Glen Island Center for Nursing and Rehabilitation
490 Pelham Road, New Rochelle, NY 10805 · For profit - Corporation · 183 certified beds · (914) 636-2800 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $36,299 in federal fines (most recent 2024-11-27)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 4 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.4% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 28.2% | 19.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.4% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.6% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.8% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 6.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 14.2% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.2% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 79.3% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.1% | 20.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.5% | 9.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.05 | 1.70 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.83 | 1.36 | 1.80 | typical |
‡ 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.
44.4% 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 187 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.4% 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 143 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% 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 | 44.4%CMS range 37.0–50.7 | 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 | 14.2%CMS range 10.2–17.7 | 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 | 66.4% | 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 | 63.6% | 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 | 65.7% | 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 | 97.2% | 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 | 1.8% | 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 | 5.7% | 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 | 7.5%CMS range 4.9–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.44 | 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 183 beds and averages 175.6 residents a day — about 96% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.02 hrs/resident/day on weekends vs 3.29 on weekdays — 8% thinner on weekends. RN hours go from 0.91 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% 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 fewer than at the previous inspection — improving. 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.
19 citations, most serious first. The 11 most serious are shown; the remaining 8 are one tap away and print in full.
- Actual harm · H2024-11-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 record review and interview during an abbreviated survey and partial extended survey (NY00349917), the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent new ulcers from developing and promote healing of facility acquired pressure ulcers for 3 out of 5 residents (Resident #1, #7, #8) reviewed. Specifically, (1) Resident #1 was admitted to the facility with intact skin and was identified as a low risk for pressure ulcer development. Interventions/measures ordered by the physician to prevent pressure ulcer development were not consistently provided by direct care staff and Resident #1 developed a facility acquired pressure ulcer to their sacrum and bilateral heels. (2) Resident #7 developed a facility acquired Stage III pressure ulcer (a full thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed) to the right buttocks after not receiving consistent incontinence care. (3) 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 · D2026-02-05 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure that residents had the right to formulate advance directives that would be honored. This was evident for two (2) of three (3) residents (Resident #10, #28) reviewed for Advance Directives out of total 38 sampled residents. Specifically, the facility did not ensure Resident #10 and Resident #28's advance directive wishes were accurately reflected in the medical record. The findings included: The facility's policy and procedure titled Advance Directives reviewed 01/21/2026 documented it is the policy of the facility to inform all adult residents of their rights to accept or refuse medical treatment by providing written and/or verbal information on Advance Directives. The individual's wishes on advance directive will be identified and honored by the facility. Resident's Advance Directives will be reviewed upon admission, re-admission from the hospital, quarterly and annually. Advance Directives are also reviewed at the request of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident for one (1) (Resident #16) of two (2) residents reviewed for rehabilitation and restorative services out of a total sample of 38 residents. Specifically, Resident #16 was observed without a left-hand splint in place as per physician order. The findings include: The facility's policy titled, Splints and Orthotic Management Policy and Procedure, last review dated 09/2025 documented that splinting and orthotic management is a therapeutic procedure designed to prevent worsening contractures of a joint to increase range of motion and/or to prevent skin breakdown. Therapists will collaborate with nursing to get an order in place once trial has completed for ongoing orthotic wearing schedule. At which time the orthotic may be donned and doffed 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 · D2026-01-05 · 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 record review and interviews during an abbreviated survey (2654597) the facility did not ensure the residents right to a dignified existence the facility must treat each resident with respect and dignity and care for each resident 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 1 out of 3 residents (Resident #5) reviewed for dignity. Specifically, on 12/05/2025 the Surveyor observed Certified Nurse Aide #2 providing personal care to Resident #5 with the door to their room open. Resident #5 was observed lying in bed, without a shirt on, and was noted to be exposed from the waist up and visible from the hallway. The findings are:The facility Resident Rights policy last reviewed 10/01/2025 documented it is the policy to provide care and services in such a manner to acknowledge and respect resident rights. Each resident has the right to be treated with dignity and respect. All interactions and activities…
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 · E2024-11-27 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00349917, NY00347905) and a partial extended survey the facility did not ensure the residents representative was informed of a significant change in the resident's physical status or a need to alter treatment significantly for 3 out of 4 residents (Resident #1, Resident #6, Resident #7) reviewed for notification of changes. Specifically, (1) Resident #1 developed multiple facility acquired pressure ulcers to their right buttocks on 6/20/2024 and bilateral heels on 6/25/2024. There was no documented evidence that Resident #1's representative was notified of these changes in the resident's condition until they inquired about them on 6/26/2024 and 7/1/2024. (2). Resident #6 developed a facility acquired sacral pressure ulcer on 7/27/2024. There was no documented evidence of Resident #6's representative was notified that the resident developed a sacral pressure ulcer or informed of the ordered treatment. (3) Resident #7 developed a facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00347905) the facility did not ensure that a resident with urinary incontinence received appropriate treatment and services for 4 out of 4 residents (Resident #6, #9, #3, #4) reviewed for incontinence care. Specifically, (1) Resident #6 was incontinent and was dependent on direct care staff for toileting. Review of Resident #6's certified nurse assistant accountability report for July and August 2024 revealed numerous signature omissions for bladder incontinence care indicating care was not provided by direct care staff. (2) Resident #9 was known to be frequently incontinent of urine and always incontinent of bowel. Review of Resident #9's certified nurse assistant accountability report for June and July 2024 revealed there were numerous signature omissions indicating bladder incontinence care was not provided by direct care staff. (3) Resident #3 was incontinent and dependent on direct care staff for toileting. Review of Resident #3's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-27 · 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 record review and interview during a partial extended survey (NY00349917, NY00347905), the facility did not provide sufficient nursing staff to consistently meet the needs of all residents. The Facility Assessment resident to staff ratios (certified nurse assistant) levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the unit staff assignment sheets for June 2024, July 2024, August 2024 and September 2024 revealed staffing was not adequate across various shifts based on the unit needs and the staffing needed as documented in the facility assessment. The findings are: The facility Staffing Assignments policy dated 7/9/2007 and last reviewed 7/21/2024 documented the policy of the facility to determine the appropriate staffing on a unit based on the census, acuity, shift and needs of the residents. The purpose of the policy is to ensure that each floor is staffed with sufficient competent staff each shift. Review 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 · Dcited before2024-11-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00349917, NY00347905), the facility did not ensure the comprehensive care plans were reviewed and revised in a timely manner for 2 of 4 residents (Resident #7, Resident #8) reviewed for care planning. Specifically, Resident #7 developed a facility acquired stage II pressure ulcer to their right buttocks on 8/21/2024. There was no documented evidence of the potential for pressure ulcer development care plan being revised to reflect the actual pressure ulcer. (2) Resident #8 developed a facility acquired stage III pressure ulcer to their sacrum on 8/14/2024. There was no documented evidence of the potential for pressure ulcer development care plan being revised to reflect the actual pressure ulcer. Findings include: Review of the facility Care Planning Process dated 1/1/2018 and last revised 1/1/2023 documented the facility shall have a care planning process in place which includes integrating assessment findings in care planning, developing and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0730 — isolatedObserve 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 interviews during an abbreviated survey (NY00349917, NY00347905), the facility did not ensure a performance review was completed for every nurse aide at least once every 12 months, and that regular in-service education was provided based on the outcome of these reviews for 2 of 7 records reviewed. Specifically, (1) Certified Nurse Assistant #7 with a date of hire of 4/28/2015 had no documented annual performance evaluations prior to 11/22/2023 and none for 11/22/2024. (2) Certified Nurse Assistant #8 with a date of 8/1/2014 did not have any documented annual performance evaluations in their personnel file prior to 11/22/2023 and none foe 11/22/2024. The Findings are: The Facility Performance Review policy last reviewed 9/2/2024 documented all written performance reviews will be performed annually based on the staff member's overall performance in relation to the job responsibilities and will also consider the staff member's conduct, demeanor, and record of attendance and tardiness. The most recent evaluation supersedes prior evaluations. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 an abbreviated and partial extended survey (NY00349917, NY0034705), the facility did not ensure the Quality Assessment and Performance Improvement committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, (1) there were no documented evidence of the facilities actionable plans being implemented for their identified facility acquired pressure ulcer issue; (2) there was also no documentation of the continued performance improvement plan for 2 areas discussed in the 2nd quarter meeting. The findings are: The facility Quality Assurance and Performance Improvement Program policy documented the purpose was to ensure the development of a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality…
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 · D2024-06-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews conducted during the recertification survey from 6/10/24-6/14/24, the facility did not ensure that for 1(Resident #57) of 5 residents reviewed for environment, they were provided with reasonable accommodations of needs and preferences. Specifically, the call bell system designated for Resident #57 whom has left sided weakness, was observed not within the resident's reach, on multiple occasions. The findings are: The undated facility policy titled Resident Call System documented the purpose was to ensure that residents had a means of direct communication between the resident and his/her caregivers. Resident #57 was admitted to the facility with diagnoses including but not limited to cerebral vascular accident, dementia, difficulty in walking, and hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side. The Quarterly Minimum Data Set, dated [DATE], documented the resident had moderately impaired cognition, was dependent on staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · D2024-06-14 · 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 observations, record reviews and interviews conducted during the recertification survey from 6/10/2024 to 6/14/2024, the facility did not ensure the development of comprehensive person-centered care plans that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 3 (Residents #47, #51, and #66) of 35 residents reviewed for comprehensive care plans. Specifically, (1) for Resident #47, the facility did not ensure a comprehensive care plan was developed to address the use of indwelling urinary catheter; and the use of a left resting hand splint, (2) for Resident #51, the facility did not ensure a comprehensive care plan was developed to address the use of bilateral palm guards and soft hip abductor cushion at all times, and (3) for Resident #66, the facility did not ensure a comprehensive care plan was developed to address the toileting schedule put into place to achieve or maintain as much…
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 before2024-06-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews conducted during the recertification survey from 6/10/24 to 6/14/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1(Resident #57) of 5 residents reviewed for Unnecessary Medications. Specifically, Resident #57 was no longer receiving Lorazepam effective 8/4/23 and Apixaban effective 4/8/22 which was replaced with Xarelto on 4/8/22, and the Care Plans were not updated and revised to reflect the discontinuations and the changes with the medications. The findings are: The undated facility policy titled Care Planning Process documented that the facility shall have a care planning process in place which includes: integrating assessment findings in care Planning, developing and interdisciplinary care plan, regularly reviewing and revising the care plan, providing, and documenting the care. When a change in a resident's status is noted during the course of a resident's treatment, the specific focus,…
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 · D2024-06-14 · 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 interview and record review conducted during the recertification and abbreviated surveys (NY00330768) from 6/10/24 to 6/14/24, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #340) reviewed for skin impairments. Specifically, the Treatment Administration Record for Resident #340 revealed the treatments ordered by the physician were not administered as per order. The findings are: The undated facility policy, 'Skin Integrity' documented that the resident with pressure ulcers/injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers/injuries from developing. Resident #340 was admitted with diagnoses which included Diabetes Mellitus, COVID-19, and Pneumonia. On 10/20/23, a new diagnosis of orthopedic aftercare following surgical amputation was documented. The admission Minimum Data Set (resident assessment tool) dated 8/29/23 documented intact cognition.…
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 before2024-06-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the recertification survey from 6/10/24 to 6/14/24, the facility did not ensure that needed services, care and equipment were provided to assure that residents with limited range of motion and mobility maintained or improved function based on the residents' clinical condition for 2 of 4 residents (Resident #51 and Resident #46) reviewed for position and mobility. Specifically, 1. Resident #51 was observed on 3 occasions without bilateral palm guard and soft hip abductor in place, and 2. Resident #46 was observed without bilateral resting hand splints or palm guard in place. Findings include: The undated Policy and Procedure titled, Adaptive Equipment Device, documented splinting and orthopedic management is a therapeutic procedure designed to prevent worsening contractures of a joint, to increase range of motion, and /or to prevent skin breakdown. 1. Resident #51 had diagnoses which included adult failure to thrive, muscle wasting and atrophy, 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 · Dcited before2024-06-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey from 6/10/24-6/14/24, the facility did not ensure all residents were provided the appropriate treatment and services to achieve or maintain as much normal bladder/bowel function and prevent urinary tract infections to the extent possible for 1(Resident #66) of 1 residents reviewed for bladder/bowel. Specifically, Resident #66 was not toileted every 2 hours and as needed as per their plan of care. The findings are: Resident #66 was admitted with diagnoses including but not limited to anxiety disorder, Charcot's joint/right ankle and foot (limited mobility), and osteoarthritis. The Quarterly Minimum Data Set, dated [DATE], documented Resident #66 had intact cognition; required supervision with bed mobility, toileting, and transfers; and was frequently incontinent of bowel and bladder. Physician orders dated 6/6/24 documented Ciprofloxacin HCL 500 mg-give 1 tablet by mouth two times a day for urinary tract infection 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 · D2024-06-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey from 6/10/24-6/14/24, the facility did not provide an influenza vaccination for 1 (Resident #19) of 5 residents reviewed for Influenza vaccination after screening and consent was obtained. Specifically, Resident #19 had consent for Influenza vaccine dated 11/29/23 and did not receive the vaccine for the 2023-2024 flu season. Findings include: The facility policy titled Influenza and Pneumococcal Immunizations for Residents, updated April 2020, documented it was the policy of the facility to ensure that residents receive Influenza and Pneumococcal immunizations in accordance with State and Federal regulations and national guidelines. Resident #19 was admitted [DATE] with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and Morbid Obesity. The Minimum Data Set (MDS, a resident assessment tool) dated 11/16/23, documented the resident was cognitively intact, required supervision for eating, partial assistance…
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 · C2026-02-05 · tag F0582 — widespreadGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident for three (3) of three (3) residents (Resident #95, #204, and #205) reviewed for Beneficiary Notification out of total 38 sampled residents. Specifically, the facility did not ensure the resident/representative received timely written Notice of Medicare Non-Coverage of potential liability and appeals rights.The findings are: The facility's policy and procedure titled, Medicare Beneficiary Notices, last review dated 01/21/2026 documented the purpose of Medicare Beneficiary Notices are to ensure that Medicare beneficiaries receive proper notice when items and services Medicare usually covers but may not pay because they are medically unnecessary or custodial in nature or the service are no longer medically necessary. Advance written notice of noncoverage should be issued to and understood by Medicare beneficiary or their representative and issued far enough in advance 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.
- No harm found · B2026-02-05 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that Minimum Data Set 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Internet Quality Improvement Evaluation System (IQIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, resident's Quarterly, Discharge and comprehensive Minimum Data Set were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for, but not limited to, 3 of the 12 residents reviewed for Resident Assessment. (Residents #19, #32 and #48), out of a total of 38 sampled residents. The findings include: The Center for Medicaid/Medicare Services Resident Assessment Instrument Manual Version 3.0 (Dated October 2017)Chapter 5 titled, Submission and Correction of the MDS Assessments, states The Minimum Data Set completion date must be no later than 14 days after the Assessment Reference Date for all non-admission, Omnibus Budget Reconciliation Act,…
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
$36,299 in federal fines across 1 penalty.
- $36,299 — penalty dated 2024-11-27
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| FLAX, MAURY | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | since 04/01/2022 |
| FRIEDMAN, LEAH | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 04/01/2022 |
| AUGUSTYNIAK, BRANDON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2022 |
| RABADI, MAZAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 335611. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.