Schaffer Extended Care Center
16 Guion Place, New Rochelle, NY 10802 · Non profit - Corporation · 150 certified beds · (914) 637-1200 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,512 in federal fines (most recent 2025-05-06)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (98%) runs well above the national median (45%)
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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 25.9% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.5% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.3% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.9% | 1.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.0% | 19.5% | 6.5% | check this* — see note marked star 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 | 1.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.7% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 5.5% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.9% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.7% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 67.0% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.8% | 20.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.1% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.45 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.47 | 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.
§ 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.
37.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 119 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.1% 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 76 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 37.5%CMS range 28.8–46.6 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.0–15.0 | 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 | 42.1% | 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 | 40.8% | 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 | 43.4% | 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 | 58.2% | 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 | 82.9% | 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 | 95.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 8.7% | 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 5.0–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 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 150 beds and averages 140.5 residents a day — about 94% occupied, or roughly 10 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 3.05 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 2.67 hrs/resident/day on weekends vs 3.20 on weekdays — 17% thinner on weekends. RN hours go from 0.73 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 98% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2025-05-06 · 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
Based on interview, observation and record review during the Recertification Survey conducted from 4/29/2025 to 5/6/2025, the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers and to prevent worsening of pressure ulcers. This was evident for one (1) of five (5) residents (Resident #32). Specifically, Resident #32 was assessed at risk for pressure ulcers, developed a sacral wound and there was no documented evidence that interventions were implemented to address off loading/incontinence schedule/incontinence care to prevent further deterioration of a sacral wound. Subsequently, when assessed by the physician on 3/4/2025 the wound was documented as Stage 3 (full thickness skin loss) and on 4/2/2025 the wound had progressed to an unstageable (damage to skin caused by constant pressure on an area for a long-time) pressure ulcer. This resulted in actual harm to Resident #32 that was not Immediate Jeopardy . The findings include: The policy titled Pressure Ulcer Prevention Protocol with a February 2025 revision…
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 · F2025-05-06 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review during the recertification survey from 04/29/25 through 05/06/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#13, #14, #15, #16, #17) did not have a performance review documented at least once every 12 months. The findings include: The Policy & Procedure titled Competency Based Performance Evaluation Program with a 4/2023 revision date documented it was the responsibility of administrative, managerial, and or supervisory staff to review the performance of all employees under their supervision and to complete and forward completion information to the human resource department. The individual departments will maintain a file of the actual performance appraisals. Performance Appraisals are to be completed annually. There was no documented evidence that performance reviews were completed in the last 12 months for Certified Nurse Aide #13 with a hire date of 11/6/13, Certified Nurse Aide #14 with a hire date of 11/6/13, Certified…
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 · F2025-05-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview conducted during the recertification survey from 4/25/25 to 5/6/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, unlabeled and undated food items in kitchen and unit pantry, expired food in kitchen storage pantry and unit pantry, and dietary staff did not perform proper hand hygiene before preparing a sandwich. The findings include: The policy titled Handwashing with a 1/2022 revision date documented food service associates are expected to perform proper hand hygiene while on duty; specifically, before and after wearing gloves. The policy titled Use and Storage of Food/Beverages brought from off-site with a 4/2025 revision date documented food may be stored in the unit pantry refrigerator for up to 48 hours, labeled with current date and discarded after 48 hours of date on the label. During the initial tour of the kitchen conducted on 4/29/25 at 9:25 AM, there was a bag of unlabeled sundried tomatoes in the salad refrigerator and two containers 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 · Fcited before2025-05-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview during a Recertification Survey on 4/29/2025 - 5/6/2025, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure an infection surveillance plan based on facility assessment was implemented for the identification, containment and prevention of infections. Findings include: The policy titled Infection Control Program last reviewed on 12/24 documented the Infection Control Committee shall investigate, control and prevent infections, decide which procedures shall be applied, such as isolation when control of infection or communicable disease is required: perform surveillance and investigation of prevention, to the extent possible, the onset and spread of infection, prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. The Antibiotic list for March 2025 and April 2025 documented residents on antibiotic therapy for wound…
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 before2025-05-06 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview during the recertification survey and abbreviated survey (NY00374695) from 4/29/25 to 5/6/25 the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with resident rights that included measurable objectives and time frames to meet a resident's needs for 1 of 5 residents (Resident #32) reviewed for pressure ulcers, 1 of 3 residents (Resident #19 ) reviewed for positioning and mobility and for 1 of 2 residents (Resident #8) reviewed for tube feeding. Specifically, 1) Resident #32 was incontinent of bladder and there was no documented evidence that a care plan to address an incontinence schedule/incontinence care was developed and/or implemented, 2) Resident #19 did not have an activities of daily living care plan prior to 5/5/25 and 3) the care plan to address Resident #8's feeding tube was incomplete and did not have measurable objectives, goals and interventions. The findings include: The Comprehensive Care Plan Policy last revised 1/2025 documented each…
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 · E2025-05-06 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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, during the recertification survey and abbreviated survey (NY00376185) and (NY00342713), the facility did not ensure residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Specifically, 1) the 5th floor call bell was not audible and did not have a centralized location to alert staff when residents needed assistance for twenty nine of twenty nine rooms and the light above the door did not light up for five of the twenty nine rooms (Rooms #104A, 105B, 111P, 115A, 115B, bathroom in room [ROOM NUMBER]). Additionally, tap or hand bells were not provided/readily available as per facility plan for ten of the twenty nine rooms (Rooms #104B, 105B, 111P, 115B, 117A, 121A, 121B, 126B, 127A, 127B, 128A, 128B, 129A, and 129B). The findings include: The Policy and Procedure titled Call Bell System last revised 2/2025 documented the promptness of the call bell…
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 · D2025-05-06 · 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
Based on observation, record review and interview during the recertification survey from 4/29/25 to 5/6/25 the facility did not ensure the right to receive services with reasonable accommodation of needs and preferences for 1 of 3 residents (Resident #19) reviewed for positioning and mobility. Specifically, Resident #19 stated they informed the Director of Social Work their wheelchair needed to be repaired 3 months ago and the wheelchair was observed in disrepair on 4/30/25. The findings include: The policy titled Physical Medicine and Rehabilitation Wheelchair Repairs last revised 7/2023 documented any wheelchair that is found to be in need of repair must be immediately taken out of service and inform Physical Medicine and Rehabilitation department notified. The Physical Medicine and Rehabilitation department will provide a replacement wheelchair while repairs are made. Resident #19 had diagnoses including Cancer, Peripheral Vascular Disease, and Asthma. The 1/25/25 Quarterly Minimum Data Set assessment documented Resident #19 was cognitively intact, used a manual wheelchair 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 · D2025-05-06 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey 4/29/25 to 5/6/25, the facility did not ensure a significant change Minimum Data Set (MDS) Assessment (tool to assess resident care needs) was completed within the 14-day requirement for 1 of 5 residents (Resident #48) reviewed for pressure ulcer/injury. Specifically, a Significant Change Minimum Data Set was not initiated within 14 days for Resident #48 with a decline in swallowing ability who required a 1/28/25 diet downgrade to nothing by mouth. The findings include: Resident #48 was admitted to the facility with a diagnosis of Dementia. The 12/3/24 Quarterly Minimum Data Set assessment documented no swallowing disorders present. The 12/6/24 Clinical Nutrition assessment dated [DATE] documented puree diet with nectar thick liquids, tolerating the modified texture and no swallowing issues. The 1/28/25 Physician Order documented Aspiration Precautions as necessary and nothing by mouth diet, texture and consistency. 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 · D2025-05-06 · 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, interview, and record review conducted during the Recertification Survey from 04/29/2025 to 05/06/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one of one resident (Resident #67) reviewed for edema. Specifically, for Resident #67 a left foot ace bandage wrap was not consistently applied in the morning to allow 12 hours of use daily and legs were not elevated when out of bed as per physician order. The findings include: Resident #67 had diagnoses including but not limited to Hemiplegia following a Cerebral Infarction, Morbid Obesity, and Heart Failure. The Care Plan titled Hypertension dated 10/26/24 documented monitor for edema. The Quarterly Minimum Data Set (an assessment tool) dated 1/31/25 documented Resident #67 was cognitively intact and independent with all activities of daily living. The 2/14/25 Care Plan Note documented blood pressure stable, lower extremities remain with swelling. Continue same plan of care. The 3/7/25 Physician Order documented wrap the left foot 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 · D2025-05-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the recertification survey from 4/29/25 to 5/6/25, the facility did not ensure irregularities identified by the pharmacist and forwarded to the facility were acted upon for 1 of 5 residents (Resident #121) reviewed for unnecessary medications. Specifically, for Resident #121 laboratory requests were not ordered and obtained as per consultant pharmacist and physician agreement. The findings include: Resident #121 was admitted to the facility on [DATE] with the diagnosis of dementia with psychotic disturbance, anxiety, and falls. The 1/21/25 Quarterly Minimum Date Set (assessment tool) documented the resident had severely impaired cognition and was taking an antipsychotic medication. The 4/4/25 Medication Regimen Review documented laboratory monitoring as a requirement for Seroquel use and there were no recent labs on file. Physician signature documented reviewed and will order. There was no documented evidence in the physician orders that the requested…
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 · D2025-05-06 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview during the recertification survey conducted 4/29/2025-5/6/2025, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 2 of 3 residents (Residents #113, #86) reviewed for food. Specifically, 1) Resident #113 had a physician order for mince and moist diet and was served a fruit cup and 2) Resident #86 had a physician order for nectar thick liquids and was provided a pitcher of water by the Certified Nurse Aide. The findings include: The policy titled Diet Orders, revised 4/2025 documented the purpose of the policy is to ensure the resident/patient receives meals that are consistent with clinical needs. 1)Resident #113 with diagnosis that include Hypertension, Heart Failure and Chronic Kidney Disease. The 9/14/24 Quarterly Minimum Data Set (an assessment tool) documented the resident's cognition was moderately impaired and they received set up assistance for eating. The 11/5/24 Physician Order documented minced and moist texture diet and thin liquids.…
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 13 citations
- Potential for harm · D2025-05-06 · 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, interview, and record review conducted during the recertification and abbreviated surveys (NY00336728), the facility did not ensure all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for 1 of 1 resident reviewed for Abuse (Resident #77). Specifically, Resident #77 was observed with a swollen right arm which was warm to touch and of unknown origin on 3/20/24 at 10:15 AM, and it was not reported to the state agency until 3/21/2024. Findings included: The policy titled Abuse, Neglect, Mistreatment and Exploitation last revised February 2025, documented an injury of unknown origin will be investigated with the assistance of the appropriate personnel. If the event which caused the allegation results in serious bodily injury they are reported immediately or no later than two hours. Resident #77 had diagnoses including dementia, hemiplegia and hemiparesis, and dysphagia. The 2/27/24 Quarterly Minimum Data Set (assessment tool) documented Resident #77 had severely impaired cognition, no behavioral symptoms,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-20 · 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 observations, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure 4 of 5 residents (Residents #114, 57, 14, and 28) reviewed for pressure ulcers, received care and services to promote healing. Specifically, Resident #114 had a Stage 4 pressure ulcer and was not turned and positioned as planned; additionally, there was not a documented wound assessment, by a qualified professional over a 3-week period. Residents #57, #14 and #28 had Stage 4 pressure ulcers and no documented evidence that wound assessments were completed as planned. Findings include: 1) Resident #114 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including right above the knee amputation, cerebral vascular accident (CVA, stroke), and Stage 4 pressure ulcer (skin impairment). The 11/25/2023 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired. The resident required total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during a recertification survey from 12/12/23 through 12/20/23, the facility did not review and revise the comprehensive care plan with appropriate interventions for 2 out of 2 residents (Residents #89 and #98) reviewed for Activities. Specifically, Residents # 89 and #98's recreation care plans were not updated quarterly and did not reflect the residents' preferred activities. Findings include: The facility comprehensive care plan policy, revised April 2023, documented the frequency of care plan updates was after any significant changes in the resident's condition, after family/team meetings, quarterly and annually. 1) Resident #89 was admitted with diagnoses including dementia, hypertension (high blood pressure), and asthma. The quarterly Minimum Data Set (an assessment tool) dated 8/29/23 and 11/26/23 documented Resident #89's cognition was intact for daily decision making. The Activity Preferences section (section F) of the MDS was not completed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-20 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that they evaluated, updated, and implemented an effective discharge plan for one of four residents reviewed for discharge (Resident #127). Specifically, Resident #127 who expressed a desire to be discharged to the community was not re-evaluated and a new discharge plan developed based on the resident's choice when the initial community discharge plan could not be implemented, and planned community support were no longer available. Findings include: Review of the facility policy entitled Discharge/Transfer, dated 7/03, last reviewed 9/23, stated the facility will discharge a resident when the interdisciplinary team, in consultation with the resident, determines that the discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, and is being made in compliance with the resident's request. Further, for discharges to the community, the Social Worker confirms that 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 · D2023-12-20 · 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, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure that residents with a Foley (indwelling) catheter (a tube inserted into the bladder via the urethra to drain urine into a drainage bag) received the treatment and services needed to prevent urinary tract infections to the extent possible for one (Resident #87) of 3 residents reviewed for indwelling catheters. Specifically, Resident #87's Foley catheter drainage bag was not changed as per physician orders, and there was a lack of Foley care provided per professional standards to prevent complications. Findings include: Resident #87 was admitted with diagnoses including hematuria (blood in the urine), neurogenic bladder (dysfunction of nerve pathways to the bladder), and sepsis (systemic infection) secondary to urinary tract infection. The Minimum Data Set assessment, dated 9/8/2023, documented the resident had intact cognition, received extensive assist 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 before2023-12-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during a recertification survey 12/12/2023-12/20/2023, the facility did not ensure an infection prevention and control program designed to provide a safe and sanitary environment was maintained. Specifically, (1) The facility could not provide evidence that a facility risk assessment was conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system and 2)Foley catheter tubing was observed on the floor without a barrier for 1 of 3 residents reviewed for foley catheters (Resident #87). The findings are: The facility Legionella Water Management Program dated 1/1/2023 documented the purpose of the water management program is to identify areas in the water systems where Legionella bacteria can grow and spread and include an assessment of the infrastructure components in terms of their potential contact with patients/visitors and a sampling and maintenance schedule for demonstrating how the effects…
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 before2019-10-24 · 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, interviews and record review during a recertification and abbreviated survey (Complaint #NY00244321), the facility failed to develop plans of care with measurable goals, time frames and interventions to address the residents assessed needs for one of two residents reviewed for respiratory therapy (Resident #102) and one of two residents reviewed with a urinary drainage bag (catheter, Resident #243). Specifically, Resident #102's plan of care failed to address strict aspiration precautions for a resident with a tracheostomy tube in place. Resident #243's Comprehensive Care Plan did not provide measurable goals and interventions to address her diagnosis of overactive bladder leading to the need for a urinary catheter. The findings are: 1. Resident #102 was admitted on [DATE] with diagnoses including Quadriplegia, Tracheotomy Dependence, Hypertension, Spasmodic Upper Extremity Weakness and Poor Dexterity in both Hands. The quarterly Minimum Data Set (MDS; an assessment tool) dated 9/23/2019…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-24 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during recertification and abbreviated surveys (Complaint #N00244321), it cannot be ensured that the facility completed a discharge summary that included a course of treatment, resident status and post-discharge plans for 1 of 4 residents reviewed for Admission, Transfer and Discharge (Resident #243). Specifically, Resident #243's discharge summary furnished to the receiving Assisted Living Facility (ALF) did not summarize the course of treatment for urinary continence, did not provide a final summary of urinary status and did not provide a post-discharge plan for urinary continence. The findings are: Resident #243 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Overactive Bladder. She was discharged to an Assisted Living Facility (ALF) on 08/20/19. The resident's Minimum Data Set (MDS; an assessment tool) dated 08/29/19 documented that Resident #243 required extensive to total assistance with activities of daily living, had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 recerfication survey, it could not be ensured that facility residents (Residents #51 and # 85) who are unable to carry out activities of daily living (ADL's) receive the necessary services to maintain personal hygiene and bathing. The findings are: 1. The Minimum Data Set (MDS; an assessment tool) dated 2/6/19 was reviewed and revealed that Resident #85 had diagnoses including Diabetes Mellitus (DM) and Depression. Resident #85 also required physical support of one person to assist with bathing. Furthermore, Resident #85's Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. A review of the Comprehensive Care Plan for Activities of Daily Living/ Functional Rehab for resident #85 dated 8/31/19 documented that Resident #85 required extensive assistance with the support of one person assist to include personal hygiene and bathing. A review of the CNA (Certified Nursing Assistant) Accountability Sheets for Resident #85 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 · D2019-10-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review on a recent recertification survey, the facility did not ensure proper care and treatment of a resident receiving oxygen therapy. Specifically, a resident with a tracheostomy received 4 liters of humified oxygen via tracheostomy collar without a physician order for twelve weeks. Additionally, there was no documentation of pulse oximetry measurements and a self-inflating bag resuscitator was not provided in the resident room. The findings are: Review of Resident #102's record showed that #102 was admitted to the facility on [DATE] with diagnoses including Spinal Cord Injury, Quadriplegia, Tracheostomy Dependence and Hypertension. Physician orders dated 10/01/2019 indicated that Resident #102 was on strict aspiration precautions with a regular consistency solid diet, no hard items to chew, no beef with honey-thickened liquids. The MDS quarterly assessment done on 9/23/2019 indicates the resident is cognitively intact. Resident #102 has spontaneous respirations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-24 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 observation, interview and record review conducted during the most recent re-certification survey, it could not be ensured that the facility provided services consistent with standards of practice and in accordance with the written plan of care for 1 of 2 residents (Resident #193) reviewed for dialysis. Specifically, the resident's pre and post dialysis weights were not consistently obtained from the dialysis center in accordance with the resident's plan of care. The findings are: Resident #193 was admitted to the facility on [DATE] with the diagnosis of End Stage Renal Disease that required hemodialysis three times weekly. The resident's Plan of Care for dialysis dated 10/9/19 noted that the goals for the resident included no volume deficit/overload and the interventions to achieve this goal included pre and post dialysis weights and a dialysis diet. The current physician's orders included a renal diet with a 1000cc daily fluid restriction. A review of the Dialysis Communication Book revealed that 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 · D2019-10-24 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the most recent re-certification survey, the facility did not ensure that 1 of 4 residents (Resident #125) reviewed for dementia care was provided appropriate care to maintain the highest psychosocial well-being and to avoid the use of antipsychotic medication for behavior management. Specifically, there was no documented evidence that 1) underlying causes for behavioral symptoms were determined during the onset of these behaviors; and 2) person-centered behavioral interventions were attempted prior to initiating the use of Haldol, an antipsychotic medication. The findings are: Resident #125, a 77- year-old male with diagnoses including Dementia, was admitted to the facility on [DATE]. The comprehensive care plan revealed that on 6/12/19 goals and intervention were developed to address the resident's cognitive status related to Dementia. The plan noted that the goal was to maintain/minimize decline in cognitive capacity. The interventions to achieve this goal…
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 · B2023-12-20 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 12/12/2023 through 12/20/2023, the facility did not ensure the required quarterly Minimum Data Set ( a resident assessment and screening tool) was conducted within the regulatory time frame as per the Centers for Medicare and Medicaid Services resident assessment instrument process. Specifically, the Minimum Data Set records for Residents #27 and #38 revealed that the quarterly Minimum Data Sets were not completed within the assessment reference date plus 14 days. The findings are: Resident # 27's quarterly Minimum Data Set was completed with an assessment reference date of 11/02/2023. Per the validation report Resident #27's quarterly Minimum Data Set was completed late with a Minimum Data Set completion date of 12/14/23, more than 14 days after the assessment reference date. Resident # 38's quarterly Minimum Data Set was completed with an assessment reference date of 11/07/2023. Per the validation report Resident #38's quarterly Minimum Data Set was completed late with a Minimum Data Set…
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
$10,512 in federal fines across 1 penalty.
- $10,512 — penalty dated 2025-05-06
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 |
|---|---|---|---|
| BLYE, COLLEEN | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 01/06/2016 |
| KOHN, RANDI | Individual | W-2 MANAGING EMPLOYEE | since 11/06/2013 |
| OZUAH, PHILLIP | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/23/2013 |
| PANCZNER, CHRISTOPHER | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/23/2013 |
| ABRAMSON, JAY | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| BLATTMAN, BARRY | Individual | CORPORATE DIRECTOR | since 09/16/2014 |
| BRAUN, JOEL | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| BRESLOW, ELLEN | Individual | CORPORATE DIRECTOR | since 06/24/2021 |
| BUTLER, JAMES | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2016 |
| CERIALE, MELISSA | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| CHIRICO, EMANUEL | Individual | CORPORATE DIRECTOR | since 10/18/2016 |
| DOCTOROFF, ALISA | Individual | CORPORATE DIRECTOR | since 03/21/2017 |
| EISENBERG, DOUGLAS | Individual | CORPORATE DIRECTOR | since 06/24/2020 |
| EMIL, JENNIE | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| GANTCHER, NATHAN | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| GOTTESMAN, RUTH | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| GREEN, PATRICIA | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| GUTFREUND, JOHN | Individual | CORPORATE DIRECTOR | since 03/21/2017 |
| HARRISON, THOMAS | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| HEFFER, JOHN | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| HENKIND, LEWIS | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| JOHNSON, HELEN | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| KEIDAN, DAVID | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| KLEIN, ALAN | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| KLEMA, CATHERINE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2014 |
| LANE, STACEY | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| LIPTON, JONATHAN | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| MOELIS, RONALD | Individual | CORPORATE DIRECTOR | since 03/21/2017 |
| NORD, MATTHEW | Individual | CORPORATE DIRECTOR | since 09/16/2014 |
| ROBINSON, GAYLE | Individual | CORPORATE DIRECTOR | since 03/13/2001 |
| ROTENSTREICH, JON | Individual | CORPORATE DIRECTOR | since 10/08/1980 |
| STERN, EDWIN | Individual | CORPORATE DIRECTOR | since 03/13/1968 |
| STOCKER, MICHAEL | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| SUNA, ALAN | Individual | CORPORATE DIRECTOR | since 11/01/2018 |
| TANNER, DAVID | Individual | CORPORATE DIRECTOR | since 03/03/1996 |
| TISHMAN, DANIEL | Individual | CORPORATE DIRECTOR | since 05/18/2018 |
CMS files one row per role, so the 43 rows in the source record cover these 36 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.
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 335337. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-06, 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.