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Bethel Nursing Home Company Inc

17 Narragansett Avenue, Ossining, NY 10562 · Non profit - Corporation · 43 certified beds · (914) 941-7300 Medicare & Medicaid certified

Call the home — (914) 941-7300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Mar 2025
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
537 N State Rd · (914) 432-7117 · Call to confirm hours
Pharmacy
162 Croton Ave · (914) 941-1660 · Call to confirm hours
Grocery
19 Campwoods Rd · (914) 762-3405 · Call to confirm hours
Park
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 3 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 fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
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 increased20.2%14.1%15.4%worse
Long-stay residents who lose too much weight4.5%5.8%5.4%better
Long-stay residents with a catheter left in their bladder2.6%0.5%0.9%worse
Long-stay residents with a urinary tract infection5.5%1.3%2.0%worse
Long-stay residents with depressive symptoms0.0%19.5%6.5%check this — see note marked star 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 worsened19.7%12.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.8%13.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers5.8%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control16.1%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table22.0%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine78.1%78.8%79.4%typical
Short-stay residents rehospitalized after admission15.3%20.6%22.6%better
Short-stay residents with an outpatient ER visit3.3%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.261.701.67better
Long-stay outpatient ER visits per 1,000 resident days0.971.361.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.0%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
85.7%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.39hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 85.7% 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 28 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 SNF49.0%CMS range 36.8–58.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.9–15.310.7%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 discharge85.7%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 discharge71.4%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 discharge75.0%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 identified92.1%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened0.0%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 hospitalization8.0%CMS range 4.6–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.201.02Oct 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

0.79
RN hours/ resident / day
0.40
LPN hours/ resident / day
2.35
Aide hours/ resident / day
3.53
Total nurse hours/ resident / day
0.67
RN hoursweekends
25.0%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 43 beds and averages 35.2 residents a day — about 82% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.41 hrs/resident/day on weekends vs 3.58 on weekdays — 5% thinner on weekends. RN hours go from 0.83 to 0.67 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%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

11
deficiencies at the latest standard inspection (2025-03-21)
7
at the previous standard inspection (2023-08-08)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · D2026-06-18 · 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 observation, interview, and record review the facility failed to ensure that an injury of unknown origin was reported to the State Agency immediately, but not later than two hours for one of two residents (Resident #6) reviewed for injury of unknown origin. Specifically, on 08-30-2025 Resident #6 was transferred to the hospital after they complained of right hip pain with right leg swelling and abduction of the right knee. On 08-31-2025 at 2:26 AM the facility was made aware that Resident #6 was diagnosed with a right hip fracture. The State Agency was not notified until 09-01-2025 at 1:19 PM. The findings include: Resident #6 had diagnoses including dementia, osteoporosis, and anxiety. The quarterly Minimum Data Set (assessment tool) dated 06-27-2025 documented Resident #6 had severe cognitive impairment and was dependent on staff for daily living activities. The Incident Report dated 08-30-2025 at 9:30 PM documented Resident #6 complained of right hip pain while being repositioned in a wheelchair and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 the facility failed to ensure that a thorough and/or accurate investigation was conducted for one of one resident (Resident #51) reviewed for abuse. Specifically, the Investigative Summary statement from Registered Nurse Supervisor #11 documented the wrong incident date and incorrect initials for Certified Nurse Aide #4 after Resident #51 called 911 on 05/01/2026 and accused staff of abuse.The findings include:The policy titled Abuse Prevention and Reporting last reviewed 3/2026 documented that any employee or volunteer that suspects hears about or witness's resident abuse, neglect or misappropriation of resident's property must complete an Accident/Incident Report.Resident #51 was admitted to facility with diagnoses of vascular dementia, anxiety and depression. The 4/29/2026 Baseline Care Plan for behavior documented that the resident had a history of trauma. Assist of one for bowel and bladder care, assist of one for transfer.The 5-day Minimum Data Set (an assessment tool)…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-18 · 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 the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and/or that each resident receives adequate supervision to prevent accidents for one of two residents (Resident #1) reviewed for accidents. Specifically, the comprehensive Care Plan did not include interventions to address supervision for Resident #1 who was assessed as at risk for elopement, was able to remove their wander guard and exit the building unsupervised on the morning of 06/22/2025. Additionally, there was no consistent documented evidence that every 15-minute monitoring x 48 hours was implemented as per the comprehensive Care Plan after Resident #1eloped on 06/22/2025. The Findings are:The Policy and Procedure for elopement prevention and follow up procedures last revised 11/22/2022 documented in the staff responsibilities: Staff who are assigned the responsibility of resident care must maintain constant awareness of the whereabouts of the resident(s)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2025-03-21 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and review of facility documents, it was determined that, the facility did not ensure each certified nurse aide received twelve hours in-service education per year based on their individual performance review. Specifically, (1) 4 out of 5 certified nurse aides did not have their mandatory annual 12 hour in services and (2) 5 out of 5 certified nurse aides (#2,6, 7, 8, 9) did not receive performance evaluations. Finding Include: Review of facility training records revealed: Certified Nurse Aide # 2 was hired on 2/28/2011 and received 10.25 hours of in-services in the last 12 months and had no documented evidence of an annual performance review. Certified Nurse Aide # 6 was hired on 12/17/2007and received 0 hours of in-services in the last 12 months and had no documented evidence of an annual performance review. Certified Nurse Aide # 7 was hired 8/23/1995, received 16 hours of in-services in the last 12 months, and had no documented evidence of an annual performance review. Certified Nurse Aide # 8 was hired 4/22/1998, received 10.5 hours of in-services in…

    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 · E2025-03-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 and interviews conducted during the recertification survey from 3/18/25 to 3/21/25, the facility did not store, distribute and serve food in accordance with professional standards for food service safety and did not maintain dishwasher heat for sanitation. Specifically, 1) expired foods were stored in dry pantry, walk in refrigerator and freezer; 2) unsealed, unlabeled and undated food were stored in dry pantry and walk in refrigerator; 3) the dishwasher wash and rinse did not maintain proper temperature standards; and 4) three (3) staff were observed not performing proper hand hygiene while serving the lunch meal. Findings include: The facility policy last revised 5/2018, Labeling and Dating stated any unopened food item will be discarded by the manufacturer labeled expiration date and all prepared menu items will be dated in compliance of a 3 day use by date. The facility policy last reviewed 11/2004, Food Storage stated contents of opened food packages will be stored in tightly sealed containers and all containers will be properly labeled as to contents. 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 · Ecited before2025-03-21 · 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

    Based on observation, record review and interview conducted during a recertification survey from 3/18/25 to 3/21/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration, or declination and education provided for 5 of 10 staff (Certified Nurse Aide #1 and #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3) reviewed for influenza and 10 of 10 staff (Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1) reviewed for pneumococcal vaccination. The findings are: The facility policy titled Prevention, Early Detection and Control of Influenza dated 6/2023 documents the purpose is to control the spread of respiratory infections which includes a preventative vaccination program. All…

    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 · E2025-03-21 · tag F0887 — pattern
    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 observation, record review and interview conducted during a Recertification survey from 3/18/25 to 3/21/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 10 of 10 staff (Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1), reviewed for COVID vaccination. The findings are: The facility COVID policy dated 12/24/20 documents newly hired staff will be asked to provide COVID vaccination information as part of their Human Resources medical record as they do with other vaccines. If they are unvaccinated, or not up to date, they will be provided education on COVID19 and offered the COVID vaccine. During the recertification survey the facility was asked…

    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 · D2025-03-21 · 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, during the recertification survey from 3/18/25 to 3/21/25 the facility did not ensured that the call bell system was accessible for 1 (Resident #16) of 35 residents reviewed for Environment. Specifically, the facility did not ensure that Resident's #16 call bell was within reach. Findings include: The Policy and Procedure titled Call Bells dated 6/16/03 documented it is the policy of the facility that each resident has a call bell at bedside within reach. The cord should be clipped to the bed. The Nursing Assistant assigned to the resident must check for malfunction of call bells on each shift and report such to the nurse in charge. Resident #16 had diagnoses including depression, diabetes mellitus, and chronic obstructive pulmonary disease. The Minimum Data Set Quarterly assessment dated [DATE] documented the resident was cognitively intact. The resident required substantial assistance with roll left to right, and lying to sitting on side of bed; 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 · D2025-03-21 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews during a recertification survey from 3/18/25-3/21/25 the facility did not ensure a resident's right to be free from misappropriation of resident property for 1 out of 1 resident (Resident #12) reviewed for personal property. Specifically, Resident #12 was missing shirts which was reported to facility staff and the facility did not complete a timely and thorough investigation of the missing property. Findings include: The facility policy titled Missing Items, dated March 2012, documented the facility shall respond to all reports of resident missing property. Once a resident or their representative reports an item missing to any facility staff member immediate action will be taken. Procedure: Clinical staff member asks for details regarding the missing item and completes Missing Item Report form. The form is given to the unit Social Worker. The Social Worker reviews missing item report, interviews the resident and family as appropriate, summarizes steps taken to locate item and documents results of the search. Social Worker notifies…

    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 · D2025-03-21 · 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 record review and interview during a recertification survey from 3/18/25 to 3/21/25, the facility did not ensure resident received treatment and care consistent with professional standards of practice for 1 of 2 Residents (Resident #13) reviewed for skin conditions. Specifically, Licensed Practical Nurse #1 failed to report a change in Resident #13's skin condition. Findings included: The facility policy titled Body Audits, reviewed 6/2017, documented body audits (skin checks) will be done on admission, re-admission and weekly thereafter per treatment order. The purpose is early identification for all potential and actual skin problems. Residents with additional factors such as bed mobility issues, paraplegia and cerebral vascular accident will be closely monitored. Resident #13 had diagnoses including cerebral infarction, flaccid hemiplegia right dominant side, and vascular dementia. The Quarterly Minimum Data Set (a Resident assessment tool) dated 1/24/25 documented Resident #13 had moderately impaired cognition and was dependent on staff for all activities of daily…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2025-03-21 · 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

    Based on observation, interview, and record review conducted during the recertification survey from 3/18/25 to 3/21/25, the facility did not ensure residents were provided supervision to prevent accidents for 1 (Resident #33) of 2 residents reviewed for accidents. Specifically, Resident #33 was at risk for aspiration and was not provided supervision or assistance by facility staff during meals. The resident was observed being fed by an unqualified companion aide. The findings are: The facility policy titled Routine Resident Care, dated October 3, 2001, documented residents are given routine daily care by a Certified Nurse Assistant under the supervision of a Licensed Nurse. Routine care by a nursing assistant includes the following: assisting resident in personal care, bathing, dressing, eating and encouraging participation in physical, social, and recreational activities. Observing and recording all aspects of personal care including bathing, food intake, ambulation activities, elimination and vital signs on the Certified Nurse Assistant Accountability Sheet. The facility 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 · Dcited before2025-03-21 · 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 observation, record review and interviews during a recertification survey conducted from 3/18/25 to 3/21/25, the facility did not ensure the provision of nutrition and hydration care and services for 1 of 3 residents reviewed for Nutrition (Resident #5). Specifically, Resident #5 had a 6.3% weight loss over 1 month, and meal intake was not consistently monitored, and the resident was not encouraged with meal and fluid intake as planned. Findings include: The policy and procedure titled L.T.C. Evaluation of Changes Intake revised on January 2004 documented all staff members observe resident intake on a regular basis to evaluate change in resident food intake. Meal consumption is recorded by the Certified Nurse Aides daily for all residents in the Certified Nurse Aide Accountability Book. Nursing staff notifies the Food and Nutrition Services Department if a resident has consumed less than 75% of meals over a two-day period. The Resident #5 had diagnoses including diabetes mellitus, depression, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during the recertification survey from 03/18/25 to 03/21/25, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 3 of 35 opportunities (8.57%) resulted in error for 1 of 3 residents (Resident #19). Specifically, Resident #19 1) was administered a crushed form of Carbodopa50mg-Levodopa 200mg-entacapone, a crushed form of Acidophilus Probiotic 35 million cell tablet, and 2) an inaccurate dose of Metamucil powder. The findings are: Resident #19 was admitted to the facility with diagnoses including but not limited to Parkinson's disease, heart failure and hypertension. The Minimum Data Set (an assessment tool) dated 3/1/25 documented the resident had severe cognitive impairment, was dependent on staff for all activities of daily living and was prescribed a mechanical diet. 1)The current physician orders as of 3/18/25 documented Carbodopa50mg-Levodopa-entacapone oral tablet, give one tablet by mouth two times a day for Parkinson's disease and Acidophilus 35million…

    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 · Dcited before2025-03-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey the facility did not maintain drugs and biologicals, labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration dates for 1 of 1 medication storage room (located on the second floor) reviewed. Specifically, the medication storage room (located on second floor) had expired drugs and biologicals that were available and ready for use. The findings include: The facility policy on Storage of Medications last revised 12/2023 documented discontinued, contaminated or deteriorated medications are removed from the medication/treatment storage area and disposed of per facility policy. On 03/19/25 at 10:03 AM, the Second-Floor Short term and Long term Medication Storage Room was observed with expired medicine and products including the following: -2 boxes omeprazole, one box had 3 bottles in it with a total 42 pills and the second box had 2 bottles in it with a total of 28 pills and both boxes expired 2/2024. -3 boxes…

    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 · Dcited before2023-09-01 · 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 record review and interview conducted during an abbreviated survey (NY00310549, NY00313330) the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 2 resident's (Resident #1 and Resident#2) of 3 residents reviewed for accidents. Specifically, (1) Resident #1 was left in the room unsupervised without prothesis (for right leg) and attempted to self-toilet and fell; (2) Resident #2 fell out of the bed and sustained a hematoma on the left side of the head. The facility did not ensure that the mats that were supposed to be on both side of Resident #2's bed was in place in accordance with the care plan. The findings are: The Policy and Procedure titled Fall Risk Assessment and Fall Prevention Revised 8/11/2022 documented that all residents will be free from falls and free of injuries associated with falls; and assess all residents for falls. Resident #1 had diagnoses that included Diabetes Mellitus without complications, Acquired absence 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-08 · 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

    Based on observation, record review, and interview conducted during the recertification survey from 7/31/23 to 8/6/23, the facility did not ensure that resident's had the right to be free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident's reviewed for restraints (Resident #24). Specifically, Resident #24 was physically restrained in bed with pillows tucked under their sheets, and wedge cushions between the mattress and bed frame, with no documentation of medical symptoms warranting the use of restraints. In addition, the restraints were applied without an assessment and without a physician's order. Findings include: Resident #24 was admitted to the facility with diagnoses including but not limited to non-alzheimer's dementia, parkinson's disease, and psychotic disorder. The Quarterly Minimum Data Set (MDS-a resident assessment tool) dated 5/1/23, documented Resident #24 suffered from severe cognitive impairment, required extensive assist of 1 person for bed mobility and eating, and extensive assist of 2 people for transfers…

    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 · D2023-08-08 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during the recertification survey from 7/31/23 through 8/8/23 and abbreviated surveys (NY00318447, #NY00314225, and #NY00320324), it was determined that for 3 of 3 residents (#13, #15, and #136) reviewed for hospitalizations, the facility did not ensure that the Office of the Ombudsman was notified when the residents were transferred to the hospital. Specifically, Residents #13, #15, and #136 were transferred to the hospital and the facility could not provide evidence that the Ombudsman was notified of their transfers out of the facility. The findings include: A review of the facility policy created 3/2018 titled 'Bed hold and return to the Facility', documented that the facility's social work director/designee will send a copy of the resident's notice of transfer/discharge to the local Office of the Ombudsman, and that notices will be grouped and forwarded monthly. 1. Resident #13 was admitted to the facility with diagnoses including but not limited to dementia, sjorgen syndrome, and major depressive disorder. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-08 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review conducted during the recertification survey from 7/31/23 through 8/8/23 and an abbreviated survey (#NY00318447, #NY00314225, and #NY00320324), it was determined that for 3 of 3 residents (#13, #15, and #136) reviewed for hospitalizations, the facility did not ensure that the resident or the resident's representative were notified in writing of the facility's Bed Hold Policy. Specifically, Residents #13, #15, and #136 were transferred to the hospital and the facility could not provide evidence that a written notice of the facility's Bed Hold Policy was provided to the residents or the resident's representatives. The findings include: A review of the facility policy created 3/18 titled 'Bed hold and return to the Facility', documented that the facility would provide written information in the form of a STATUS OF BEDHOLD form letter at the time the resident is transferred to the hospital or goes on therapeutic leave. 1. Resident #13 was admitted to the facility with diagnoses including but not limited to dementia, Sjorgen syndrome, and major…

    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 before2023-08-08 · 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 record review and interview during the recertification survey from [DATE] to [DATE] and an abbreviated survey (#NY00320324), the facility did not ensure that the environment was free of accident hazards, and that each resident received adequate supervision and assistance to prevent accidents for 3 (Resident #3, #30, and #136) of 3 residents reviewed for accidents. Specifically, 1. Resident #3, with impaired cognition and at risk for elopement successfully made it off the unit and to the facility lobby unsupervised on two occasions and 2. Resident #136 and Resident #3 were cut out of a Hoyer Lift after the battery had died and the machine stopped working. The findings include: 1. Resident #3 was admitted to facility [DATE] with diagnoses of nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, and peripheral vascular disease. The Quarterly Minimum Data Set (MDS- a resident assessment tool) dated [DATE] documented Resident #3…

    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 before2023-08-08 · 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

    Based on observations, interviews, and record reviews conducted during recertification survey from 7/31/23 to 8/8/23, the facility did not ensure services were provided to maintain acceptable parameters of nutritional status for 1 of 1 residents reviewed for nutrition (Resident #17). Specifically, the facility did not ensure Resident #17 was consistently offered assistance and supervision during meals, resulting in missed meals on 2 observed occasions. The findings are: Resident #17 was admitted to the facility with diagnoses including but not limited to non-alzheimer's dementia, diabetes, and depression. The Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 6/10/23 documented Resident #17 had a Brief Interview of Mental Status (BIMS- a tool used to assess a resident's cognition) score of 3 (severe cognitive impairment), required set-up assistance and supervision during meals, and was on a prescribed therapeutic diet. The 6/5/23 comprehensive care plan documented Nutrition interventions including but not limited to the resident will consume at least 75% 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview conducted during the recertification survey from 8/1/23 through 8/8/23, the facility did not ensure that medications were discarded to prevent their use beyond the expiration dates for 1/1 medication rooms inspected (2nd floor medication room). Specifically, multiple medications were discovered in the 2nd floor medication room that were expired. The findings are: During observation of the 2nd floor medication room on 8/3/23 between 10:45 AM and 11:00 AM; the following was observed: 3 Heparin lock flushes (50 units/5 ml) with an expiration date of 8/1/23. 2 Heparin lock flushes (500 units/ml) with an expiration date of 2/28/23. 4 100mg 0.9% Sodium Chloride Injection bags with an expiration date of 5/23. 2 Levofloxacin injection 500 mg in 100mg 5% with an expiration date of 5/23. During an interview on 8/3/23 at 10:55 AM, Licensed Practical Nurse (LPN) #2 stated they are not sure who is responsible for medication storage or ensuring that all medications kept in the room are not expired. LPN #2 stated that it is not acceptable to have expired…

    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 · Dcited before2023-08-08 · 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 observations, record review, and interviews during the recertification survey from 7/31/23 to 8/8/23, the facility did not ensure that infection control practices were maintained. Specifically, A physician (MD) #2 exited the room of a resident on contact precautions (Resident # 679) without performing hand hygiene. The findings are: Resident #679 was admitted to the facility with diagnoses including but not limited to hypertension, hyperlipidemia, and COVID-19. A physician order for Resident #679 dated 8/2/23 at 12:00 AM documented, Contact and droplet precautions for Covid 19, Positive 8/1/23. On 8/2/23 at approximately 9:30 AM, Physician (MD) #2 was observed exiting the room of Resident #679, properly doffing their personal protective equipment, and passing a hand sanitizer station outside the room without performing hand hygiene. MD #2 then proceeded to the 2nd floor nurses station to work on the computer without washing their hands. During an interview on 8/2/23 at approximately 9:35 AM, MD #2 stated all staff should perform hand hygiene when exiting a resident's room.…

    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 · D2023-08-08 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey from 8/1/23 to 8/8/23 and an abbreviated survey (#NY00320108), it was determined that the facility did not ensure a discharge planning process was in place which addressed each resident's discharge goals and needs, including caregiver support and referrals to local agencies as appropriate, and involved the resident and the interdisciplinary team in developing the discharge plan for 1 of 3 residents (Resident #32) reviewed for discharge planning. Specifically, Resident #32's discharge was appealed with Medicare/Medicaid and the facility discharged the resident during the appeal process. The findings are: Resident #32 was admitted to the facility with diagnoses including but not limited to a cerebral vascular accident, aphasia and arthritis. The 6/12/23 admission Minimum Data Set (MDS- a resident assessment tool) assessment documented Resident #32 suffered from severe cognitive impairment and that the resident was expected to be discharged into…

    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 · D2021-07-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not ensure a person-centered care plan was developed for 2 of 2 residents (#3, #8) reviewed for Dementia Care. The findings are: Review of the Facility Policy and Procedure on Resident Assessment and Comprehensive Care Planning updated on 01/2021 documented that using assessments from the Minimum Data Set (MDS) 3.0 and implementing care planning decisions, the staff develops a comprehensive care plan (CCP) for the resident. All care plans include measurable objectives and timetables to meet each identified problem/need/strength. Care Plans are developed for all residents to ensure that decline is avoided, if possible. Professional staff individualizes each care approach and design actions…

    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 before2021-07-27 · 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, interview and record review conducted during a recertification survey, the facility did not ensure that proper hand hygiene was performed during wound care treatment for 1 out of 2 residents (#23) reviewed for pressure ulcers. The findings are: Review of the facility policy & procedure on Wound Care: Clean Technique Nonsterile Dressing Change dated 10/19/2020 documented that it is the facility policy to provide treatment of wound per Medical Doctor (MD) orders for protection and to promote healing. Hand hygiene should be performed before and after wound care even if gloves will be worn and after removal of Protective Personal Equipment (PPE) including if gloves are changed during the procedure. Gloves should be worn during wound care procedures. Gloves should be changed, and hand hygiene performed when moving from dirty tasks to clean tasks. Resident #23 was admitted to the facility on [DATE] with diagnoses that included Advance Dementia, Congestive Heart Failure Exacerbation 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.

    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.

Who owns this facility

Owner / managerTypeRoleSince
ALEXANDER, JENNIFERIndividualW-2 MANAGING EMPLOYEEsince 01/01/2014
MARKOPOULOS, ANASTASIOSIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/23/2004
GOLDSTEIN, BETHIndividualCORPORATE OFFICERsince 08/22/2011
THE BETHEL METHODIST HOMEOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/17/1987

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$5.6M
Net patient revenuemost recent cost report
-14.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 51%Medicare 22%Other / private 26%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$503per resident / day
operating cost
$15,303per month
≈ monthly operating cost
$440per 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 335490. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-21, 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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