The Emerald Peek Rehabilitation And Nursing Center
2000 East Main Street, Peekskill, NY 10566 · For profit - Corporation · 100 certified beds · (914) 737-8400 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $139,425 in federal fines (most recent 2024-08-28)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 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 held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.7% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 43.5% | 19.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 23.2% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.1% | 13.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.6% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 59.2% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.2% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.4% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.75 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 1.36 | 1.80 | better |
‡ 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.
51.2% 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 136 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.8% 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 85 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 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 51.2%CMS range 41.6–58.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.1%CMS range 6.2–13.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 70.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.9–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.45 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 90.2 residents a day — about 90% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 2.89 hrs/resident/day on weekends vs 3.25 on weekdays — 11% thinner on weekends. RN hours go from 0.59 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · H2024-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 reviews and interviews during the abbreviated surveys (NY00321069), it was determined the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for accidents. Specifically, Resident # 1 fell from their bed on [DATE] when the plan of care for a 2-person assist with bed mobility was not followed. Resident #1 sustained a subdural hemorrhage (brain bleed) and a lip laceration. The resident expired in the hospital on [DATE]. This resulted in actual harm that was not immediate jeopardy. Findings include: Resident #1 was admitted to the facility with diagnoses including a history of subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane) with residual neurological deficits, and a Stage IV sacral pressure injury. The admission Minimum Data Set (a resident assessment tool) dated [DATE] documented the resident had severely impaired cognition and required total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-08 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview conducted during the recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure Annual Performance Reviews were completed at least once every 12 months. Specifically, the facility was unable to provide Annual Performance Reviews for 5 of 5 Staff Members ( #11, #12, #13, #14, #15) reviewed. The findings are: The facility policy titled Job Performance Review, dated 10/01/2024, stated: The job performance of each employee shall be reviewed and evaluated at least annually. During an interview with Assistant Director of Nursing/Nurse Educator on 11/06/24 at 4:14 PM, they stated the facility had just resumed Annual Performance Appraisals for nursing staff. The Assistant Director of Nursing/Nurses Educator stated they were unable to provide performance appraisals for the 5 staff members requested (#11, #12, #13, #14, #15). During an interview with the Administrator on 11/08/24 at 3:17 PM, the Administrator stated the facility had not completed staff Annual Performance Appraisals for the last few years. They stated the facility 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.
- Potential for harm · Dcited before2024-11-08 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 11/4/2024 to 11/8/2024, the facility did not ensure the resident's right to a sanitary environment. This was evident during environmental observation of 1 (3rd Floor) of 2 resident units. Specifically, the shared resident bathrooms between rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS] were observed with a strong odor of urine on multiple occasions. The findings are: The facility policy titled Terminal Cleaning Complete Room Cleaning dated 1/5/2024 documented Housekeeping staff allowed the floor in resident rooms to dry after damp-mopping it with disinfectant. On 11/05/2024 at 11:05 AM and 11/06/2024 at 04:42 PM, the shared bathroom between rooms [ROOM NUMBERS] was observed with a strong odor of urine. The caulking around the bottom edge of the toilet bowl was stained a dark yellow/orange color. There were 2 broken tiles at the base of the toilet bowl. There were no obvious signs of urine on the toilet bowl or on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-08 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews during the Recertification survey from 11/3/2024 to 11/8/24, the facility did not ensure that a complete preadmission screening for individuals with a mental disorder was conducted. This was evident for 1 of 24 residents (Resident #82) reviewed for Preadmission Screening and Resident Review (PASARR) out of 24 sampled residents. Specifically, the SCREEN DOH 695 form was incomplete and a determination of a resident's need for Level II services had not been documented. Findings include: Resident #82 arrived at the facility on 8/12/24 with diagnoses that included, chronic pain, bipolar disorder, and major depressive disorder. The resident refused to proceed with admission upon arrival at facility and was discharged against medical advice on 8/12/24. The facility policy titled PASRR dated 7/15/24 stated that it is the policy of the facility that all residents have the required pre-admission screen prior to admission to the facility, and any time that there is a significant change that has bearing on the resident's specialized service needs.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure services provided met professional standards of quality. This was evident for 1 (Resident #20) of 4 residents reviewed for pressure ulcers out of 22 total sampled residents. Specifically, Licensed Practical Nurse #1 discontinued a physician ordered wound care treatment for Resident #20 without notifying the provider for an order to discontinue. The findings are: The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 6/24/2024 documented the Physician will authorize pertinent orders related to wound treatments. The facility policy titled Pressure Injury Risk assessment dated [DATE] documented a skin assessment tool was used to document findings of skin inspections. Care plan interventions must be current and recognized standards of care. Report information in accordance with professional standards of practice. The facility Role of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing. This was evident for 1 (Resident #20) of 4 residents reviewed for pressure ulcers. Specifically, Licensed Practical Nurse #1 discontinued a physician ordered wound care treatment for Resident #20 without notifying the provider and getting an order to discontinue. The findings are: The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 6/24/2024 documented the Physician will authorize pertinent orders related to wound treatments. The facility policy titled Pressure Injury Risk assessment dated [DATE] documented a skin assessment tool was used to document findings of skin inspections. Care plan interventions must be current and recognized standards of care. Report information in accordance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification and abbreviated survey (NY00338157) conducted 11/4/2024 to 11/8/2024, the facility did not ensure they provided medications and/or biologicals, as ordered by the prescriber, to meet the needs of 1 (Residents #184) of 2 residents reviewed for Pharmacy Services. Specifically, Resident #182 did not receive methylprednisolone (a medication used to treat lupus) on 3/30/24 and 3/31/24. The medication was not acquired from the pharmacy and administered as ordered. Findings include: The facility policy titled Medication Administration dated 10/05/2024 stated: Medication shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time. If medication is unavailable from the pharmacy or E-box or First Done Machine (Med-bank) for the scheduled time, the practitioner will be contacted for further instructions. Resident #184 was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-08 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews during a survey from 11/4/24-11/8/24, the facility did not ensure each resident's drug regimen was free from unnecessary drugs, use for 1 (Resident #73) of 5 residents reviewed for unnecessary drugs. Specifically, Resident #73 had an order for Tramadol 50 milligrams three times a day for a pain scale of 5-10 and was administered 12 times from 11/1/24-11/6/24 with a pain scale less than 5. Findings included: Resident # 73 had diagnosis including Cerebral infarction, Aphasia, and Type 2 diabetes. A Policy and Procedure titled Medication Administration dated 10/5/2024 documented Medication must be administered in accordance with orders, including any required time frames. If a dosage is believed to be inappropriate or excessive for the resident, the person preparing or administering the medication will contact the resident's attending physician or the facility medical director to discuss concerns. A quarterly Minimum Data Set (an assessment tool) dated 10/1/2024 documented the resident's cognition was severely impaired. The resident required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 a recertification survey from 11/04/24 to 11/08/2024, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled substances on 1 of 2 facility units (Third Floor) reviewed for drug storage. Specifically, injectable Ativan (a controlled substance) was not stored in a double locked permanently affixed compartment. The findings are: Facility policy on Medication Labeling Storage dated 10/5/2024 documented the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Controlled substances (listed as Schedule II-4 of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews conducted during a recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure infection control and prevention practices were maintained. This was evident for 2 (Resident #11 and #14) residents during a dining observation and 2 (Resident #70 and #38) of 4 residents during medication administration observation. Specifically, 1) Certified Nurse Aide #16 was observed feeding Residents #11 and #14 without performing hand hygiene between residents, and 2) Licensed Practical Nurse #1 was observed administering medication to Residents #70 and #38 without performing hand hygiene after touching other items in the room and administering eye drops. The findings are: 1) Residents #11 and #14 both had diagnoses of dysphagia and dementia. During a lunch meal observation in the Main Dining Room on 11/4/2024 at 12:43 PM, Certified Nurse Aide #16 picked up a spoon and fed Resident #11. Certified Nurse Aid #16 then set the spoon down, turned and picked up Resident #14 ' s spoon with the same hand and fed Resident #14. Certified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interviews during the Abbreviated Survey (NY 00315316) the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours to the New York State Department of Health. This was identified for one (Resident #2) of 3 residents reviewed for abuse. Specifically, the facility received an accusation of abuse of Resident #2 on 4/24/2023 and did not report the allegation of abuse to the New York State Department of Health. Findings include: The facility Policy and Procedure titled Abuse, Neglect, Exploitation or Mistreatment - Reporting and Investigating, documented if resident abuse, neglect, exploitation, or misappropriation of resident property or injuries of unknown origin is suspected, the suspicion must be reported immediately to the administrator and other officials. The Care Plan titled Victim of Abuse dated 4/19/2023, documented a goal that the resident would not be a victim of abuse. Interventions included to investigate all allegations of abuse, provide support, and ensure resident is not a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2024-04-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F580 Based on record review and interviews conducted during an abbreviated survey on 3/20/2024 (NY00305021), the facility did not ensure that a resident representative or their physician was informed of the need to alter treatment to gradually reduce a resident's psychotropic medication for 1 of 3 residents reviewed. Specifically, on 9/9/2022 through 10/31/2022 the facility initiated a gradual reduction of Resident #1(who had a diagnosis of schizophrenia) psychotropic medications (Clozapine and Risperdal), despite a recommendation from the psychiatrist to maintain psychotherapy until the next follow up. Resident #1's representative or psychiatrist was not notified of significant alteration in treatment. On 10/14/2022 Resident #1 would not follow redirection and was yelling at staff and on 10/17/2022 Resident #1 reported to staff they did not feel like themselves and had outburst of cursing and yelling. The findings are: The Policy and Procedure titled, Notification of change, dated 1/15/2023 documented it will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-12-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during a recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety in a manner to prevent contamination. Specifically, a 5-pound package of open cheese and 5-pound package of open boloney which were not dated to document date of having been opened were observed in the refrigerator in the kitchen, and 3 boxes frozen apple juice and 3 boxes frozen orange juice were observed sitting on a cart in the kitchen at room temperature. The findings are: The facility's policy and procedure regarding food storage dated 10/15/20, revised 12/14/21 documents that perishable foods must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality, and that leftover food should be clearly labeled and dated. During the initial tour of the kitchen on 12/14/21 at 9:30 AM, an opened 5-pound package of [NAME] cheese and an opened 5-pound package of boloney were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-22 · tag F0880 — failed to prevent and control infections — patternProvide 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, interviews, and record review, the facility did not ensure infection control/infection precautions were maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not performed appropriately during wound care. This was evident for 2 of 5 residents reviewed for Pressure Ulcer/Injury. (Resident #4 & #30). The findings are: 1. Resident # 4 was admitted to the facility with diagnoses that included Diabetes Mellitus, Multiple Sclerosis, Septicemia, Methicillin-Resistant Staphylococcus aureus (MRSA, a staph infection resistant to some antibiotics). The admission Minimum Data Set (MDS, a resource tool used to assess residents) dated 2/24/21 documented the resident was mildly cognitively impaired and had 1 Stage 2, 1 Stage 3 and 1 Stage 4 pressure ulcer. The MDS also indicated the resident had an infection in the foot described as a surgical wound. The December 2021 Physicians wound treatment orders documented: cleanse wounds to right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews on a recertification survey, the facility did not ensure the resident's right to a dignified existence for 2 of 2 residents screened for dignity. Specifically, for Resident #30, the privacy curtain was not pulled between the Resident and roommate, Resident #78, during a dressing change, exposing Resident #30 right thigh and legs and Resident #54 was not provided privacy with a drawn privacy curtain during a wound dressing change and uncovered skin was exposed and visible to the resident's roommate, Resident #60. The findings are: The Facility policy Quality of Life-Dignity dated 2/22/21 documents each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, feeling of self-worth and self-esteem. 1) Resident #30 was admitted to the facility with diagnoses of, but not limited to; Diabetes Mellitus, dysphagia, aphasia and hemiplegia. The Minimum Data Set (MDS) quarterly assessment dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during Recertification Survey and Abbreviated Survey (#272045) the facility did not ensure the Comprehensive Care Plan was implemented to meet the needs for 1 of 6 Residents (#391) reviewed for Nutrition. Specifically, the CCP was not developed to address a resident at risk for weight loss. The CCP did not document frequency of weight monitoring as documented in the physician's order. The CCP also did not document measurable goals or timeframes. The Findings Are: The Policy and Procedure titled Care Plans, Comprehensive Person Centered (Revised December 2016) documented the CCP should meet the resident ' s physical, psychosocial and functional needs and is developed and implemented for each resident. The CCP would describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. The Policy & Procedure (P&P) dated 11/15/21 titled Nutritional Assessment documented the dietician, 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.
- Potential for harm · D2021-12-22 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews during Recertification Survey conducted the facility did not ensure a resident who required dialysis receive services consistent with professional standards of practice for 1 of 2 residents (#81) reviewed for Dialysis. Specifically, the facility did not ensure that for Resident #81 ongoing communication and collaboration with the dialysis facility regarding dialysis care/services and physician orders for the delivery of dialysis. The Finding is: The facility manual titled Dialysis section D; Post Dialysis Monitoring dated 2/11/21 documented a) licensed nurse should obtain blood pressure, pulse, pressure/absence of bruit/thrill as indicated and b) licensed nurse will monitor for signs/symptoms of fluid overload/deficit. Section G: Communication documented communication with the Dialysis Center will be maintained through the use of a communication book. The communication book is sent with the resident each time they are transported to dialysis. The nursing staff and the Dialysis center will communicate any pertinent information through the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-22 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review on a recertification survey, the facility did not ensure that residents were free from significant medication errors. Specifically, a resident did not have fingerstick blood sugar (FSBS) performed as ordered and subsequently did not receive insulin to lower elevated blood glucose level. This was evident for 1 of 6 residents reviewed for Unnecessary Medication out of a sample of 24 residents. (Resident # 30) The finding is: The facility policy dated 9/23/21 titled Schedule for Medication Administration documented it is the policy of Emerald Peek Rehabilitation and Nursing Center to have a uniform schedule medication administration. The purpose is to ensure timely and accurate administration of medications by all nursing staff during all shifts. Medications administered four times a day shall be 09:00AM, 01:00PM, 05:00PM, 09:00PM. Resident #30 was admitted to the facility with diagnoses that included Hemiplegia, Type 2 Diabetes Mellitus (DM), and Hypertension.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on observation and interview during the recertification survey, the facility did not ensure the safe and secure storage of medications in accordance with currently accepted professional standards. Specifically, a medication cart was observed unattended, with a Novolog insulin pen unattended placed on top of the medication cart. This was evident on one of two units. The finding is: On 12/14/21 at 12:32 PM, on the 3rd floor unit, the medication cart was observed unattended. A Novolog insulin pen was observed on top of the medication cart. During an interview on 12/14/21 at 12:35 PM, an interview was conducted with Licensed Practical Nurse (LPN #1) who stated, I forgot to put the medication into the cart and lock it. I should have locked it up because someone could have come and taken it. 483.45(H)
- Potential for harm · D2019-01-18 · tag F0623 — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that written notification of hospital transfers was communicated to the family and to the Ombudsman's office. This was evident for 1 resident reviewed for hospitalization. (Resident #'s 75). The findings are: 1. Resident #75 was admitted to the facility on [DATE]. Current diagnoses include Hypertension, Obstructive Uropathy, Diabetes Mellitus and Bipolar Disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 12/7/18 indicated the resident's Brief Interview for Mental Status (BIMS) resulted in a score of 15 out of a possible 15 indicating her cognition was intact. At the time of the assessment there were no behavioral issues identified. The 12/26/18 MDS 30-day assessment was reviewed for cognition and behavior and there was no change from the 12/7/19 assessment. Review of the Progress Notes in the Electronic Medical Record (EMR) noted the following events: 1/13/19 Physician's Progress Note: Patient with frequent disruptive behavior,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-01-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident # 23 was admitted to the facility on [DATE]. The resident's current diagnoses included Cardiovascular Disease, Hemiplegia and Diabetes Mellitus. The annual MDS dated [DATE] revealed that the BIMS (Brief Interview for Mental Status) score was 15 out of a possible 15 indicating no cognitive deficits. Resident # 23 was interviewed on 1/14/19 at 1:00 PM. When the resident was asked if she was invited to care plan meetings she stated she didn't know anything about them. During an interview with the Director of Social Work on 1/15/19 at 10:00 AM she stated that she is responsible for inviting the resident and or representative to the comprehensive care plan (CCP) meeting. She further stated that the resident is overdue for a comprehensive care plan meeting. A review with the Director of Social Work of the sign in sheets for the past year revealed that the resident was not invited and no signature appeared on the sign in sheet. The resident last signed the CCP sign in sheet on 11/9/2017. The Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-01-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review conducted during the recertification survey, the facility did not ensure that 1 of 2 residents (#62) reviewed for quality of care issues related to constipation/diarrhea were provided the necessary care to maintain bowel regularity and skin integrity, and 2 of 2 residents (#5) and (#53) reviewed for position and mobility were provided necessary positioning devices. Specifically, 1) bowel movements were not consistently monitored and recorded in accordance with the plan of care for Resident #62 and the necessary interventions in accordance with the facility's bowel protocol were not implemented for the resident; 2) physician's orders for R#5 use of a left hand palm protector was not consistently implemented and 3) physician's orders for R#53 use of a knee separator when out of bed was not consistently implemented. The findings are 1. Resident #62 is a 72 year male with the diagnoses of Schizoaffective Disorder, Dementia and Depression. According to the current physician's orders the resident was prescribed Lasix 40 mg daily and three psychoactive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-01-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
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 facility thoroughly implemented interventions to remove risk factors when a resident developed a pressure ulcer. This was evident for 1 of 3 residnets reviewed for pressure ulcers. (Resident #73). The findings are: Resident #73 was admitted to the facility on [DATE] with diagnoses including Cerebrovascular Accident, Non Alzheimer's Dementia and Diabetes. The 12/24/18 significant change MDS (Minimum data Set; a resident assessment tool) indicated the resident had severe cognitive impairment, received extensive assist x 2 staff support for bed mobility, toilet use ,total assist x 2 staff support for transfers, had an impairment on one side upper and lower extremities, was always incontinent of bowel and bladder, had a stage 2 and a stage 4 pressure ulcer not present…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-01-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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, interview and record review the facility did not ensure that parameters of nutritional status were maintained for 2 residents. Specifically, two residents experienced a consistent weight loss since admission to the facility that had not been adequately addressed.(Resident #70 and # 88). The findings are: 1. Resident #88 was admitted to the facility on [DATE] for short term rehabilitation. His current diagnoses included Traumatic Subdural Hemorrhage (following a fall at home), Unsteady Gait and History of Transient Ischemic Attacks. The resident was observed eating his lunch on 1/14/19 at 12:03 PM. He ate half or less of the lunch meal. The Minimum Data Set (MDS- a resident assessment tool) dated 12/13/18 indicated the resident's weight was 167 lbs and his height was 71 inches at the time of the assessment. There was no identified significant weight loss in the past 1-6 months and the resident was receiving a mechanical soft, therapeutic diet. The Brief Interview for Mental status score 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.
- Potential for harm · Dcited before2019-01-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview conducted during the recertification survey, the facility did not ensure that the staff followed proper hand hygiene during meals. The findings are: During meal observation on 1/14/19 at 12:45 PM in the Unit three dining room. The Certified Nursing Assistant (CNA #1) was assisting Resident #24 during the lunch meal. CNA #1 touched the hands of resident #24 and then picked up her spoon handing it back to her and touching her plate. After assisting Resident #24 she then proceeded to assist Resident #28 by picking up his spoon and directing it towards his mouth. During the same meal observation on 1/14/19 at 12:54 PM CNA #1 was feeding Resident #75. She then approached Resident #24 opened a container of apple juice and handed it to Resident #24. At no time during this observation did CNA #1 perform hand hygiene. An interview was conducted on 1/17/19 at 3:09 PM via telephone with CNA #1 and she stated she had made a mistake and should have washed her hands. She added she just wanted to help the residents and she knew she should wash her hands between…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2019-01-18 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews conducted during the most recent recertification survey, the facility did not ensure that floors in multiple resident rooms and in hallways on 2 of 2 units ( rooms 202, 203, 204, 206, 207, 208, 210, 211, 301, 309, 311, 314, 317, 318, 321 and 325 were maintained in a clean and homelike manner. The findings include but are not limited to the following: During inspections of resident rooms on 1/14/19 and 1/15/19 floors in multiple residents room on both units (second and third floors) were noted to be either soiled, exhibited multiple streaks and/or dullness. A closer inspection on 1/17/19 in the morning and afternoon revealed these rooms to include but not limited to the following: Unit 2/second floor - 202, 203, 204, 206, 207, 208, 210 and 211. Unit 3/third floor - 301, 309, 311, 314, 317, 318, 321 and 325. The hallway floors on both units were dull throughout the duration of the survey from 1/14/19 to 1/18/19. The Director of Environmental Services was interviewed on 1/17/19 at 11:20 AM. He stated that he had been at the facility for the past six…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$139,425 in federal fines across 1 penalty.
- $139,425 — penalty dated 2024-08-28
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CARERITE CENTERS — 34 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 33 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EINHORN, SHARON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | 43% | since 04/01/2016 |
| FRIEDMAN, DEVORAH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | 43% | since 04/01/2016 |
| SHUR, SHAINDL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2016 |
| SALEM, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/17/2024 |
| STOJADINOVIC, BILJANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/10/2020 |
| UNTERREINER, SARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/05/2005 |
| ZUCKER, YOSSIE | Individual | ADP OF THE SNF | — | since 04/01/2016 |
CMS files one row per role, so the 12 rows in the source record cover these 7 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.
This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335003. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-08, 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 →
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