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Sapphire Nursing At Meadow Hill

172 Meadow Hill Road, Newburgh, NY 12550 · For profit - Partnership · 190 certified beds · (845) 564-1700 Medicare & Medicaid certified

Call the home — (845) 564-1700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 20241 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — 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 payroll-based staffing rating is low (2/5)

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 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 2 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
1425 Rte 300 · (845) 674-9735 · Call to confirm hours
Pharmacy
1429 Route 300 · (845) 566-4266 · Call to confirm hours
Grocery
1429 Route 300 · (845) 566-4214 · Call to confirm hours
Park
54 Powder Mill Rd · (845) 615-3830 · Typically dawn to dusk
Place of worship
128 Old South Plank Rd · (845) 576-0730

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 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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 rating4★
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 increased9.7%14.1%15.4%better
Long-stay residents who lose too much weight10.8%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.1%0.5%0.9%better
Long-stay residents with a urinary tract infection1.4%1.3%2.0%better
Long-stay residents with depressive symptoms74.7%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 injury3.4%3.1%3.3%typical
Long-stay residents whose ability to walk worsened5.4%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.5%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine82.2%95.3%95.3%worse
Long-stay residents with pressure ulcers3.8%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control30.1%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.7%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine62.1%78.8%79.4%worse
Short-stay residents rehospitalized after admission14.3%20.6%22.6%better
Short-stay residents with an outpatient ER visit7.7%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.201.701.67better
Long-stay outpatient ER visits per 1,000 resident days0.721.361.80better

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.

44.8% 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 201 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.8%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
71.5%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 71.5% 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 165 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.8%CMS range 38.5–50.351.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 6.8–13.810.7%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 discharge71.5%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 discharge65.5%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 discharge61.8%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 discharge100.0%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 stay1.2%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 worsened1.6%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 hospitalization7.0%CMS range 4.0–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.401.02Oct 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

0.45
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.30
RN hoursweekends
25.2%
Total nursing turnover
25.9%
RN turnover

How full it usually is: this home is certified for 190 beds and averages 184.0 residents a day — about 97% occupied, or roughly 6 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 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.57 on weekdays — 18% thinner on weekends. RN hours go from 0.51 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below the national median of 45%. 1 administrator has left in the past year.

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 (2025-04-01)
11
at the previous standard inspection (2022-12-07)

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2022-12-07 · 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 completed during the Recertification Survey conducted 11/28/2022-12/7/2022 the facility did not ensure that a resident assessed as high risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and to promote healing of a facility acquired stage 3 pressure ulcer for one of four residents (Resident #135) reviewed for pressure ulcers. Specifically, interventions and treatment measures were not implemented timely for Resident #135 who developed a facility acquired new and worsening stage 3 pressure ulcer. This resulted in actual harm that is not immediate jeopardy for Resident #135. The findings are: The facility Policy and Procedure titled Pressure Ulcer Risk assessment dated 6/20/2019 with no revision date documented the staff at Sapphire will assess residents for risk of pressure ulcers in attempts to aid in prevention of pressure ulcers. The intent of the policy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-01 · tag F0550 — failed to protect resident dignity and rights — isolated
    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

    Based on observation, interview, and record review during the Recertification survey from 3/26/2025 through 4/1/2025, the facility did not ensure residents had the right to a dignified dining experience for 2 of 35 residents (Residents #2 and #113) reviewed for dignity while dining. Specifically, Certified Nurse Aides were observed standing over Resident #2 and Resident #113 while assisting with their meals. The findings include: The facility policy titled Quality of Life-Dignity dated 9/1/17 documented: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Resident #2 was admitted to the facility with diagnoses including malnutrition, non-Alzheimer dementia and cerebrovascular accident (stroke). The Comprehensive Care Plan for Activities of Daily Living- Range of Motion dated 11/29/19 documented Resident #2 required extensive assistance of one person for eating. The 2/22/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #2 had severely impaired cognition and was…

    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 · Dcited before2025-04-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 3/26/25 to 4/1/25, the facility did not ensure the Residents right to a safe, clean, comfortable, and homelike environment. This was evident for 1 of 35 resident rooms (Resident #10) and the hallways of 2 [NAME] Unit during observation of the environment. Specifically, Resident #10's room was observed with a strong odor of urine on multiple occasions and there was a strong odor of urine in hallways of 2 [NAME] unit. The findings included: The facility policy titled Homelike Environment reviewed 10/18/24 documented: It is the policy of facility to ensure that all Residents live in an environment that is clean and neat, with appropriate furnishings in a state of good repair. Resident #10 had diagnoses including hyperkalemia, repeated falls, and schizoaffective disorder. A significant change Minimum Data Set, dated [DATE] documented Resident #10 had moderately impaired cognition, was dependent for toileting hygiene,…

    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 · D2025-04-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based on observation, record review, and interview conducted during the recertification survey from 3/26/2025-4/1/2025, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 1 (Residents #90) of 5 residents reviewed for Activities of a Daily Living. Specifically, Resident #90, who required supervision with Activities of Daily Living, was observed during multiple observations with long, greasy hair, an unshaven face, and long, ungroomed fingernails. The findings include: The Policy and Procedure titled Activities of Daily Living was last reviewed on 10/1/2024 and documented. This center's policy is to provide activities of daily living care to all residents based on an assessment of their needs. Resident #90 had diagnoses including dementia, chronic kidney disease, and hypertensive heart disease. The Annual Minimum Data Set (a resident assessment tool) dated 3/13/2025 documented Resident #90 had severely impaired cognition and needed supervision or touching…

    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 · D2025-04-01 · 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

    Based on observation, record review, and interviews during the recertification survey from 3/26/2025- 4/1/2025, the facility did not ensure that needed services, care, and equipment were provided to ensure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for 1 of 6 residents (Resident #40) reviewed for position and mobility. Specifically, Resident #40 was observed three times without a left palm guard in place, as ordered by the physician, to prevent further contractures. Findings include: The Policy and Procedure titled Issues of Splints, Orthoses, and Prostheses, last reviewed 8/17/2024, documented that the Nursing department will take responsibility for daily applications and removal of devices, and the Nurse Manager will be responsible for ensuring that the information is entered in the Certified Nurse Aide Accountability Record. Resident #40 had diagnoses that included dementia, muscle weakness, and a stroke affecting the left nondominant side. The Quarterly Minimum Data Set (resident assessment…

    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 · D2025-04-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews conducted during the Recertification survey from 3/26/2025 to 4/1/25, the facility did not ensure that 1 of 1 Resident (Resident #129) reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice. Specifically, Resident #129, had a physician's order for oxygen to be administered via nasal cannula at 2 liters per minute, and was observed with the oxygen rate not consistent with the physician's order. The findings include: The facility policy titled OxygenTherapy - Face Mask and Cannula (undated) documented: Oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Oxygen is administered by licensed staff. Oxygen administration requires physician order. Resident #129 had diagnoses including failure to thrive, cough, fatigue and diabetes. A Significant Change Minimum Data Set (a resident assessment tool) dated 1/14/25, documented Resident #129 was severely cognitively impaired, aphasic, was…

    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 · D2025-04-01 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during the recertification survey on 03/26/2025-04/01/2025, the facility did not ensure each staff was screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks, and potential side effects associated with for 2 of 10 staff reviewed for COVID-19 vaccines. Specifically, there was no documented evidence of immunization records for Covid-19 vaccination for Certified Nurse Aide #1, and Certified Nurse Aide #2. Findings include: The facility policy titled COVID-19 revised 11/20/2024, documented it is the policy of the facility to follow the regulatory guidelines for COVID-19. In addition, providing all staff and residents who declined to be vaccinated a written affirmation of their signature, which indicates they were offered the opportunity for COVID-19 vaccination but declined. The New Hire Report dated 3/26/25, documented Certified Nurse Aide #1 was hired 3/19/25 and Certified Nurse Aide #2 was hired 3/5/25. The facility's immunization records for staff revealed Certified Nurse Aide #1 and #2 had no…

    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 · D2025-04-01 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview conducted during a recertification survey from 03/26/2025 to 04/01/2025, the facility did not ensure Certified Nurse Aides were provided the required hours of training and/or annual in-services on dementia care management to ensure safe delivery of care. Specifically, the facility was unable to provide documentation that 3 of 5 Certified Nurse Aides (#23, #24, and #25), had the required hours of the mandatory training. Findings include: The facility policy titled: Employees' Annual Mandatory Education, revised 11/28/2024, documented all staff must complete a series of mandatory annual education modules to comply with regulations and ensure high-quality resident care. The policy further states that completion records will be maintained by the Education Coordinator. A review of the facility's Certified Nurse Aide annual in-service training records revealed that the following Certified Nurse Aides did not meet the 12-hour annual training requirement and lacked documentation of mandatory dementia care management education: - Certified Nurse Aide #23…

    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
  • Potential for harm · Dcited before2025-04-01 · tag F0880 — failed to prevent and control infections — isolated
    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 interview during the recertification survey from 3/26/25 to 4/1/25, the facility did not ensure an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection was maintained for 2 of 3 residents (Residents #129 and #118) reviewed for Infection Control. Specifically, 1) Licensed Practical Nurse #21 and Certified Nurse #21 were observed providing cares to Resident #129, on enhanced barrier precautions, without donning a gown. 2) Resident #118 had an indwelling urinary catheter and the drainage bag and a portion of the drainage tube were lying on the floor. The findings are: The Policy titled Enhanced Barrier Precautions, last reviewed 1/6/25, documented: It is the policy of this facility to follow Center for Disease Control guidelines by utilizing Enhanced Barrier precautions in the care of patient susceptible to multiple drug-resistant organisms and to reduce the spread and prevalence of multiple…

    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 · D2024-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00337556, NY00340055, NY00348324) the facility did not ensure a resident's right to be free from abuse for 2 (Resident #1 and Resident #2) out of 4 residents reviewed for abuse. Specifically, on 3/30/2024, Resident #2 was witnessed by 2 certified nurse assistants(Staff #6 and Staff #7) being fondled under their shirt by Resident #3. Resident #2 was removed from Resident #3's room and Resident #2's shirt was pulled down by the certified nurse assistant. 2) On 4/22/2024, Resident #1 stated that a certified nurse assistant(Staff #1) was grabbing and pulling their right arm roughly while attempting to change their shirt and Resident #1 sustained an ecchymosis to the area.There was no care plan to address potential victim for abuse. Findings include: The facilities Resident Abuse, Neglect, Exploitation or Misappropriation policy statement documented it is the policy of the facility that acts of physical, verbal, mental and financial abuse including…

    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 · Ecited before2022-12-07 · 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 and Abbreviate Survey (NY304719) conducted from 11/28/22 to 12/7/22, it was determined the facility did not ensure that a safe, clean, comfortable, and homelike environment was maintained on 3 of 4 units (units 1 West, 1 East, and 2 West). Specifically, peeling wall paper, chipped paint, cracked broken plaster were observed in multiple resident rooms and dining room. The findings are: The facility Environmental Services Manager Job Description documented the primary purpose of the job position is to assure facility is maintained in an efficient, clean, safe, and comfortable manner. On 11/28/22 at 9:43 AM during a tour of unit 1 West, room [ROOM NUMBER] and 122 were noted with peeling discolored wall paper. On 11/29/22 at 9:55 AM during a tour of unit 2 West, room [ROOM NUMBER] was noted with peeling wall paper by the window and room door. Dark brown stains were noted underneath the peeling wall paper. On 12/2/22 03:03…

    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 19 citations
  • Potential for harm · D2022-12-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the Recertification Survey conducted 11/28/22 to 12/07/22, the facility did not ensure that residents received services with reasonable accommodation of resident's needs and preferences for one of one resident (R#1) reviewed for Resident Rights. Specifically, the facility did not provide Resident #1 with adaptive equipment such as a lip plate and built-up utensils for meals as per care plan. The findings are: A review of the facility's policy and procedure titled, Nutrition Services dated 1/2019 documented Residents' food, beverage and feeding assistive devices/silverware will be placed appropriately to accommodate their needs. Resident #1 was admitted to the facility on [DATE] with diagnoses including Hemiplegia Left Non Dominant Side and Cerebrovascual Accident (CVA). A review of the Minimum Data Set (MDS; a resident assessment tool) dated 11/20/22 documented moderately impaired cognition and a Brief Interview of Mental Status (BIMS) score 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-07 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 completed 11/28/22 to 12/7/22, it was determined that for one of two residents (R#13) reviewed for Choices, the facility did not ensure that it promoted and facilitated the resident's right to self-determination through support of resident choice. Specifically, Resident #13 who is requires extensive assist and the use of a Hoyer lift, was put to bed early on multiple occasions at the request of the assigned CNAs. The findings are: The facility Policy and Procedure titled Residents' Rights-Nursing Homes dated 8/1996, with a revision date of 5/2022 documented all staff, whether directly or indirectly involved in the residents' care, are expected to aide by, adhere to, protect, and promote the residents' rights. The policy further documented the resident rights and policies shall ensure that each resident admitted to the facility is treated with consideration, respect, and full recognition of dignity, individuality…

    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 · Dcited before2022-12-07 · 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 conducted from 11/28/22 to 12/7/22, the facility had not ensure that they developed a thorough care plan based on the resident's assessment to ensure the services were provided to maintain the resident's highest practicable physical well-being for one of two residents (Resident #112) reviewed for Rehabilitation Services, Specifically, Resident #112 who was admitted to the facility for rehabilitative services after a fall at home, had no Acitivities of Daily (ADL) goals or interventions established on the Comprehensive Care Plan (CCP). The Findings Are: The facility Policy and Procedure titled Comprehensive Care Planning (CCP) undated documented the facility will develop a comprehensive, person-centered care plan for each resident that include measurable objectives and time tables to meet a resident's medical, nursing, mental, and psychosocial needs which are identified in the comprehensive assessment and lead to the highest…

    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 before2022-12-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey conducted from 11/28/22 to 12/7/22, it was determined that for one of three residents (Resident #58) reviewed for Accidents, the facility did not ensure that the Comprehensive Care Plan was revised to reflect the resident's current condition. Specifically, Resident #58 Comprehensive Care Plan (CCP) was not reviewed to determine effectiveness of interventions and not revised to include new interventions after a fall with major injury. The Findings Are: The facility Policy and Procedure titled Falls and Fall Risk, Managing with a revision date of 9/2022 documented based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy further documented if falling reoccurs despite initial interventions, staff will implement addition or different…

    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 before2022-12-07 · 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

    Based on observation, interview and record review conducted during the Recertification Survey completed 11/28/22 to 12/7/22, it was determined that for one of one resident (Resident #91) reviewed for quality of care, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice necessary to maintain or improve the resident's highest practicable physical, mental, and psycho-social well-being. Specifically, the facility failed to provide consistent routine oral care for Resident #91. The findings are: The facility Policy and Procedure titled Mouth Care dated 3/1/17 documented the purpose of the procedure is to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. Preparation includes review the resident's care plan to assess for any special needs of the resident, oral care is provided with am and pm care as needed and assemble the equipment and supplies as needed. The policy further documented if the resident refused mouth care, the reasons(s) why…

    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 · D2022-12-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 [NAME] review, observation and interview during the Recertification Survey conducted 11/28/22-12/08/22, the facility did not ensure residents were provided nutritional care and services consistent with the resident's comprehensive assessment for 1 of 3 residents (R#75) reviewed for Nutrition. Specifically, the facility did not consistantly provide dietary supplements to Resident #75 with significant weight loss. The finding is: Resident #75 was admitted to the facility on [DATE] with diagnose including Chronic Kidney Disease, Dehydration, Dementia, and Depression. A review of the Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 9/26/22 documented the resident had moderately impaired cognition and a BIMS score of 8. The resident required limited assistance for eating, had 1 stage 3 Pressure Ulcer and 4 venous and arterial ulcers and received Nutrition or Hydration to manage skin problems. A review of the December 2022 Physician's orders documented Ensure Plus 8 oz by mouth twice a day.…

    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 · D2022-12-07 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review during the Recertification Survey conducted 11/28/22-12/08/22, the facility did not ensure liquids concistantly remained at a safe and appetizing temperature for 1 of 1 meal (lunch) observed. Specifically, a lunch tray temperature check on 12/6/2022 revealed a container of milk and juice were not kept at safe and appetizing temperatures. This is evidenced by: During an observation of a Test Tray on 12/6/2022 at 1:25 on the East Unit the Food Service Director sampled beverages temperature revealing a milk container was 56 degrees F, and a juice container was 62 degrees F. During an interview on 12/6/22 at 1:30PM, the Food Service Director stated milk and juice should be served below 40 degrees and food temperature can affect palatability The Food Service Director stated juice at 62 degrees may not necessarily be harmful, but it should be cool for palatability. The juice, and milk were not palatable because they were too warm. The Food Service Director stated the milk and juice became warm after being in the cart with warm food 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews conducted during the Recertification 11/28/2022-12/7/2022 the facility did not ensure food was procured, distributed, and served in accordance with professional standards of food service safety. Specifically, the facility did not ensure supplements were available, monitored and ordered to maintain the residents' nutritional needs. Specifically, during meal observation from12/2/2022-12/3/2022 Resident #75 was not provided Magic Cup as per Physician order. The findings are: Resident # 75 admitted to the facility 5/22/22 with diagnosis of Chronic Kidney Disease, Acute Kidney Failure, Dehydration, Dementia, and Depression The MDS (Minimum Data Set) dated 9/26/22 Quarterly Assessment documented a Brief Interview of Mental Status ( BIMS) score of. 8 The December 2022 Physician Orders documented Magic Cup three times a day. During an Observation on 12/01/22 at 01:11 PM revealed the meal ticket for Resident # 75 reflected Magic Cup 4 oz. The lunch meal was delivered to the resident by the nurse. The meal was set up by the nurse 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-07 · 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, interview, and record review conducted during the Recertification Survey conducted from 11/28/22 to 12/07/2022, the facility did not ensure that medical records were complete and accurately documented for one of three residents (Resident # 81) reviewed for Nutrition. Specifically, the Medication Administration Record for Resident #81 documented that the resident received Ensure although no Ensure was observed by the surveyor on the resident's tray, The findings are: A review of the facility Policy and Procedure (P&P) titled Physician Medication Orders dated 1/2019 documented that the physician will be notified immediately for all identified medication errors and or missed dose of medication/treatment. Resident #81 was admitted on [DATE] and diagnoses included Congestive Heart Failure, Hypertension, and Pleural Effusion. A review of the Minimum Data Set (MDS; a resident assessment tool) dated 9/15/22 documented no Brief Interview of Mental Status ( BIMS) was completed and the resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-02 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review conducted during the most recent recertification survey, the facility did not ensure that it provided sufficient nursing staff to meet the needs of residents on 2 of 4 units (Units 1 and 2). This was evidenced by Units 1 and 2 (1 East and 1 West) being staffed below the maximum par levels for Certified Nurse Aides (CNAs) approximately 50 % of the time during the past 3 months, multiple residents and staff complaints related to insufficient nursing staff, and observation of untimely care on one of the two units (Unit 1) for Residents #10, #42, #52, #83, and #138. The findings are: 1. Residents' Complaints During confidential interviews held on 4/24/19 to 4/26/19 residents made the following complaints: - Sometimes only 2 CNAs on the unit. It's hard for them. Sometimes don't get showers. - They don't have enough staff; supposed to have 4 CNAs and don't always. - There is not enough staff to use the Hoyer lift for her to get into bed and be changed. Sits in soiled diaper for long periods of time. - Long waits for call bell response. -…

    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
  • Potential for harm · E2019-05-02 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview conducted during the most recent recertification survey, the facility did not ensure that the daily posting of nursing staff information consistently reflected all shifts and required data. The findings are: The Director of Nursing (DON) was asked on 4/30/19 to provide the daily posting on nursing staff information for the past 30 days prior to 4/24/1. A review of these postings revealed that the following information was missing: 3/24 - no data regarding evening shift; 3/25- no data for the day and evening shifts; 3/26, 3/27, 3/28, 3/29, 4/1, 4/2, 4/3- 4/4, 4/9, and 4/10 - no data for the day shift; The data for the census was missing on the postings for 4/11, 12, and 13 for all shifts. The DON was interviewed on 5/2/19 regarding the missing information. She stated that the nurse mangers were responsible to furnish the information. The facility was cited for not providing sufficient certified nurse aides frequently (approximately 50 % of the time on 2 of 4 units. See F725. 415.13

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-02 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during the recertification survey the facility did not ensure that residents were free of significant medication errors. Specifically on 4/29/19 a Licensed Practical Nurse (LPN) did not administer medications prescribed by the physician to 12 of 14 residents. this was evident for Residents #32, 41, 64, 69, 72, 75, 86, 94, 101, 104, 119, and 142.) whose Medication Administration Records were reviewed for the omission of medications. Complaint #NY00237913 The findings are: Review of the 4/1/19 - 4/30/19 Medication Administration Record (MAR) revealed the following medications were not administered on 4/29/19: 1. Resident #32 -was not administered 9:00 AM Eliquis 2.5 mg (1 tablet), Metroprolol ER 100 mg (1 tablet), and Levetiracetam 500 mg (1 tablet). Additional review of the MAR revealed on 4/29/19 the following medications were not signed out as being administered: Finasteride, Polyethylene Glycol, Magnesium Oxide, and Ranitidine. 2. Resident # 41 was not administered 9:00 AM Lisinopril 5 mg (1 tablet) and Metroprolol Tartrate 25 mg (1…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-02 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review conducted during the most recent recertification survey, the facility did not ensure that proactive quality assurance measures were put in place to identify and address problems related to the implementation of a new electronic system for the administration of medications. This was evidenced by 1) medications being administered late, 2) nursing staff complaints that there was a delay in administering medications related to the new system, 3) a licensed Practical nurse not administering medications to 12 residents (Residents #32, #41, #64, #69, #72, #75, #86, #94, #101, #104, #119, and #142) on 4/29/19, and 4) lack of a structured Performance Improvement Plan to address actual and potential problems of the implementation of the new administration system in accordance with the facility's Quality Assurance Performance Improvement Plan (QAPIP) . The findings are: According to the facility's QAPIP dated 2/1/17, Any change that is made has the potential to have broader impact than intended. The impact of all changes to specific systems or…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-02 · 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 the facility did not ensure that the comprehensive person-centered care plan was followed for 2 of 7 residents (Residents #12 and #76) reviewed for pressure ulcers, and a comprehensive person- centered care plan was developed for 1 of 2 resident (#58) reviewed for constipation. Specifically, 1.Heel boots were not applied for a resident with a suspected deep tissue injury in accordance with the care plan. 2. A bed cradle was not used/applied in accordance with the resident's care plan. 3.A care plan was not developed for a resident with a diagnosis of Rectal Cancer The findings are: 1. Resident #12 was admitted to the facility on [DATE] for long term care and had diagnoses and conditions including Heart Disease, Dementia, and Coronary Artery Disease. The Annual Minimum Data Set (MDS, a comprehensive resident assessment tool) dated 7/20/18 and the Quarterly MDS dated [DATE] indicated Resident #12 was cognitively impaired and was at risk for pressure ulcer. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the most recent recertification survey, the facility did not ensure that the plan of care addressing falls for 1 of 3 residents (Resident #180) reviewed for accidents was reviewed after each fall to determine if there was a need for revision. Specifically, during a six-week period the resident, who required assistance with transfers, was seen out of bed and on the floor 4 times. There was no evidence that the resident's plan of care was reviewed to address the adequacy of the supervision being provided and effectiveness of other planned interventions until after the fourth fall which resulted in the resident sustaining a left hip fracture. The findings are: Resident #180 is a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of Cerebrovascular Accident and Dementia. According to the Annual Minimum Data Set (an assessment instrument) dated 2/15/19, the resident had moderate cognitive impairment, was able to move around in bed…

    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 before2019-05-02 · 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 interview and record review conducted during the most recent re-certification survey, the facility did not ensure that each resident received treatment and care based on the comprehensive assessment of the resident that was in accordance with professional standards of practice. Specifically, 1. Resident #76 with a diagnosis of Diabetes did not receive timely Podiatry follow-up care, and 2. Resident #58 with a diagnosis of Rectal Cancer did not receive timely Oncology follow-up care. The findings are: 1. Resident #76 was re-admitted to the facility on [DATE] and had diagnosis and conditions including Diabetes, Polyneuropathy, and Parkinson's Disease. Review of the Quarterly Minimum Data Set (MDS, a resident assessment tool) dated 1/5/19 and the Annual MDS dated [DATE] indicated that Resident #76 was cognitively impaired and was at risk for skin breakdown A care plan for risk for skin breakdown related to chronic toe/foot issues was initiated on 2/5/18; a podiatry care plan related to history Left great…

    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 · Dcited before2019-05-02 · 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, record review and interview conducted during the recertification survey, the facility did not ensure that a resident received treatment and services to prevent and/or heal pressure ulcers. Specifically, there was no evidence the nursing staff implemented interventions to remove risk factors for a resident with a pressure ulcer This was evident for 1 of 7 residents reviewed for pressure ulcers. (Resident #12)). The findings are: Resident #12 was admitted to the facility on [DATE] with the diagnoses of Coronary Artery Disease and Dementia. The 7/20/18 Annual MDS Assessment Minimum Data Set (MDS, an assessment tool) indicated the resident was cognitively impaired, received total dependence for bed mobility, was at risk for pressure ulcers, and had a pressure reducing device in bed and chair. The 1/16/2019 Quarterly Minimum Data Set indicated the resident was cognitively impaired, required extensive assistance for bed mobility, had functional limitation range of motion to one lower extremity,…

    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 · D2019-05-02 · 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 interview and record review conducted during the most recent recertification survey, the facility did not ensure that falls were thoroughly investigated to determine the contributory factors and if planned interventions, were implemented to prevent recurrent falls for 1 of 3 residents reviewed for accidents (Resident #180). Specifically, during a six-week period the resident, who required assistance with transfers, was seen out of bed and on the floor 4 times. The investigations of these falls did not determine if the resident's plan of care regarding the wearing of nonskid socks when in bed was implemented. Also, the resident's plan of care was not reviewed to determine if revision was needed to more effectively address unassisted transfers from bed. The fourth incident resulted in the resident sustaining a left hip fracture. The findings are: Resident #180 is a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of Cerebrovascular Accident and Dementia. According to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during the most recent recertification survey, the facility did not ensure that nursing staff followed proper hand hygiene during wound care treatment for 1 of 7 residents (#12) reviewed for pressure ulcers. The findings are: Resident #12 had diagnoses and conditions including Suspected Deep Tissue Injury, Coronary Artery Disease and Hypertension. The Quarterly Minimum Data Set (a resident assessment tool) of 1/16/19 revealed that the resident had cognitive impairment. The Pressure Ulcer Care Plan was initiated on 4/14/19 to address the resident's Right Heel Blister. The Physician Orders, on the following 4/23/19 included: right heel blister cleanse area with Normal Saline, apply Calcium Alginate, and cover with dry protective dressing daily. A dressing change observation was conducted on 4/30/19 at 10:30 AM and the following was noted: The Registered Nurse (RN #1) washed her hands and donned a pair of gloves. She then blotted the right heel wound 8 times with a saline soaked 4 x 4. Following cleansing of the wound RN#1…

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

    Infection Control 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 SAPPHIRE CARE GROUP — 8 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 4 of 52.6+1.4 vs chain
Health inspection 3 of 51.9+1.1 vs chain
Staffing 2 of 52.1-0.1 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 7 homes this chain runs (chain average 2.6★, 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
ABRAMCZYK, MACHLAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST20%since 09/01/2017
FARKOWITZ, ESTHERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST33%since 09/01/2017
PLATSCHEK, RICHARDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL33%since 09/01/2017
SCHUCK, ROBERTIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 09/01/2017

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$25.3M
Net patient revenuemost recent cost report
-4.6%
Operating marginrevenue minus expenses
$2.4M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 16%Other / private 17%

This home reported $2.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$413per resident / day
operating cost
$12,569per month
≈ monthly operating cost
$395per 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 335464. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

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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