King Street Home Inc
787 King Street, Port Chester, NY 10573 · For profit - Corporation · 120 certified beds · (914) 937-5800 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (30) — 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)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — 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 | 4 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.
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 | 17.2% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.0% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 1.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 8.8% | 19.5% | 6.5% | better 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 | 2.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.7% | 12.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 12.1% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 73.5% | 95.3% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.4% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 5.9% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.4% | 13.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 64.4% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 31.3% | 20.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.3% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.90 | 1.70 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.88 | 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.
69.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 833 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 325 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 0.87 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 56% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 69.4%CMS range 65.6–72.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.4%CMS range 10.4–14.8 | 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 | 72.3% | 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 | 67.1% | 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 | 71.1% | 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 | 90.8% | 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 | 97.9% | 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 | 1.3% | 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 | 0.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 5.6–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 120 beds and averages 65.2 residents a day — about 54% occupied, or roughly 55 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.06 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 3.35 is at or above 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 4.98 hrs/resident/day on weekends vs 5.10 on weekdays — 2% thinner on weekends. RN hours go from 0.92 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Ecited before2026-03-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a recertification survey from 3/23/26 - 3/30/26, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, during a Norovirus (very contagious stomach virus that causes nausea, vomiting and diarrhea) outbreak on 4/11/2025, the facility did not ensure an infection surveillance plan based on facility assessment was implemented for the identification, containment and prevention of infections and did not complete and submit a Nosocomial Outbreak Reporting Application ([NAME]) report as requested by the New York State Department of Health (NYSDOH) on 04/16/2025; and 2) the facility's infection control line list was incomplete and did not document signs and symptoms of infection, diagnostic tests/laboratory results, precautions used and outbreak potential.The findings included: The policy titled Routine Infection Control…
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 · D2026-03-30 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification and abbreviated (2564447) surveys conducted 03/23/2026 - 03/30/2026, the facility did not ensure an appropriate discharge plan for one (1) of three (3) residents (Resident #30) reviewed for discharge. Specifically, Resident #30 was sent to the hospital for a medical condition and provided a discharge notice while hospitalized . The discharge was appealed, and the resident was not accepted back to the facility when medically cleared to return to the facility. Findings included:A facility policy titled Discharge reviewed 1/2026 documented it is the policy of facility that each resident has the right to remain in the facility and not transfer or discharge a resident unless a transfer or discharge from the facility is: the resident/family/representative request, necessary for the resident's welfare and the resident's needs cannot be met in the facility; the resident/patient requires immediate transfer or discharge based on 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 · D2026-03-30 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the recertification survey from 03/23/2026 to 03/30/2026, the facility did not ensure that a copy of the notice of transfer or discharge was sent to the State Long Term Care Ombudsman for one (1) of three (3) residents (Resident #30) reviewed for Hospitalization. Specifically, there was no documented evidence that a notice of transfer was sent to the New York State Ombudsman when Resident #30 was sent to the hospital on June 20, 2025. The findings included:Resident #30's diagnoses included vascular dementia with other behavioral disturbance, other sequelae of cerebral infarction, constipation, and atrial fibrillation.The quarterly Minimum Data Set, dated [DATE] documented Resident #30 had short- and long-term memory problems, had verbal and physical behavior symptoms towards others and was dependent for toileting and transfers. A nursing progress note dated 06/20/2026 at 3:59 AM documented Resident #30 was transferred to the hospital via ambulance.During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-18 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 record review and interview during an abbreviated survey (NY00354758), the facility did not ensure residents were free from significant medication errors for 2 out of 3 residents (Resident #3, Resident #8) reviewed for medication. Specifically, (1) during Resident #3's discharge instruction on their medications with Registered Nurse #1 on 9/16/2024, their family representative alerted Registered Nurse #1 that two medications: Lexapro (an antidepressant) and Seroquel/Quetiapine Fumarate(anti-psychotic) were prescribed to the resident in error because the resident was never on those medications. Resident #3 had received the antidepressant (Lexapro 10 mg) from 9/4/2024 to 9/16/2024. Resident #3 also received the anti-psychotic (Seroquel 50 daily at bedtime) from 9/5/2024 to 9/16/2024; (2) Resident #8 who was receiving an antipsychotic (Seroquel 25mg x2 daily) had a psychiatry consult on 9/4/2024 and was ordered for their antipsychotic to change to Seroquel 50 mg daily at bedtime. The change was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-18 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews during an abbreviated survey (NY00349278), the facility did not ensure the resident's legal representative was provided with a copy of the resident's medical records upon request and 2 working days advance notice to the facility for 1 out of 3 residents (Resident #1) reviewed for medical records. Specifically, Resident #1's legal representatives requested the medical records for Resident #1 via email to the facility administrative coordinator on 8/23/2024. Resident #1's legal representative did not receive requested medical records until 9/10/2024, twelve days after the request was received by the facility. In addition, review of the facility policy revealed it did not meet federal regulations The findings are: The facility Access to Medical Records policy last reviewed January 2024 documented it is the policy to only allow the resident and/or legal representatives access to his/her medical records. All other requests to view a resident's medical record will be declined unless legal documentation is obtained, or a representative of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-18 · tag F0575 — isolatedPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations and interviews during an abbreviated survey (NY00349278) the facility did not ensure postings were in a form and manner accessible and understandable to residents, resident representatives a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation. Specifically, during the on-site visit there were no posting of the information above observed throughout the facility, accessible to residents or resident representatives. The findings are: During an observation 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 · D2025-04-18 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during an abbreviated survey (NY00349278), the facility did not ensure the results of the facilities most recent New York State Department of Health survey were posted in a place readily accessible to residents, and family/legal representatives of residents. The facility also did not have a posted notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Specifically, the surveyor did not observe any results posted anywhere in the facility regarding the most recent survey conducted by the New York State Department of Health. The findings are: The facility Posting Survey Information policy last reviewed August 2024 documented it is the policy to comply with New York State Department of Health regulations by posting the results of the most recent Certification Survey in a location that is readily accessible to residents, their families, and other interested parties. Review of the visitor sign in logbook revealed a stack of visitor log in forms separated by a tab that stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-18 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 an abbreviated survey (NY00349278), the facility did not ensure the residents right to personal privacy and confidentiality of his or her personal and medical records for 1 out of 3 residents (Resident #5) reviewed for confidentiality. Specifically, on 1/14/2025 Resident #1's representative requested medical records which they forwarded to Resident #1's physician. Resident #1's representative was informed by Resident #1's physician's office that they had received medical records for Resident #5 instead of Resident #1. The Administrative Coordinator stated Resident #5's care plans were sent to the physician office in error. The findings are: The facility undated Resident's [NAME] of Rights policy documented it is the policy that each resident is treated with consideration, respect and in full recognition of his/her dignity and individuality, including privacy. Each resident shall enjoy the right to confidential treatment of personal and medical records. 1) Resident #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-18 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during an abbreviated survey (NY00349278, NY00364670) , the facility did not ensure residents/resident representatives were notified through postings in prominent locations throughout the facility of the right to file grievances orally or in writing; the contact information of the grievance official with whom a grievance can be filed, a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency or protection and advocacy system; or ensuring that all written grievance decisions include a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 out of 4…
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 before2025-04-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 an abbreviated survey (NY00349278) the facility did not ensure the Minimum Data Set assessment accurately reflected the resident's status for 1 out of 4 residents (Resident #1) reviewed for assessments. Specifically, review of Resident #1's Minimum Data Set assessments dated 8/21/2024, 9/30/2024 and 12/17/2024 revealed discrepancies regarding the resident's extremity impairments, use of assistive devices and functional abilities. The Findings are: The Facility Completion of the Resident Assessment Instrument (RAI) Process policy last reviewed January 2024 documented the policy assures that all residents achieve their highest level of functioning possible in maintaining their sense of individuality. Assessments will be completed within the guidelines outlined in the Resident Assessment Instrument Manual and include the Care Area Assessment and care planning processes to lead to the development of a plan of care to address and monitor each residents needs and function,…
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 20 citations
- Potential for harm · Dcited before2025-04-18 · 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 an abbreviated survey (NY00364670), the facility did not ensure a comprehensive person-centered care plan was implemented for 1 out of 3 residents (Resident #2) reviewed for care planning. Specifically, on 11/16/2024 Resident #4 was diagnosed with pneumonia and was ordered to start on antibiotic and oxygen therapy. Review of Resident #2's care plans revealed there were no care plans initiated for pneumonia, antibiotic use or oxygen use. The findings are: The facility Care Plan Development and Implementation policy last reviewed 5/2023 documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of each resident are ongoing, and care plans are revised as information about the residents' conditions change. Resident #2 was admitted with diagnoses including but not limited to Difficulty in walking,…
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 before2025-04-18 · 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 Based on record review and interviews during an abbreviated survey (NY00349278), the facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 out of 4 residents (Resident #1) reviewed for care planning. Specifically, Resident #1's comprehensive care plans for medication refusals, physical aggression, social needs and nutritional problems were not reviewed and revised with the quarterly Minimum Data Set completed on 12/17/2024. The Findings are: The facility Care Plan Development and Implementation policy last reviewed 5/2023 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-11 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during the recertification survey from 1/4/24 to 1/11/24, the facility did not ensure residents were free from physical restraints for 7 of 7 residents (#15, #7, #17, #40, #49, #226, #227) reviewed for physical restraints. Specifically, Residents #15, #7, #17, #40, #49, #226, and #227 were observed with bed or chair alarms and (1) thorough assessments and re-evaluations were not conducted to address the use of alarms, (2) the physician's order was not obtained to address the medical symptoms that may warrant the use of the device, and (3) there was no evidence of consent for the use of the device. Findings include: The facility policy dated November 2023, 'Use of Safety Alarms', documented it is the policy of the facility that the safety of the residents be enhanced by the use of personal safety alarms. All residents using personal alarms will be identified on Certified Nurse Aide accountability care records, alarms will be checked every shift to ensure…
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 · E2024-01-11 · 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
Based on observation, record review and interviews conducted during the Recertification survey from 1/4/24 to 1/11/24, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1) opened, undated, unlabeled, and/or expired foods were stored in two (2) refrigerated units and one (1) freezer unit; and 2) the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than required by the manufacturer to ensure sanitization of food preparation and service equipment. The findings are: A facility policy dated 5/2023 and titled Food storage and labeling policy, documented that food is stored at a safe temperature, and for safe lengths of time. The policy section titled Labeling documented that foods must be used by, on, or before the expiration dates; containers are clearly marked with a use by date, and to keep a constant check on dating and labeling of food products. A facility policy dated November 2023 and titled Manual Pot Washing - Three Compartment…
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 · D2024-01-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the Recertification survey from 1/4/24 to 1/11/24, the facility did not ensure did not ensure that the call bell system was accessible for 1 of 1 residents (Resident #7) reviewed for Accidents. Specifically, Resident #7, who had a history of falls and was assessed to be at high risk for falls, was observed without their call bell within reach as per their plan of care. Findings include: The facility policy reviewed 5/23, 'Fall Risk Assessment and Fall Prevention', documented to institute a preventative plan of care for any resident assessed as at risk for falls, and each resident must have an individual plan considering risk factors, functional status, cognitive status, and how the plan of care will affect the quality of life. Interventions included but were not limited to; call bell within reach for low risk, and scheduled monitoring/move resident closer to the nurse's station for high risk. Resident #7 was admitted with diagnoses which included anxiety,…
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 before2024-01-11 · tag F0625 — isolatedNotify 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification survey from 1/4/24 to 1/11/24, the facility did not ensure for 1 of 3 residents reviewed for hospitalization (Resident #43) that the resident or the resident's representative was given a timely written notice of the facility's bed hold policy upon transfer to the hospital. Specifically, Resident #43 was transferred to the hospital and the facility could not provide evidence that a written notice of the facility Bed Hold Policy was provided to the resident or the resident's representatives. Findings include: Resident #43 had diagnoses including cerebrovascular accident, dysphagia, and hemiplegia/hemiparesis. The quarterly Minimum Data Set assessment dated [DATE] documented the resident's cognition was moderately impaired for decision making. Nursing notes documented on 12/1/2023 at 7:37PM resident was transferred to the hospital emergency room accompanied by their daughter in law. There was no documented evidence in the resident's record…
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 before2024-01-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 1/4/24 to 1/11/24, the facility did not ensure that resident Minimum Data Set assessments (MDS-an assessment tool) accurately reflected the resident's status. This was evident for 7 of 7 residents (Residents #7, #17, #21, #227, #15, #40, #49) reviewed for Minimum Data Set accuracy. Specifically, 1) the Minimum Data Set assessments for Residents #7, #17, #227, #15, #40, and #49 documented alarms not used although alarms were observed in use and were documented on the Certified Nurse Aide Care Guides for the residents, and 2) the Minimum Data Set assessment for Resident # 21 documented the presence of one or more pressure ulcer/injury but documented the current number of unhealed pressure ulcers/injuries at each stage as zero. Findings include: The Minimum Data Set directions documented for 'Minimum Data Set Section P-Restraints and Alarms, section P 0200 Alarms' documented, 'An alarm is any physical or electronic…
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 · D2024-01-11 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the Recertification survey from 1/4/24 to 1/11/24, the facility did not ensure Preadmission Screening (SCREEN) was complete for 2 of of 24 (Residents #220 and #224) residents reviewed. Specifically, for Residents #220 and #224, the facility did not ensure the SCREEN form DOH-695 included answers to the questions regarding Mental Retardation/Developmental Disability. The findings are: The facility policy dated May 2023 'PASRR-Pre-admission Screen' included documentation that it was the policy of the facility that all residents have the required screen prior to admission to the facility. Prior to a resident's admission, the policy included that the Admissions Department/designee will obtain a screen and Level l referral, and a Level ll screen if indicated. 1. Resident #220 was admitted to the facility with diagnoses including trauma subdural hematoma without loss of consciousness, insomnia, and spinal stenosis. The Minimum Data Set (MDS- an…
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 before2024-01-11 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the Recertification survey from 1/4/24 to 1/11/24, the facility did not ensure for 2 of 3 residents (#15, #43), reviewed for care planning, that each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. Specifically, Residents #15 and #43's resident representatives expressed interest in attending care planning meetings and reported they had not been invited for six months and one year, respectively. The findings are: 1) Resident #15 was admitted with fractures of the left wrist and left femur, autonomic neuropathy, major depressive disorder, and history of falls. A significant change Minimum Date Set (MDS-an assessment tool) dated 9/5/2023 documented Resident #15 had severely impaired cognition for decision making. On 1/05/24 at 10:14 AM during an interview of the resident's representative, they stated that they get a phone call to schedule care planning…
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 · D2024-01-11 · tag F0730 — isolatedObserve 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 records during the Recertification survey from 1/4/2024 to 1/11/2024, the facility did not ensure certified nurse aides (CNAs) performance reviews were completed at least once every 12 months. Specifically, six of ten randomly selected CNAs (staff #22, #23, #24, #27, #28, #30) did not have a performance reviews documented at least once every 12 months. Findings include: Certified Nurse Aides #22, #24, #27, #28, and #30 last performance evaluations were not available. Certified Nurse Aide #23's last performance evaluation was completed on 11/4/2020. Review of Certified Nurse Aides #22, #23, #24, #27, #28, and #30 hire dates, provided by the facility, revealed all six of the Certified Nurse Aides had been working at the facility for more than one year. During an interview on 1/10/2024 at 9:15 AM, the Administrator stated they had not completed performance reviews for the Certified Nurse Aides since the COVID pandemic. The Administrator stated they used to complete them and stated they would complete them in the near future. During 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.
- Potential for harm · D2020-11-12 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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, observations and interviews during a Recertification Survey, it could not be ensured that the facility promoted the right to participate in the development and implementation of person-centered plans of care, including but not limited to the right to participate in the planning process and attend care planning meetings. This was evident for 1 of 2 residents (Residents #13) reviewed for care planning. Specifically, Resident #13 has not participated in the planning process and has not participated in a care planning meeting. The findings are: Resident #13 was admitted on [DATE] with diagnoses including Systemic Sclerosis, Bilateral Above Knee Amputations and Atrial Fibrillation. The Minimum Data Set (MDS; a resident assessment tool) dated 5/20/2020 indicates that Resident #13 is cognitively intact and transferred with supervision and assistance from one staff for set up only. A significant change made was reflected in the 8/15/2020 MDS indicating that Resident #13 needed extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-11-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews during the Recertification Survey, it could not be ensured that the facility consistently implemented Comprehensive Person-Centered Care Plan (CCP) for each resident. This was evident for 1 of 1 resident (Resident #28) reviewed for accidents and 1 of 3 residents reviewed for Pressure Ulcers (PUs). Specifically, 1) Resident #28 was not consistently monitored at 15-minutes intervals for 9 of 11 days reviewed and, 2) Resident #28 was observed without the chair alarm in place and 3) Resident #38 did not have a CP in place to address a stage 4 PU. The findings are: An undated facility Policy and Procedure (P/P) titled Fall Risk Assessment and Fall Prevention indicated that residents assessed to be at risk for falls are to have a preventive CCP in place. Suggested possible interventions included increased monitoring and movement alarms. Resident #28 was hospitalized following a fall on 9/3/2020 and subsequently readmitted on [DATE] with diagnoses including Fractured…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2018-11-21 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during a recertification survey, the facility did not ensure that it completed a risk assessment or that its potable water system was tested, as required by public health laws and regulations, to determine the presence of Legionella and/or other opportunistic waterborne pathogens, that could grow and spread in the facility's water system and affect the health of the residents, staff, and visitors. Legionella can cause a serious type of pneumonia in persons at risk. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including long-term care facilities. The Public Health Law Section 225(5)(a) Subpart 4-2.4 Sampling and Management Plan states that all covered facilities shall adopt and implement a Legionella culture sampling and management plan for their potable water systems. The findings are: The Director of Maintenance (DM) was interviewed on 11/21/18 at 2:15 PM to discuss Legionella water management plan,…
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 before2018-11-21 · 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 observation interview and record review conducted during a recertification survey, the facility did not ensure for 1 of 1 resident (#54) reviewed for tube feeding that the necessary care was provided to ensure sufficient fluid intake in accordance with the physician's order for this resident assessed as at risk for fluid and electrolyte imbalance and ensure that the resident received the prescribed amount of feeding. The findings are: Resident #54 was admitted to the facility on [DATE] with diagnoses that include dysphagia, unspecified atrial fibrilation and hypertension. The admission Minimum Data Set (MDS, a resident assessment and screening tool) of 10/26/18 revealed that the resident was fed via a feeding tube. The November 2018 physician's orders revealed that the resident was to receive via feeding tube the formula Jevity 1.5 for 20 hours from 2:00 PM until 10:00 AM via pump at 65 ml/hour. At this infusion rate, the resident is scheduled to receive a total of 1300ml of enteral feeding. Observation…
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 · D2018-11-21 · 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 most recent recertification survey, the facility did not ensure that 1 of 3 residents ( #13) reviewed for bowel regularity was provided the appropriate treatment based on comprehensive person-centered care plan. Specifically, the facility did not consistently implement the plan of care as it related to monitoring and recording the frequency of the resident's bowel movements (BM) and did not implement the physician's orders (or bowel protocol) as written consistently to ensure bowel regularity. The finding is: Resident #13 has diagnoses of Dementia and Depression. The admission Minimum Data Set (a resident assessment tool) of 8/10/18 documented that the resident has severely impaired cognitive skills for daily decision making; was totally dependent on two persons for assistance with toilet use and personal hygiene; and was always incontinent of bowel (no episodes of continent bowel movements). The physician orders since August 2018 included Senna 8.6 mg at bed time and Docusate 200 mg (both stool softeners) for constipation.…
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 · D2018-11-21 · 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 interview and record review conducted during a recertification survey, the facility did not ensure that each medication prescribed for 1 of 5 residents (#7) reviewed for unnecessary medications continued to be necessary. Specifically, the nursing staff did not promptly inform the resident's physician of potential adverse effects of two medications in order for the physician to determine if the medications should be continued or reduced. The finding is: Resident #7 has diagnoses of Dementia, Congestive Heart Failure (CHF), and Diabetes Mellitus. The November 2018 physician's orders included Divalproex (Depakote) 125 mg daily for mood disorder and Furosemide (Lasix; a diuretic) 80 mg daily for CHF. The care plan for hydration dated 11/15/18 noted that the resident had the potential for fluid deficit related to diuretic use. The goal was for the resident to be free of signs and symptoms of dehydration. The interventions to achieve this goal included to administer medications as ordered; monitor/ document for side effects and effectiveness; obtain and monitor laboratory (lab)…
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 · D2018-11-21 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 observation, interview and record review conducted during a recent recertification survey, the facility did not ensure that its medication error rate did not exceed 5%. This was evident for 2 of 4 residents (# 334 and # 335) observed during a medication pass, for a total of 2 out of 27 opportunities for error resulting in an error rate of 7.4%. The findings are: 1. Resident # 334 has diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, and Diabetes. A medication pass observation was conducted on 11/20/18 at 9:42 AM. Licensed Practical Nurse (LPN #1) administered Symbicort Aerosol 160-4.5mcg, 2 inhalations orally, along with other morning medications. LPN #1 gave the resident the metered dose medication to administer by herself without providing instructions to the resident on the number of inhalations (puffs) to be taken. The resident demonstrated she could take the medication and took two inhalations orally. Review of the Physician Order form dated 11/3/18 revealed the resident should have received Symbicort Aerosol 160-4.5mcg one 1 inhalation orally…
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 before2020-11-12 · tag F0623 — patternProvide 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 record reviews and interviews conducted during a Recertification Survey, it could not be ensured that the facility provided timely written notification of a transfer in a language and manner they could understand to a resident or their representative/s. This was evident for 1 of 2 residents reviewed for hospitalization. Review of the facility's Transfer and Discharge policy which was updated in June 2020 documented that before the facility transfers or discharges a resident, the facility will provide written notice to the resident and/or their representative/s in a manner and language in which they can understand. The finding is: Resident #48 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Fracture of Nasal Bones, Muscle Weakness and Atrial Fibrillation. The admission Minimum Data Set (MDS; a resident assessment tool) dated 9/27/2020 indicated that Resident #48 was severely cognitively impaired and needed extensive assistance with bed transfers, dressing, tray 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.
- No harm found · Bcited before2020-11-12 · tag F0625 — patternNotify 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews conducted during a Recertification Survey, it could not be ensured that the facility provided written notice of the facility's Bed Hold policy to residents and their representative/s at the time of transfer. This was evident for 1 of 2 residents (Resident #48) reviewed for admission/transfer/discharge. The facility policy for Bed Holds and Returns, revised June 2020 states that prior to transfers and therapeutic leaves, residents or residents' representative/s will be informed in writing of the Bed Hold and Return policy. The finding is: Resident #48 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Fracture of Nasal Bones, Muscle Weakness and Atrial Fibrillation. The admission Minimum Data Set (MDS; a resident assessment tool) dated 9/27/2020 indicated that Resident #48 was severely cognitively impaired and needed extensive assistance with bed transfers, dressing, tray set up and supervision with meals. Review of the Physician'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.
- No harm found · Bcited before2018-11-21 · tag F0623 — patternProvide 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 record review and interview conducted during a recertification survey, the facility did not ensure for 2 of 2 residents (#32 and #59) reviewed for hospitalization that residents or their representatives received written notice of discharge and the reason for transfer for the move in a language and manner they understood. Specifically, the facility did not ensure that written notifications of discharge were provided to the residents and/or their representives. Additionally, the facility did not ensure that a copy of discharge notice was sent to the Office of the State Long-Term Care Ombudsman. The findings are: 1. Resident # 59 has diagnoses and conditions including Fractures and other multiple trauma, Coronary Artery Disease, and Chronic Obstructive Pulmonary Disease. The admission Minimum Data Set (MDS; an assessment tool) dated 10/22/18, revealed the resident had a BIMS score of 15 out of 15 (Brief Interview for Mental Status; used to measure orientation and memory) which suggested that the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LOGAN, JOAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 50% | since 01/22/2025 |
| WILNER, ROBERT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 50% | since 01/22/2025 |
| BORZYKOWSKI, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/19/2025 |
| RIDDLE, ALBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2013 |
CMS files one row per role, so the 10 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $144K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 335447. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-01-11, 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.