New Paltz Center For Rehabilitation And Nursing
1 Jansen Road, New Paltz, NY 12561 · For profit - Limited Liability company · 79 certified beds · (845) 255-0830 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — 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 (1/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 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 | 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 2 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 | 9.3% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.3% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 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 | 31.4% | 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 | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 5.6% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.9% | 13.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 6.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.2% | 19.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.0% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.7% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.6% | 20.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.3% | 9.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.54 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.13 | 1.36 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
43.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 148 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.4% 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 92 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% 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 | 43.7%CMS range 35.6–50.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.2–14.6 | 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 | 67.4% | 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 | 55.4% | 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 | 72.8% | 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 | 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 | 78.3% | 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 | 0.0% | 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 | 0.7% | 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 | 9.1%CMS range 5.7–13.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 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 79 beds and averages 74.4 residents a day — about 94% occupied, or roughly 5 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 2.84 hrs/resident/day on weekends vs 3.81 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.62 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · D2025-11-20 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review during an abbreviated survey #2616039, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, and the comprehensive person-centered care plan for two (2) of three (3) residents (Resident #1 and Resident #3) reviewed for pain medication. Specifically, for Resident #1 and Resident #3 there was lack of consistent documentation of pain assessments each shift prior to and after administration of physician ordered as needed oxycodone 5 mg tablets.The findings include:The policy and procedure titled Pain Management revised 4/28/2025 documented prior to administering as-needed pain medication the nurse will evaluate and document in the clinical record the location of pain, pain level prior to medication administration, and the pain scale used. 1. Resident #1 had diagnoses including but not limited to bipolar disorder (psychiatric disorder), fracture of the right femur (long bone in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review during an abbreviated survey #2616039 the facility did not provide pharmaceutical services including procedures that assure the accurate dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two (2) out of three (3) residents reviewed for pain medication administration. Specifically, for Resident #1 and Resident #3 oxycodone 5mg tablets (narcotic) were signed out on the narcotic control sheets but were not accounted for and documented in the resident's Medication Administration Record as administered to the residents. Additionally, there was no evidence that a pharmacist conducted periodic audits or oversight to ensure accurate record keeping and accounting of the controlled substances.The findings include: The policy and procedure titled Medication Administration, revised 2/2019, documented the individual administering the medication must initial the resident's Medication Administration Record on the appropriate line after giving…
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 before2025-09-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (Intake #2569939), the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the Daily Nurse Staffing Rosters reviewed from 08/10/2025 through 09/12/2025 documented on four (4) of 34 days, there was one (1) certified nurse aide documented for the A unit night shift (1:35 or 1:36 ratio ) and on one (1) of 34 nights, there was one (1) certified nurse aide assigned to B unit (1:36 ratio). On 29 of 34 days reviewed, assigned staff did not complete their assigned shift (came in late or left early). A nurse supervisor was not assigned on 4 of 34 dates reviewed for day shift, 15 of 34 dates for evening shift and 26 of 34 dates for the night shift. Additionally, during the 11:00PM to 7:00 AM shift on 09/11/2025, Resident #32 sustained…
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 before2025-07-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 during the Abbreviated Survey (NY00376400) the facility did not ensure that 1 of 3 residents (Resident #1) investigated for abuse remained free from abuse. Specifically, on 3/27/2025, Resident #1, who was severely cognitively impaired with a history of wandering and entering other residents' rooms, was found in Resident #2's bed. Resident #2, who was cognitively intact, stated that they did touch Resident #1 on their breasts per their request. Resident #1 lacked the capacity to make sound decisions at the time of the incident. The facility investigative conclusion found that no abuse had occurred.The findings include:The Facility Policy titled Abuse revised 6/1/2024 documented that the facility has designed and implemented processes which strive to ensure the prevention, and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment and /or misappropriation of property. The Facility incident report dated 3/27/2025 documented that 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 · E2024-11-22 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did ensure that a Registered Nurse worked eight cosecutive hours a day, seven days a week. Specifically, the facility was unable to provide documented evidence that a Registered Nurse worked 10/20/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24. Findings include: The Facility Wide assessment dated [DATE] documented the staffing plan as follows: Day shift unit A and B: 2 nurses each unit. Evening shift units A and B: two nurses each unit. Night shift Units A and B: 1 nurse each unit. The Facility Wide Assessment does not include Registered Nurse for at least eight consecutive hours per day, seven days per week as per the regulations. The 10/10/24-11/21/24 Daily Nurse Staffing Roster documented the facility did not have a Registered Nurse at least 8 consecutive hours a day for 7 days a week on 10/20/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24. During an interview on 11/20/24 at 10:17 AM the Staffing…
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 · E2024-11-22 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview conducted during the recertification survey from 11/16/2024 to 11/22/2024, the facility did not ensure Annual Performance Reviews were completed at least once every 12 months. Specifically, the facility was unable to provide Annual Performance Reviews for 3 of 5 Staff Members (#9, #10, #12) reviewed. The findings are: The facility policy titled Employee Evaluations, dated 9/29/2019, documented: A performance evaluation will be completed on each employee at least annually. During an interview and record review with the Assistant Director of Nursing/Nurse Educator on 11/20/24 at 11:07 AM, they stated they were not able to provide documentation of an Annual Performance Review for Staff Members (#9, #10, #12). They stated they are new to the facility and have not completed annual performance reviews as of yet. During an interview and record review with the Director of Nursing on 11/20/24 at 11:07 AM, they stated they were aware the Assistant Director of Nursing/Nurse Educator was not able to provide documentation of an Annual Performance Review 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.
- Potential for harm · E2024-11-22 · 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 and interview during the Recertification survey from 11/14/24 to 11/22/24, the facility did not ensure residents were provided food and drink that is palatable, attractive, and at a safe and appetizing temperature. Specifically, food was not served at palatable and safe temperatures for 2 of 3 residents (Resident #17 and Resident #23) reviewed for Food. The findings are: The Policy titled Food Temperatures last reviewed 3/2023 documented temperatures of cold and hot food items will be recorded on all menu items and substitutions for meal service to maintain a high level of quality and to monitor potentially hazardous food temperatures as per state and federal regulations thus ensuring that food is provided in a safe, palatable manner. All employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit). During an interview on 11/15/24 at 11:27 AM Resident #17 stated they do not like the food, the food is always cold. During 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 · E2024-11-22 · 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
Based on observation, record review and interview conducted during a recertification survey from 11/14/24-11/22/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections. Specifically,1) the Water Management Plan had not been updated annually and the Environmental Risk Assessment had not been performed annually to identify areas where Legionella could spread, 2) Resident #13's urine collection bag was not maintained or emptied in a manner to prevent infection, 3) Resident #51 consented to receive the Respiratory Syncytial Virus vaccine but did not receive it until almost two months later. 4) 4 of 10 Staff, Certified Nurse Aide #4, Minimum Data Set Coordinator, Dietary Aide #1, and Cook, reviewed for vaccinations were not screened, offered, or given the opportunity to accept or decline pneumococcal vaccination. 5) Staff did not apply proper Personal Protective Equipment while assisting Resident #23 and #26, who were on Enhanced Barrier Precautions. The findings are: The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-22 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview conducted during a recertification survey from 11/14/24 to 11/22/24, the facility did not ensure Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services to ensure safe delivery of care. Specifically, the facility was unable to provide documentation that 3 of 6 Certified Nurse Aides (#10, #14, and #15), reviewed for Certified Nurse Aide training, were provided 12 hours of mandatory training. The findings are: The facility policy titled: Staff Development and In-service Programming, revised 1/18/23, documented: Personnel shall participate in in-service training to remain current in knowledge which affects the delivery of services within the facility and meets Federal and State Requirements. Policy Implementation: Certified Nurse Aides shall complete any additional in-services / education as required by topic and numbers of hours in accordance with state and federal regulations (e.g., 12 hour minimum). Certified Nurse Aide #10: 6.5 hours of annual in-service training documentation was provided. Certified Nurse…
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 before2024-11-22 · 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
Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 of 3 residents reviewed for Abuse (Residents #176) that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation is made, to the State Agency. Specifically, 1) Resident #176's family reported Resident #176 was found with bruises on their forehead when transferred to the hospital for altered mental status. A 2/19/24 Investigation/Accident Report statement written by Licensed Practical Nurse documented on 2/17/24 they overheard Resident #174 yelling and screaming at their family ouch you're hurting me and they beat me up last night, and the facility did not report the allegations to the State Agency. The findings are: The Policy titled Abuse last reviewed on 6/1/24 documented the facility is to notify the local law enforcement and appropriate State Agency(s) immediately…
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 17 citations
- Potential for harm · D2024-11-22 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 (Resident #176)) of 3 resident reviewed for Abuse that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, there was no documented evidence the facility conducted a complete thorough investigation after Resident #176's family member reported Resident #176 had multiple bruises on their forehead when they were transferred to the hospital on 2/19/24. The findings are: The facility policy titled Abuse last reviewed on 6/1/24 documented that Allegations / reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. Resident #176 was admitted with diagnosis including but not limited to anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis. The 2/1/24 admission Minimum Data Set documented Resident #176 had severely…
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 · D2024-11-22 · tag F0623 — isolatedProvide 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
Based on record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 resident (Resident #63) reviewed for hospitalization. The findings are: Resident #63's diagnoses included Acute Kidney Failure, Neuromuscular Dysfunction of Bladder and Encephalopathy. The 5/7/24 Situation Background, Assessment and Recommendation documented send to the hospital for further evaluation Blood in stool, Gastrointestinal bleed. Family notified. The 5/7/24 Nursing Progress note documented called family representative to notify them the resident was being transferred to the hospital for possible Gastrointestinal Bleed. The 5/8/24 Nursing Progress Note documented Resident #63 was sent to the emergency room for evaluation due to an abnormal hemoglobin 6.9 or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-22 · 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
Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure the comprehensive care plan was revised for 1 of 5 resident ( Resident #53) reviewed for Accidents. Specifically, for Resident #53, who sustained falls on 8/20/24, 9/27/24 and 10/9/24 there was no documented evidence that care plan interventions were reviewed and/or revised to address the falls. Findings include: The Policy and Procedure titled Falls Management and Prevention last revised on 1/2023 documented if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. Resident #53 was admitted with diagnoses including but not limited to encounter for hip fracture, muscle weakness, benign prostatic hyperplasia. The 5/23/24 Care Plan titled Risk for Falls/Actual Falls documented anticipate and meet the resident needs/occupational and Physical Therapies 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 · D2024-11-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336697 and NY00324141) from 11/14/24 to 11/22/24, the facility did not ensure 2 (Residents #174 and #177) of 2 residents reviewed for Quality of Care received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, 1.) for Resident #174 who was admitted with a wearable defibrillator (Life Vest) related to a history of Sudden Cardiac Arrest, became unresponsive on 3/16/24 the nurse tending to the resident documented they pushed the response button. Additionally, there were multiple omissions on the March Medication Record that the nurses were not addressing and signing for the Life Vest as per physician order and 2.) for Resident #177 with diagnosis of Type 1 Diabetes Mellitus and history of Diabetic Ketoacidosis there were multiple omissions in the Medication Administration Record for insulin administration/ blood sugar monitoring from 5/2024-7/2024. 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 · Dcited before2024-11-22 · 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 record review, observation and interview conducted during the recertification and complaint (NY00336704) surveys from 11/14/24 to 11/22/24, the facility did not ensure adequate supervision to prevent accidents for 1 (Residents #176) of 5 residents reviewed for Accidents. Specifically, fall risk assessments were not completed to identify Resident #176's risk for accident and need for supervision after falls on 1/26/24, 1/28/24, and 2/1/24. There was no documented evidence of enhanced monitoring and one to one supervision as per the 2/27/24 Accident and Incident Report after Resident #176 verbalized suicidal ideation. Additionally, Resident #176 had one unwitnessed fall on 1/28/24, two on 2/1/24, two on 2/22/24, 2/27/24, 2/29/24, 3/11/24, and one on 3/19/24 and there was no documented evidence neurological checks were done to assess for neurological status or underlying conditions. Findings include: The facility policy titled Falls Management and prevention last revised 1/2023 documented obtain…
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 before2024-11-22 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification from 11/14/24 to 11/22/24, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the staffing schedule from 10/10/24 through 11/21/24 revealed the facility did not consistently provide adequate staffing on all units/shifts to meet the needs of the resident/s 35/43 days reviewed. The findings are: The Facility Wide assessment dated [DATE] documented Day shift, Units A and B: 2 nurses/5 certified nurse aides per unit. Evening shift: 2 nurses/4 certified nurse aides per unit. Night shift: 1 nurse/2 certified nurse aides per unit. The facility staffing from October 10, 2024 through November 21, 2024 and the staffing plan based on Facility Wide Assessment, documented the facility was understaffed 35/43 days for Certified Nurse Aides. During a Resident Council meeting on 11/15/24 ad 1:32 PM, Resident #23 stated…
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 · D2024-11-22 · 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
Based on interview and record review conducted during the recertification survey from 11/14/2024 to 11/22/2024, the facility did not ensure the attending physician documented in the resident's medical record that the identified drug regimen review recommendations were reviewed, and any action taken to address recommendations were completed. This was evident for 1 (Resident #42) of 5 residents reviewed for unnecessary medications, psychotropic medications and medication regimen review. Specifically, there was no documented evidence the Medical Director reviewed and responded to Resident #42's Drug Regimen Reviews dated June 2024. The findings are: The facility policy title Medication Regimen Reviews (revised 11/2021) documented the Consultant Pharmacist reviews the medication regimen of each resident at least monthly. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The attending physician documents in the medical record that the irregularity has been reviewed and (if any) action was taken to address it…
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 before2024-11-22 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
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 11/14/22-11/22/24, the facility did not ensure necessary dental services were provided in a timely manner for 1 of 1 resident (Resident #25) reviewed for Dental Services. Specifically, Resident #25 was not provided routine dental services since their 2/29/24 admission to facility. The findings are: The facility policy titled Dental Services, last revised 9/2019, documented routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. Resident #25 was admitted with diagnoses including but not limited to Peripheral Vascular Disease, Major Depressive Disorder, and Acquired Absence of Left Leg above Knee. The Quarterly Minimum Data Set (resident assessment tool) dated 11/3/24 documented Resident #25 had intact cognition. There was no documented evidence of a Dental Consult for Resident #25. During an interview and observation on 11/19/24 at 9:31 AM, Resident #25 stated they have not received a routine dental…
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 before2024-11-22 · 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 interview conducted during the Recertification Surveys from 11/14/24 to 11/22/24, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, there was undated ice cream in the meat freezer and vegetable freezer, a dietary aide was observed in the kitchen without a beard covering, there was 8 boxes of deluxe original cheddar macaroni noodles with an expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food room was peeling and had black/brown stains. The findings are: The facility policy titled Food service last revised on 5/10/24 documented dry storage rooms must be well ventilated. All storage areas should have adequate illumination with temperature and humidity controls to prevent condensation of moisture and growth of mold. All refrigerated foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-22 · 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
Based on observation and interview conducted during a recertification survey (11/14/24-11/22/24), the facility did not ensure a safe, clean, comfortable, and homelike environment was provided on 3 of 4 units (West, East and North). Specifically, North Unit had noticeable dirt and food throughout the hallway, a resident over bed table was dirty with food stains and caked on food in room [NAME] 7, and Resident #5 had no privacy curtain dividing the toilet area from the resident's room, allowing anyone entering the room to see the resident on the toilet and 2) Resident #23 was transferred into a wheelchair with a broken left wheel brake. The findings are: During observation on the North Unit on 11/14/24 at 11:16 AM, the floor area in the hallway near double doors had dirt, dust, and food crumbs and dirt was on the floor outside room B-15-N. During an interview on 11/15/24 at 12:03 PM Resident #5 stated they were able to use the toilet but, would like a curtain because it was embarrassing because anyone could see them while they are on the toilet. During observation on 11/15/24 at 12:07…
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 · D2024-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews conducted during an abbreviated survey (NY00329438), the facility did not ensure that care and treatments were provided to prevent the development of new pressure ulcers for 1 of 3 (Resident #3) residents reviewed for pressure ulcers. Specifically, Resident #3 was admitted to the facility with a deep tissue injury and skin integrity care plan was not put in place; physician orders for the use of a CAM boot (controlled ankle movements, a walking boot) when out of bed and skin checks every shift were not followed; Resident #3 developed a pressure ulcer to the left heel and treatments were not completed as ordered. Findings include: Resident #3 had diagnoses including fracture of the shaft of the left fibula (fracture of the long bone in the lower leg), Type 2 Diabetes, and Depression. The Nursing admission Evaluation dated 11/2/23 at 6:44 PM, documented Resident #3 had an unstageable pressure injury to the left dorsal (top) foot that measured 4 centimeters by…
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 before2024-09-11 · 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 an abbreviated survey (NY00336418) the facility did not maintain adequate supervision to prevent an elopement for 1 of 4 residents reviewed for accidents (Resident #2). Specifically, Resident #2 left the building on 1/22/24 and staff did not notice the resident's absence until 1/23/24 when the nurse could not find the resident for morning medications. The facility called a Code Gray (missing resident alert) and the resident was located by phone at a friend's house. The resident returned to the facility around 2 PM on 1/23/24. Findings include: The policy and procedure titled Elopement - Missing Resident, revised 1/2020 documented it was the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Should an employee discover that a resident is missing from the facility, they should announce on the overhead paging system CODE GRAY. Upon return to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews conducted during an abbreviated survey (NY00326941), the facility did not ensure residents right to be free from abuse for 1 of 3 sampled residents (Resident #1) Specifically, on 10/19/2023 and 10/24/2023 a Certified Nursing Assistant (CNA #2) was witnessed slapping Resident #1 in the face and push them back to bed forcibly. The findings are: The Facility Policy titled 'Abuse' last revised on 12/2022 documented that the facility prohibits abuse and strives to ensure the prevention and reporting of suspected or alleged resident abuse. Resident #1 had diagnoses that included hypertension, cerebrovascular accident, and dementia. The Minimum Data Set (MDS-a resident assessment tool) dated 9/08/2023 documented that Resident #1 had severe cognition impairment and required one-person physical assistance with Activities of daily Living (ADLs). The facility Accident & Incident (A&I) report / investigation dated 10/26/2023 concluded that abuse occurred on 10/19/2023 and on 10/24/2023. The facility documented CNA#1 reported they saw CNA#2 push Resident #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-07 · 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 conducted during an abbreviated survey (NY00326941), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours of occurrence. This was evident for 1 of 3 residents (Resident #1) reviewed for abuse and mistreatment. Specifically, a Certified Nursing Assistant (CNA #2) was witnessed by CNA #1 on 10/19/2023 and 10/24/2023 slap Resident #1 in the face and push them back to bed forcibly. The facility did not report the incident to the NYSDOH until 10/26/2023. The findings are: The policy and procedure titled Abuse last revised 12/2022 documented that the facility has designed and implemented process, which strive to ensure the prevention and reporting of suspecting or alleged resident/patient abuse, neglect, or mistreatment and or misappropriation of property. Trainings for staff include obligation to report alleged violations, reinforce staff education, with the emphasis on required reporting…
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 before2023-11-07 · 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
Based on record review, and interviews conducted during the Abbreviated Survey (NY00326941), it was determined the facility did not ensure a resident's care plan was revised to reflect the resident's change in condition for one of three residents (Resident #1) reviewed for Abuse. Specifically, when the resident had demonstrated new behaviors related to agitation and aggression on 9/30/2023, 10/01/2023, and 10/19/2023, the care plans for Dementia Care and Behaviors were not updated to include new interventions. The findings include: The facility Comprehensive Care Plan Policy and Procedure documented that comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #1 diagnoses included hypertension, cerebrovascular accident, and dementia. The Minimum Data Set (MDS; a resident assessment tool) dated 9/08/2023 documented Resident #1 had severely impaired cognition and required one-person physical assistance with Activities of 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.
- Potential for harm · Dcited before2022-01-06 · 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 observations, record review and interviews conducted during a recertification survey, it was determined that the facility did not ensure proper food storage in the facility kitchen according to professional standards for food safety practice to prevent foodborne illness. The findings include: The Food Storage Policy created 4/2017 and last revised 3/9/2018 was reviewed. The Policy states sufficient storage policies will be provided to keep foods safe, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Perishable food such as meat, poultry, fish, dairy products, fruits, vegetable, and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees F and freezer temperatures to keep food frozen solid. Refrigerated food…
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 before2019-12-06 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the most recent recertification survey, the facility did not ensure that necessary dental services were provided in a timely manner for one of two residents reviewed for dental services (Resident #12). Specifically, a dental follow-up visit recommended by the dentist was not scheduled to address the resident's need for a partial lower denture. The findings are: Resident #12 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Seizure Disorder. The quarterly Minimum Data Set ( MDS-a resident assessment tool) dated 9/5/19 showed that the resident obtained a BIMS (brief interview for mental status) score of 7 indicating severe cognitive impairment. A review of the dental consultation notes dated 9/3/19 showed that the resident wears an upper denture and that his lower jaw has few remaining teeth. The dentist recommended that the resident be seen for a follow-up visit for a partial lower denture. A review of the medical…
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 CENTERS HEALTH CARE — 36 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 | 2.2 | -0.2 vs chain |
| Health inspection | 1 of 5 | 2.1 | -1.1 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 5 of 5 | 3.8 | +1.2 vs chain |
The other 35 homes this chain runs (chain average 2.2★, 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 |
|---|---|---|---|---|
| ROZENBERG, KENNETH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | 97% | since 01/01/2025 |
| GOLDMAN, NATHAN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| HENDRIX, HEIDI | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| LANTZITSKY, AHARON | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| MENON, JAIKUMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/17/2018 |
| SAVIN, CHAIM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/28/2023 |
CMS files one row per role, so the 9 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 $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 335188. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-22, 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 →
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