitalization, received a notice of the transfer or discharge and the reasons for the move in writing in a language and manner they understand, and a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Specifically, for Resident #19, the facility did not ensure that written notification of transfer/discharge was provided to the resident and/or the resident's representative(s,) and the facility did not ensure a copy of the notice was sent to the Office of the State Long-Term Care ombudsman. This was evidenced by: Resident #19: The resident was admitted to the facility on [DATE], with diagnoses of cervicalgia (a term used to describe pain or significant discomfort in your neck, especially at the back and/or sides), central cord syndrome (form of cervical spinal cord injury) at C3 level (third cervical vertebrae) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-05-22 · tag F0725 — failed to have enough nursing staff — patternProvide 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 observations, record review, and interviews during a recertification survey the facility did not ensure that it had sufficient nursing staff with the appropriate competencies and skills sets 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, as determined by resident assessments and individual plans of care, for one of one dementia care unit (Wing 1). Specifically, the facility did not ensure a sufficient number of staff available to provide assistance with meals on 5/20/19. This is evidenced by: A facility-wide list of residents documented that 14 of those residents were appropriate to be fed by a feeding assistant and resided on Wing 1. The Census on 5/20/19 on Wing 1 was 36 residents, 14 of which required extensive to total assist with eating and 6 additional residents that required feeding as needed. The Daily Assignment sheets for staffing on Wing 1 documented: 5/20/19 - 11:00 PM - 7:00 AM (night shift) = 1 nurse and 2 CNAs from 11:00 PM to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-05-22 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during the recertification survey, the facility did not ensure food and drink was palatable, attractive, and at an appetizing temperature. Specifically, the facility did not ensure cold drinks were served cold and sandwich bread was palatable to ensure resident satisfaction. This is evidenced by: During an interview on 05/16/19 09:14 AM, Resident #103 stated the bread used at the facility is stale. During an interview on 5/16/19 at 10:37 AM, Resident #61 stated the bakery the facility uses and the quality of the bread used was not good. During an interview on 5/17/19 at 9:13 AM, Resident #21 stated the bread on the peanut butter and jelly sandwich is hard. The summer 2019 week 1 menu documented the Wednesday breakfast meal included oatmeal, bacon, banana, scrambled egg, and a fruited muffin. The food cart delivery schedule dated 4/31/19 documented the second meal cart for breakfast was to be delivered to Wing 2 at 8:10 AM, and Wing 1 at 8:20 AM. During an observation on 5/22/19 at 8:10 AM, the second meal cart containing the test…
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 before2019-05-22 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced by: A Policy and Procedure (P&P), titled Food Brought by Family/Visitors dated 3/12/19, did not include documentation on providing family and visitors education on safe food handling practices (such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.). During an interview on 5/22/19 at 10:09 AM, Registered Dietitian #11 stated the facility did not provide food safety education when food was brought in to residents by family and visitors. 10 NYCRR 415.14(h)
- Potential for harm · D2019-05-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #'s 54, and 63) residents observed on Wing 1, and 1 (Resident #57) resident observed on Wing #3. Specifically; for Resident #'s 54, 57 and #63, the facility did not ensure that the residents' pants were not pulled up to their waist while lying in bed, and did not ensure that Resident #'s 54 and 63's briefs and bare thighs were not visible from the hallway. This is evidenced by: Wing 3: Resident #57: The resident was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following unspecified cerebrovascular (brain and its blood vessels) disease affecting the non-dominant side,…
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 · D2019-05-22 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the recertification survey, the facility did not ensure 1 (Resident #19) of 1 resident reviewed for hospitalization, received a bed-hold notice upon transfer. Specifically, for Resident #19, the facility did not ensure that the resident and/or the resident's representative were notified in writing of the bed hold policy when the resident was transferred to the hospital. This was evidenced by: Resident #19: The resident was admitted to the facility on [DATE], with diagnoses of cervicalgia (a term used to describe pain or significant discomfort in your neck, especially at the back and/or sides), central cord syndrome (form of cervical spinal cord injury) at C3 level (third cervical vertebrae) of cervical spinal cord and fracture of neck, subsequent encounter (after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery). The Minimum Data Set (MDS) dated [DATE], documented the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-05-22 · 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 interview during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 5 (Resident #'s 41, 54, 82, 215, and #315) of 25 residents reviewed for comprehensive care plans. Specifically, for Resident #41, the facility did not ensure that a care plan was developed for a pressure ulcer on the resident's coccyx, for Resident #215 the facility did not ensure that a CCP was developed for the diagnosis of dehydration or use of IV therapy, for Resident #315, the facility did not ensure a CCP was developed and implemented for the resident's respiratory diagnoses, use of oxygen and BIPAP therapy (Bilevel Positive Airway Pressure) (a non-invasive form of therapy for patients suffering from sleep apnea). This is evidenced by: 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 · Dcited before2019-05-22 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure drug regimen review recommendations were acted upon for 2 (Resident's #'s 7 and 82) of 7 residents reviewed for unnecessary medications. Specifically, for Resident #'s 7 and 82, the facility did not ensure that the time frame for the step for physician intervention was met according to the facility policy for the Medication Regimen Review (MRR). This is evidenced by: A Policy and Procedure (P&P) titled Drug Regimen Review dated 12/2006, documented that drug regimen reviews that require physician intervention will be responded to no later than the next 30/60 day physician visit. The P&P documented the pharmacist's findings are part of the clinical record and readily available for review. Resident #7: The resident was admitted on [DATE], with major depressive disorder, dementia with behavioral disturbance, and Alzheimer's Disease. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could usually…
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 · D2019-05-22 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 a recertification survey the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, for four (Resident #'s 19, 21, 37 and #82) of four residents reviewed for unnecessary medications. Specifically, for Resident #'s 19, 21 and #37, the facility did not ensure the residents' pain levels were monitored prior to and after the administration of as needed (PRN) medications for pain. This is evidenced by: The facility's Policy and Procedure (P&P) titled Pain Management, revised on 2/2016, documented: The pain flow sheet (back of the Medication Administration Record (MAR) will be used to document the resident's level of pain prior to administration of the medication and to document the effectiveness of the PRN medication 15-30 minutes after administration. The documentation should reflect the numerical pain management scale (0 is no pain, and 10 is the worst pain imaginable) or the Wong-Baker or dementia scales. Resident #19:…
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 · D2019-05-22 · tag F0811 — isolatedEnsure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
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 the recertification survey, the facility did not ensure a resident fed by a feeding assistant did not have complicated feeding problems for 1 (Resident #81) of 1 resident reviewed for the feeding assistance program. Specifically, the facility did not ensure a resident with who had difficulty swallowing and risk of aspiration was assessed for appropriateness for a feeding assistant program. This is evidenced by: Resident #81: The was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease, dementia, and anxiety. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could usually understand others, and was sometimes understood. A Policy and Procedure titled Paid Feeding Assistant, last updated 1/19 documented the facility was to ensure that a feeding assistant should provide dining assistance only to residents who had no complicated feeding problems, and appropriateness for the feeding assistant…
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 before2019-05-22 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during the recertification survey, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, the facility did not ensure that; dry food items were stored in an area free from contaminants, kitchenette equipment was clean, and food stored in the freezer was labeled and dated. This is evidenced by: During an observation on 5/17/19 at 8:26 AM, the Wing 1 kitchenette microwave and refrigerator were soiled, and food in the freezer was unlabeled. Micro-kill+ germicidal wipes were stored in cabinet with dry food items. A safety data sheet documented Micro-kill+ germicidal wipes should be stored in a ventilated area and stored away from incompatible materials. During an interview on 5/17/19 at 8:34 AM, Food Service Director #26 stated the Micro-kill+ germicidal wipes should not have been stored in the unit kitchenette with dry food items. He stated the food service department does not use Micro-Kill+ germicidal wipes, and all food service related chemicals were…
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 · D2019-05-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 observation, record review and interviews during the recertification survey the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized for 1 (Resident #105) of 25 residents reviewed. Specifically, for Resident #105, who was on a fluid restriction and received dialysis treatments, the facility did not ensure that the resident's daily intake was completed and accurately recorded. This was evidenced by: Resident #105: The resident was admitted to the facility on [DATE], with the diagnoses of End Stage Renal Disease (ESRD), Dialysis, and Chronic Obstructive Pulmonary Disease (COPD). The Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact and he was able to make himself understood and understand others. The Policy & Procedure (P&P) titled Guidelines for Initiating, Maintaining and Removing Residents from Intake & Output (I&O) Recording, and dated 1/2016, documented it is 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.
- No harm found · Ccited before2021-06-09 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview during the recertification survey and an abbreviated survey (Case #NY002713116), the facility did not provide effective housekeeping and maintenance services. Specifically, floors and tables were not clean and resident room walls were not maintained on 3 of 3 resident units. This is evidenced as follows. The 3-Wing, 2-Wing and 1-Wing units were inspected on 06/04/2021 at 1:15 PM. The 3-Wing unit corridors are carpeted; the carpeting in the corridors required vacuuming and were stained with black blotches throughout the unit. The 2-Wing and 1-Wing unit's flooring is entirely vinyl tile; the corridor floors, the floors behind doors in the dining and lounge areas, and where the corridor door frames meet the floors were soiled with dust, cob webs and/or dirt and grime. The Housekeeping Supervisor stated in an interview on 06/04/2021 at 1:36 PM, that the Environmental Services Department knows the floors need cleaning; the facility had kept the floors clean but things have slipped lately; and the facility has only one floor care person and it 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.
“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.
Part of a chain
This home belongs to PERSONAL HEALTHCARE MANAGEMENT — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 20 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BARTH, ALEXANDER | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 35% | since 01/01/2020 |
| WALDEN, YEHUDAH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 15% | since 04/25/2016 |
| ZAGELBAUM, EPHRAIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 04/25/2016 |
| ODUWA, FELIX | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| WOODWARD, XYIER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2022 |
| OSTROVITSKY, ISRAEL | Individual | ADP OF THE SNF | — | since 01/01/2020 |
CMS files one row per role, so the 10 rows in the source record cover these 6 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 $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335766. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-09-01, 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 →
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