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Harlem Center for Nursing and Rehabilitation, L L

30 West 138th Street, New York, NY 10037 · For profit - Corporation · 200 certified beds · (212) 690-7400 Medicare & Medicaid certified

Call the home — (212) 690-7400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609) — most recent Mar 2023Behavioral-health or dementia-care citation — no harm found (F0740)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 24% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2238 5th Ave Fl 1 · (877) 364-8191 · Call to confirm hours
Pharmacy
3 W 137th St · (917) 965-2763 · Call to confirm hours
Grocery
KeyFood0.1 mi
592 Malcolm X Blvd · (212) 926-5470 · Call to confirm hours
Park
5 E 135th St · (212) 491-1714 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.2%14.1%15.4%better
Long-stay residents who lose too much weight5.1%5.8%5.4%typical
Long-stay residents with a catheter left in their bladder0.2%0.5%0.9%better
Long-stay residents with a urinary tract infection0.5%1.3%2.0%better
Long-stay residents with depressive symptoms29.6%19.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury0.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened8.8%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication2.9%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine91.0%95.3%95.3%typical
Long-stay residents with pressure ulcers5.0%6.5%4.7%typical
Long-stay residents with worsening bladder/bowel control9.7%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.2%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine69.0%78.8%79.4%worse
Short-stay residents rehospitalized after admission21.9%20.6%22.6%typical
Short-stay residents with an outpatient ER visit11.3%9.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.291.701.67better
Long-stay outpatient ER visits per 1,000 resident days0.931.361.80better

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.

31.9% 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 105 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

31.9%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
68.3%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 68.3% 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 186 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 62% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF31.9%CMS range 24.4–44.451.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.0–13.710.7%Oct 2022–Sep 2024no 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 discharge68.3%56.6%Oct 2024–Sep 2025CMS 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 discharge66.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge67.7%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge34.8%98.7%Oct 2024–Sep 2025CMS 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 stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 4.8–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.661.02Oct 2022–Sep 2024CMS 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

0.90
RN hours/ resident / day
0.54
LPN hours/ resident / day
2.41
Aide hours/ resident / day
3.86
Total nurse hours/ resident / day
0.51
RN hoursweekends
50.5%
Total nursing turnover
52.8%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 196.6 residents a day — about 98% occupied, or roughly 3 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 3.86 hrs/resident/day is at or above 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 2.41 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 3.26 hrs/resident/day on weekends vs 4.10 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.07 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

7
deficiencies at the latest standard inspection (2025-02-12)
10
at the previous standard inspection (2023-03-16)

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.

ABCDEFGHIJKL

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during an abbreviated survey (NY00375711), the facility did not ensure each resident received adequate supervision to prevent an elopement. This was evident for one (1) of four (4) residents (Resident #1),sampled for elopement. Specifically, the facility's video surveillance footage dated 03/19/2025 at 4:04:06 PM showed Resident #1 walked past Security Guard #1, who was sitting at the front desk in the lobby with their head down. Security Guard #1 did not stop Resident #1 from leaving the facility. Resident #1 exited the automatic front doors and left the facility. Staff interviews and the facility's investigative report revealed that the facility was not aware Resident #1 was missing until 7:30 PM. To date, Resident #1 has not been located. This resulted in the potential for serious harm to Resident #1 that was determined to be Immediate Jeopardy Past Noncompliance. The findings are: The facility's Policy and Procedure titled Elopement, dated 02/24/2024,…

    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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2025-12-17 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during an on-site abbreviated survey (457794), it was determined that for five (Second, Third, Fourth, Fifth, and Sixth Floors) of five resident-occupied floors, the facility did not maintain a comfortable environment. Issues included residents feeling uncomfortable and resident room temperatures ranging from 46 F to 57 F, from approximately 3:00 AM on 12/16/2025 through approximately 4:00 PM on 12/17/2025.Observations in the presence of the Director of Maintenance during an initial tour of the facility on 12/17/2025, between 9:30 AM and 10:30 AM, included but were not limited to the following: Utilizing an infrared temperature gun, the temperatures in resident rooms on the Sixth Floor were recorded at 49.4 F in resident room [ROOM NUMBER], with the highest temperature 54.6 F in resident room [ROOM NUMBER]. The corridor temperature was 54.6 F, and the Day Room was 60.2 F.Utilizing an infrared temperature gun, the temperatures in resident rooms on the Fifth…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Abbreviated Survey (Complaint #2634618) the facility failed to ensure that one (1) (Resident #1) of three (3) residents reviewed for quality of care, received treatment and care in accordance with professional standards of practice. Specifically, an order for comprehensive metabolic panel and complete blood count was made for Resident #1 but was not carried out. There was no documentation available in the medical record to explain why the test was not completed. The findings include:The undated facility policy titled Physician Services documented the resident's Attending Physician is responsible for prescribing new therapy, ordering a transfer to the hospital, conducting required routine visits, delegating and supervising follow-up visits from Nurse Practitioners or Physician Assistants, etc., to ensure that the resident receives quality care and medical treatments.Resident #1 had diagnoses of Diabetes Mellitus, Hypertension, and Urinary Tract…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-12 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    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 02/05/2025 to 02/12/2025, the facility did not ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee consisted at a minimum of the Medical Director, or their designee attended quarterly meetings. Specifically, the Medical Director has not participated in Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings for 4 out of the four meetings as required. The findings are: The facility Quality Assurance and Performance Improvement (QAPI) policy, last revised on August 31, 2022, documented that the Quality Assessment and Assurance Committee consists of, at minimum, the director of nursing services, the medical director or designee, and at least one other member of the facility staff. One of them must be the administrator, the owner, a board member, or another individual in a leadership role. Meetings will be held quarterly. The facility policy and procedure titled Medical Director, with the last…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification Survey from 02/05/2025 - 02/12/2025, the facility did not ensure that infection control practices and procedures were maintained. This was evident for 2 Residents (Resident # 389 and Resident #63) of 12 residents observed for medication administration and 1 Resident (Resident #389) observed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, 1.) Licensed Practical Nurse #2 failed to follow Enhanced Barrier Precautions by not donning a gown while administering intravenous medications for a Resident with a Peripherally Inserted Central Catheter. 2.) Licensed Practical Nurse #3 failed to follow Enhanced Barrier Precautions by not donning a gown while administering medications for a Resident with a Gastrostomy tube. 3.) Licensed Practical Nurse #1 did not establish a clean field for the placement of wound supplies while performing a dressing change and did not perform hand hygiene after removing 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 staff interviews conducted during the Recertification survey from 02/05/2025 to 02/12/2025, the facility did not ensure that care and services were provided according to accepted standards of clinical quality and practice. This was evident for 1 (Resident #389) of 2 residents reviewed for Intravenous medication administration out of a total of 35 sampled residents. Specifically, Intravenous antibiotics for Resident #389 were administered through a Peripherally Inserted Central Catheter by a Licensed Practical Nurse. The findings are: The facility Policy and Procedure titled Administering Medication by Central Line Access, reviewed and or revised 01/02/2025, documented guidelines for safe administration of medications intravenously through a central line access: 1) An LPN may Not Flush any venous central line for patency including a Peripherally Inserted Central Catheter. 2) An LPN may Not administer any intravenous solutions through a central venous line including a…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a Recertification survey from 02/5/2025 to 02/12/2025, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing. This was evident for 1 of 4 residents (Resident #389) reviewed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, Resident #389 did not receive pressure relieving devices and preventative measures to promote wound healing. The findings are: The Facility Policy titled Prevention of Pressure Ulcers reviewed/revised 01/02/025, documented the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors, interventions for specific risk factors, and preventative measures. General preventive measures include 1) Identify risk factors for pressure ulcer development 2) For a person in bed: Change position at least every two hours or more frequently…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-12 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the observations and staff interviews conducted during the Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure garbage and refuse were disposed properly. This was evident during kitchen observation. Specifically, the facility garbage bins did not have a lid or cover to prevent the harborage and potential feeding of pests. The findings: The facility's policy and procedure titled Disposal of Garbage and Refuse revised 1/2025 documented all garbage and refuse will be disposed of in a safe and efficient manner throughout the day. The exterior dumpster area shall be maintained and free of rubbish and other debris. All waste shell be kept in lined containers that are covered with lids, leak-proof and non-absorbent prior to disposal. On 2/10/2025 at 1:02PM, an observation was made of the garbage disposal room. The garbage bins all containing garbage were observed without a lid or cover. On 2/10/2025 at 1:13 PM and 2/11/2025 at 3:40PM, the garbage bin located in the garbage pickup area was observed without lid or cover, exposing garbage piled high in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during the Complaint (NY#00347998) and Recertification Survey from 2/5/2025 to 2/12/2025, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with Range of Motion exercises, but documentation reflected that resident was provided with Range of Motion exercises. The findings are: The facility's policy and procedure titled Charting and Documentation undated documented all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Resident #66 was admitted to the facility with diagnoses that included Multiple Sclerosis, Hemiplegia, and Osteoarthritis. The Minimum Data Set, dated [DATE] documented Resident #66 is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 conducted during the Complaint (NY#00347998) and Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure a resident with limited range of motion received treatment and services to maintain and/or to prevent further decrease in range of motion. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with range of motion exercises in accordance with a Physician's Order. The findings are: The facility's policy and procedure titled Rehabilitative Nursing Care undated documented rehabilitative nursing care is performed daily for those residents who require such service include assisting residents with their routine range of motion exercises, floor ambulation, standing and transfer. Resident #66 was admitted to the facility with diagnoses that included Multiple Sclerosis, Hemiplegia, and Osteoarthritis. The 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evidenced for 2 of 5 units (Unit 5 and Unit 2). Specifically, 1) Unit 5 had multiple rooms with dirty and stained bathroom disinfectant tanks (DT) in disrepair, a wheelchair in disrepair, and a missing closet door in resident's room, and 2) Unit 3 contained wheelchairs in disrepair, a rusty shower chair, torn mesh on a large shower chair, torn mesh covering the clean linen carts, and heaters in the dining room area littered with dirt and debris. The findings are: The facility policy titled Equipment - General Use for All Residents last reviewed 2/2023 documented wheelchairs are maintained by the facility for general use of all residents. The facility policy titled Building Services last reviewed 2/2023 documented the Building Services employees maintain restrooms and toilets. Broken…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2023-03-16 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #94) of 1 resident(s) reviewed for Physical Restraints out of 40 total sampled residents. Specifically, Resident #94 was observed with bilateral upper 1/3 siderails (SR) in place on multiple occasions. The findings are: The facility policy titled Physical Restraint Application last reviewed 2/2023 documented the definition of restraint is based on the functional status of the resident and not the device. If the resident cannot mentally and physically self-release, then the device is considered a restraint. Resident #94 had diagnoses of dementia and hemiplegia and hemiparesis following non-traumatic intra-cerebral hemorrhage affecting the right dominant side. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #94 was severely cognitively impaired, required extensive…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during a recertification and complaint survey (NY00298773, NY00295726), the facility did not ensure an alleged violation involving resident to resident physical abuse was and allegations that did not involve serious bodily injury to the New York State Department of Health (NYSDOH) within a timely manner. This was evident for 2 (Resident #246 and #119) of 3 residents reviewed for Abuse and 1 (Resident #25) of 7 resident reviewed for Accidents out of 40 total sampled residents. Specifically, the facility did not report a resident-to-resident altercation involving Resident #246 and Resident #119 to the NYSDOH within 2 hours of occurrence, and 2) the facility did not report an incident resulting in Resident #25 sustaining a leg laceration requiring 11 staples and hospital intervention within 24 hours of occurrence. The findings include: The facility's current Policy and Procedure, titled Abuse Prevention Policy and Procedure stated that all reports of 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification and Complaint (NY00295726) Survey from 3/9/23 to 3/16/23, the facility did not ensure a comprehensive person-centered care plan (CCP) was developed and implemented for each resident to meet the resident's needs. This was evident for 1 ( Resident #25) of 7 residents reviewed for Accidents out of 40 total sampled residents. Specifically, a CCP was not developed to address Resident #25's right leg laceration requiring 11 staples. The findings are: The facility policy titled Care Planning-Interdisciplinary Team last reviewed 2/2023 documented the care plan is based on the resident's comprehensive assessment. Resident #25 had diagnoses of dementia and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] and 2/9/23 documented Resident #25 had severe cognitive impairments, required total assistance of 2 people for transfers and bed mobility, and did not document any other wounds or skin problems. On 03/14/23 at 10:22…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during the Recertification survey from 3/09/2023 through 03/16/2023, the facility did not ensure that each resident's person-centered comprehensive care plan (CCP) was reviewed and revised. This was evident for 1 (Resident #68) of 1 resident reviewed for Behavior out of a sample of 40 residents. Specifically, the Resident #68's CCP related to hoarding behavior was reviewed and revised to include person-centered interventions to address clutter in the resident's room. The findings are: The facility policy and procedure titled Problematic Behavior Management- Clinical Protocol dated 02/2023 documented staff and the physician will identify problematic behavior and interventions to address the nature and causes of problematic behavior. The staff and physician will document reassessments of positive or negative changes in the individual's behavior. Resident #68 with diagnoses that included unspecified dementia without behavioral disturbance and anxiety. The Minimum Data Set 3.0 dated 12/13/2022 documented that the resident was cognitively…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0696 — isolated
    Provide appropriate care/assistance for a resident with a prosthesis.
    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, interviews, and record review during the Recertification Survey initiated on 3/9/23 and completed on 3/16/23, the facility failed to ensure residents who had a prosthesis (artificial limb) were provided care and assistance consistent with resident preferences to use the prosthetic device. This was evident for 1 (Resident #24)of 1 resident reviewed for Mobility out of 40 total sampled residents. Specifically, Resident #24 did not receive assistance applying a cosmetic prosthetic limb. The findings are: The facility policy titled Artificial limb, care of, reviewed February 2023, documented guidelines for use of artificial limbs, including reviewing care plans and assembling equipment, ensuring cleanliness, checking for changes or complaints, reporting on skin conditions, and documenting if the resident refuses. Resident #24 had diagnoses of acquired absence of the left leg above the knee (AKA) and depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #24 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #94) of 1 resident(s) reviewed for physical Restraints. Specifically, Resident #94 was observed with bilateral upper 1/3 siderails (SR) in place on multiple occasions. The findings are: The facility policy titled Bed Safety last reviewed 2/2023 documented to prevent deaths, maintenance staff inspect beds for entrapment risks. The review shall consider resident weight and movement. Identify safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g. altered mental status, restlessness, etc.) Siderail use shall be in consultation with the Attending Physician. Resident #94 had diagnoses of dementia and hemiplegia and hemiparesis following non-traumatic intra-cerebral hemorrhage affecting right dominant side. The Minimum…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 3/9/23 to 3/16/23, the facility did not ensure menus were followed. This was evident for 1 (Resident #64) of 40 sampled residents. Specifically, Resident #64 did not receive a sandwich on their tray in accordance with the meal ticket. The findings are: The facility policy titled Resident Food Preference last reviewed 2/2023 documented the Dietician will discuss resident food preferences and will visit residents periodically to determine if revisions are needed. The Nursing staff will inform the kitchen about resident requests. The facility policy titled Tray Identification last reviewed 2/2023 documented tray tickets are placed on the tray to ensure the correct diet is being served and food preferences are being honored. Resident #64 had diagnoses of chronic kidney disease and major depressive disorder. The Minimum Data Set 3.0 dated 12/8/22 documented Resident #64 had mild cognitive impairment and had a…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0888 — isolated
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during the Recertification Survey initiated on 3/9/23 and completed on 3/16/23, the facility did not implement policies and procedures to ensure that staff who were granted an exemption to the Covid-19 vaccine requirement adhere to additional precautions that are intended to mitigate the spread of Covid-19. This was evident for 1 of 1 medical exemptions provided by the facility. Specifically, an unvaccinated staff member providing direct care for residents had a valid medical exemption, but no additional precautions were in place. The findings are: The facility policy titled Mandatory Covid-19 vaccination for covered personnel, undated, documented when reasonable accommodations have been granted to personnel with a medical exemption, additional precautions that are intended to mitigate the spread of Covid-19 should be in place. These include but are not limited to reassigning staff to non-patient care areas or duties, requiring at least weekly testing for exempted personnel regardless of level of community transmission, and requiring…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and record review conducted during the Recertification Survey from 3/9/23 to 3/16/23, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was evident for 1 (Unit 5) of 5 units. Specifically, the Unit 5 Nursing Station was in disrepair with dirt and debris covering utility wires. The findings are: The facility policy titled General Departmental Responsibilities dated 2/2023 documented broken equipment is reported immediately to the Maintenance Department (MNT) for repair. On 03/10/23 at 11:55 AM, the Unit 5 Nursing Station located in the center of the unit in public view was observed with 1 broken hanging drawer, outer Formica layer that is chipped and cracked off in multiple areas, duct tape holding part of the Formica into place where a large portion is cracked off, and a large nest of wires covered in dirt and dust under the desk. The Unit 5 Maintenance Safety Log reviewed from 2/12/23 through 3/14/23 did not document any repair requests for the Unit 5 Nursing Station…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-02-27 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 observations and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect during care. Specifically, staff entered multiple residents room without knocking on the door. This was evident of 5 out of 5 residents reviewed for Dignity out of a total investigated sample of 40 residents (Resident #117, #155, #180, #458 and #459). The findings are: The facility untitled and undated Policy documented under the section titled Policy Interpretation and Implementation under # 6 Residents' private space and property shall be respected at all times. Number A under the same section documented Staff will knock and request permission before entering resident's room. 1) Resident #117 and Resident #459 resided in the same room. Resident #117 was admitted to the facility on [DATE], diagnosis included Urinary Tract Infection, Congestive Heart failure and Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-02-27 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews during the Recertification Survey, the facility did not ensure that a safe, clean and homelike environment was maintained. Specifically, there were damaged and broken furniture, damaged walls, broken ceiling tiles, torn upholstery and missing brake handle covers. This was evident for 2 out of 5 Nursing Units (4th floor and 5th floor). The findings are: The facility provided a document that listed 4 items as follows: A) Prioritization of Work - The priority system ensures that the most important maintenance work is done at a time it can be performed most cost-effectively. The maintenance priorities of the Facility are the following: 1) Emergency Repairs. 2) Resident Requests. 3) General Cleaning. 4) Unit Turnover. 5) Inspection. 6)Miscellaneous. 7) Preventive Maintenance. On 02/21/2020 at 9:00 AM during the initial tour of the 4th and 5th floor, the following was observed: 4th floor: 1.) Resident # 67: broken desk drawer. 5th floor: 1.) Nurse Station: Desk corner with rough edges, missing large section of desk top covering. 2.) Resident # 191:…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-02-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews and staff interviews during the recertification survey the facility did not maintain infection control practices help prevent the development and transmission of communicable diseases and infections. Specifically, (1) oxygen tubing was observed on the floor; and (2) staff were obsrved entering the room of residents on contact preacutions without donning the appropriate Personal Protective Equipment (PPE). This was evident for 1 of 1 resident reviewed for oxygen therapy (Resident #5) and 2 of 2 residents reviewed in the area of Urinary Tract Infection (UTI). (Resident #4 and #126) The findings are: 1) The facility policy titled Oxygen Administration revised 12/19 documents: Purpose- the purpose of this procedure to provide guidelines for safe oxygen administration. Steps in Procedure 3) Check the tubing connected to the oxygen supply to assure that it is free of kinks and obstruction. 7) Ensure proper length of oxygen tubing so its not touching the floor. Resident #5 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that a person-centered care plan with measurable goals, time frames and interventions was developed to address a resident behavior. Specifically, there was no documented evidence that a comprehensive person-centered care plan was developed to address a resident's hoarding behavior. This was evident for 1 of 1 resident reviewed for Behavior/Emotional (Resident #34). The Findings are: The facility Policy titled Care Planning - Interdisciplinary Team with no effective, reviewed or revised date, documented under the section titled Policy Statement The Allure Groups' Care Planning/Interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The section titled Policy Interpretation and Implementation under #2 documented the care plan is bases on the resident's comprehensive assessment and is developed by a care Planning/Interdisciplinary team. Resident # 34 was admitted with diagnoses including Peripheral…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision to prevent accidents. Specifically: (1) an oversized television was positioned on a slant, on top of a smaller dresser in a resident's room; (2) the cause of a resident's fall was not evaluated to determine if updates were needed to the plan of care to prevent further falls. This was evident for 2 (two) of 4 (four) residents investigated for the Accident Care Area. (Resident # 163 and Resident # 176). The findings are: 1.) Resident # 163 is [AGE] years old, admitted to the facility on [DATE], with a re-entry date of 01/14/2020. Diagnosis included: Cardiac Vascular Incident (CVA) with Hemiplegia, Aphasia and Anemia, Stroke. The Quarterly Minimum Data Set (MDS) Assessment Reference Date (ARD) of 01/21/2020 documented, clear speech, usually understood and usually…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-27 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 the facility did not ensure that an appropriate environment and atmosphere were in place that was conducive to a resident's mental and psychosocial well-being; and the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident with hoarding behaviors were not addressed. This was evident for 1 of 1 resident reviewed for Behavior/Emotional. (Resident #34) The findings are: The facility undated Policy titled Cleaning Resident and Non-resident Areas under the title Purpose documented to improve sanitation and ensure the highest level of cleanliness throughout the facility. To control cross contamination, the spread of bacteria and infection and to maintain the outward appearance of the facility. The section titled Resident Room and Bathroom documented under the section titled Daily Procedures 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-27 · tag F0924 — isolated
    Put firmly secured handrails on each side of hallways.
    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 and interviews during the Recertification survey, the facility did not ensure that the corridor hand rails were firmly affixed to the wall. Specifically, during the initial tour of the 5th floor unit several corridor areas had loose hand rails. This was evident for 1 of 5 resident units observed for the Environment (5th floor) . The findings are: On 02/21/2020 at 9:54 am, on the 5th floor unit, the following was observed: 1.) long hand rail loose underneath room [ROOM NUMBER]. 2.) small loose hand rail between the Shower Room and the Recreation Closet. 3.) long loose hand rails by room [ROOM NUMBER], located in front of the Refuse Chute Door. On 02/24/2020 at 10:00 AM the 5th floor maintenance worker was interviewed and he stated that he checks the hand rails on a daily basis and that a Maintenance Log Book is located on each unit floor for staff to log in anything that needs further repairs. He stated that securing hand rails is important for the safety of all residents. I will take care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-02-12 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews conducted during the Recertification Survey from 02/05/2025 to 02/12/2025, the facility did not ensure the daily nurse staffing was posted. Specifically, there was no indication of the daily nurse staffing information with the total number of staff and total number of hours posted. This was evident during the review of the Staffing task. The findings include: The facility policy and procedure titled Posting Daily Nurse Staffing Information, last revised 01/02/2025, documented that the facility's policy is to ensure that nurse staffing information is always readily available in a readable format to residents and visitors. The facility will post daily nurse staffing information in a prominent place in each unit and in common areas that are readily accessible to residents and visitors. During multiple observations conducted on 02/05/2025 through 02/11/2025, there was no indication of the daily nurse staffing information being posted in the lobby or the nursing unit. The daily schedule was posted in the lobby inside a bulletin board.…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ALLURE GROUP — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 54.0-1.0 vs chain
Health inspection 2 of 53.2-1.2 vs chain
Staffing 2 of 53.2-1.2 vs chain
Quality measures 5 of 55.0≈ chain avg
The other 5 homes this chain runs (chain average 4.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
LANDAU, JOELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 12/07/2018
RUBIN, MARVINIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 12/07/2018
RUBIN, SOLOMONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF33%since 12/07/2018
ALLURE CARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/19/2025
ALPHA REHABILITATION SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/07/2018
HARLEM CENTER PROPERTIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/07/2018
AYINLA, RAJIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/19/2025
CESAR, THARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/17/2020

CMS files one row per role, so the 16 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$36.5M
Net patient revenuemost recent cost report
-4.8%
Operating marginrevenue minus expenses
$9.1M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 24%Other / private 16%

This home reported $9.1M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$543per resident / day
operating cost
$16,501per month
≈ monthly operating cost
$518per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

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 335522. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-12, 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.

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