Waters Edge at Port Jefferson for Rehabilitation a
150 Dark Hollow Road, Port Jefferson, NY 11777 · For profit - Limited Liability company · 120 certified beds · (631) 473-5400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $153,911 in federal fines (most recent 2025-08-11)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- about 22% 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 15.3% | 14.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 10.9% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.4% | 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 | 9.2% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.9% | 13.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.4% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.8% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.0% | 19.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.1% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 80.0% | 78.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.0% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.2% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.88 | 1.70 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.86 | 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.
58.0% 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 318 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.3% 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 176 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 58.0%CMS range 52.1–63.2 | 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 | 13.6%CMS range 10.8–16.7 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 65.3% | 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 | 65.3% | 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 | 66.5% | 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 | 100.0% | 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 | 99.2% | 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 | 1.6% | 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 | 3.5% | 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 | 7.9%CMS range 5.3–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.34 | 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 115.0 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 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 2.71 hrs/resident/day on weekends vs 3.04 on weekdays — 11% thinner on weekends. RN hours go from 0.57 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · K2025-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
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 initiated on 07/21/2025 and completed on 08/11/2025, the facility failed to ensure that a resident requiring respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for two (2) (Resident #74 and Resident #119) of four (4) residents reviewed for Respiratory Care. Specifically, Resident #74 with a diagnosis of Chronic Obstructive Pulmonary Disease had a physician's order for supplemental oxygen and did not receive it. On 07/25/2025, the resident was in respiratory distress and was utilizing accessory muscles, appeared pale with gray lips, and verbalized I need air. Licensed Practical Nurse #4 stated the resident's breathing difficulty was due to a panic attack and that the resident was exaggerating; and they would administer Xanax (an antianxiety medication) when available. Licensed…
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.
- Immediate jeopardy · Jcited beforedisputed · IDR2025-02-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and closed record reviews , during an abbreviated survey (NY00370917), the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice for one (1) out of three (3) residents. Specifically, on [DATE] at 8:01 PM, Resident #2 was evaluated for symptoms including fever and tachycardia. Nurse Practitioner #1 was notified on [DATE] at 6:30 PM of critical lab values and ordered to send Resident #2 to the hospital for an emergent blood transfusion. Registered Nurse Supervisor #1 documented Resident #2 would be sent to the hospital in the morning. Subsequently, on [DATE] at 1:20 AM, Resident #2 was found to be unresponsive, pulseless, and without respirations. Resident #2 expired at 2:01 AM. This resulted in Immediate Jeopardy with the likelihood for serious injury, serious harm, or death for all residents. Findings include: The facility policy titled Health Care Providers Services dated [DATE] documented (3) The health care providers…
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 · E2025-08-11 · 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, interviews, and record review conducted during the Recertification Survey, initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen Task observation. Specifically, 1) the walk-in freezer, the storage shelf in the kitchen, and the two-door reach-in freezer had one opened and undated food or food packages. 2) The cooked poultry meal temperatures were not maintained within the required range (above 135 degrees).The findings are:The facility's policy titled Food Storage documented that food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. Food should be dated as it is placed on the shelves. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-11 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, during the re-certification survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for two (2) (Resident #74 and Resident #119) of (4) four residents reviewed for Respiratory care. Specifically, the facility was not effectively administered to ensure two (2) (Resident #74 and Resident #119) of (4) four residents were monitored for respiratory care. On 07/25/2025 and 07/28/2025, Resident #74 was observed without Oxygen in their portable Oxygen tank, and on 08/08/2025, Resident # 119 was observed without oxygen in their portable Oxygen tank. Additionally, the facility policy did not provide guidance related to monitoring and handling the portable oxygen tanks to ensure residents were not left without supplemental…
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 · D2025-08-11 · 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 observations, record reviews, and staff interviews, during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that each resident had the right to receive services in the facility with reasonable accommodation of resident needs and preferences. This was identified for one (Resident #40) of seven residents reviewed for Activities of Daily Living. Specifically, during the Resident Council meeting on 07/21/2025, Resident # 40 stated they were not getting their showers as per their preference. A review of the record documented that Resident # 40 was receiving bed baths and not receiving showers as per the resident's care plan and preference.Finding is:The facility's policy and procedure for Bathing and Shower, revised on 2/14/2025, documented that the purpose of this procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin.Resident # 40 was admitted with diagnoses including Multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-11 · 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 observations, record reviews, and staff interviews, during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for two (Resident # 74 and Resident #119) of four residents during the Respiratory Care. Specifically, Licensed Practical Nurse #4 did not provide respiratory care to Resident #74 when the resident's oxygen tank was observed to be empty. The resident complained of difficulty breathing. Licensed Practical Nurse #4 dismissed the resident's complaint as a panic attack and that the resident was exaggerating their distress and proceeded to complete the medication administration to other residents. Licensed Practical Nurse #4 did not evaluate the resident until the surveyor and the Director of Nursing Services intervened. Additionally, the ancillary staff were observed changing the residents' oxygen tanks and did not notify…
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 · D2025-08-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and staff interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition. This was identified for one (Resident #7) of five residents reviewed for Limited Range of Motion. Specifically, during an observation on 07/22/2025 at 11:20 AM, Resident #7's breakfast tray was observed unopened and untouched on the overbed table. Resident #7 required setup help and was not assisted with their breakfast meal.The finding is: The facility's policy and procedure titled Assisting the Resident With In-Room Meals, revised on 2/14/2025, documented placing the (meal) tray on the overbed table or serving area. Be sure it is adjusted to a comfortable position and height for the resident. Arrange the dishes and silverware so that they can be easily reached by the resident. Place the drinks within easy reach.…
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 before2025-08-11 · 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 observations, record review, and interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/112025, the facility did not ensure that each resident with a Pressure Ulcer or potential for a Pressure Ulcer received the necessary treatment and service consistent with professional standards of practice to promote healing, prevent infections, and prevent new ulcers from developing. This was identified for one (Resident #112) of three residents reviewed for Pressure Ulcers. Specifically, Resident #112, with a history of Stage 4 pressure ulcer, was observed on multiple occasions in bed on an air mattress that was set to 450 pounds and had a history of pressure ulcers and currently weighs 167 pounds. The finding is:The facility's policy titled Low Air Mattress, dated 1/04/2025, documented that low air loss systems are medical devices designed to prevent and manage pressure ulcers by providing air circulation to reduce pressure and moisture on the skin. Clinical staff must document…
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 · D2025-08-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure that all drugs were labeled in accordance with currently accepted professional principles, including the expiration dates. This was identified for one (Resident #66) of seven residents reviewed during medication pass observation, one (2 North medication cart) of two medication carts observed during the medication storage and labelling task, and for one (Resident #83) of three residents reviewed for Accidents. Specifically, 1) during medication pass observation, Resident #66's nebulizer treatment medication, Budesonide Inhalation, was not dated. 2) Unit 2 North medication cart was observed with a souffle cup containing three prepoured unlabeled medication tablets. 3) During an initial screening, Resident #83 was observed with two medication cups with unidentified medications on the overbed table. Resident #83 had moderately impaired cognition and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 07/21/2025 and completed on 08/11/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #112) of one resident reviewed for infection control and one (Resident #19) of seven residents reviewed for Medication Pass Observation. Specifically, Resident #112 had a physician's order for Enhanced Barrier Precautions secondary to the use of an indwelling Foley Catheter. There was no Enhanced Barrier Precaution signage posted outside the resident's door to alert staff and visitors regarding the resident's precaution status. On 07/21/2025, two Certified Nursing Assistants were observed providing personal hygiene care to Resident #112 without wearing the proper Personal Protective Equipment. 2) Licensed Practical Nurse #1 was observed during medication…
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 · E2025-02-21 · 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 observation, interview and record review conducted during an abbreviated survey (NY00370917), the facility did not provide person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being for three of six residents (Resident #2 #3 #5) reviewed for Accidents. Specifically, (1) Resident #2 was identified as high risk for aspiration (choking) and was to be fed via percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that allows nutrition directly through your stomach.) Resident #2 physician orders documented medications to be administered by mouth. (2) Resident #3 was evaluated by speech and deemed to be at risk for aspiration, a physician's order indicated a puree diet. Resident #3 was given a dog biscuit which Resident #3 ate and subsequently began coughing and noted with abnormal lung sounds (stridor). (3) Resident #5 was identified at risk for aspiration, Resident # 5 was evaluated by speech with recommendations for nothing by mouth…
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 · E2025-02-21 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 (NY00370917) the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit and a decision about the continued appropriateness of the resident's current medical regimen for 2 out of 6 residents (Resident #5, #2) reviewed for Quality of Care. Specifically, (1) Resident #2 was admitted to the facility with orders for nothing to be administered by mouth and a feeding tube the facility did not address Resident #2 ability to receive oral medication or include an order for nothing by mouth (NPO) on the admission orders. Additionally, Physician Assistant #1 ordered Tylenol 325mg by mouth every 8 hours and Tamiflu capsules 30mg daily by mouth. (2) Resident #5 was admitted with orders for nothing by mouth with a feeding tube, Resident #5 was evaluated on 1/19/2025 by Physician Assistant #1 with orders including amoxicillin tablet, prednisone tablet and Tamiflu capsules to be administered by…
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 11 citations
- Potential for harm · Dcited before2025-02-21 · 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 Based on record review and interviews during the Abbreviated Survey (NY00370917) the facility did not ensure that each resident's representative was immediately informed when a resident had a change in condition or the potential for change of condition requiring physician intervention. This was identified for one (Resident #1) of six residents reviewed for Quality of Care. Specifically, on 1/26/2025 and 1/27/2025 Resident #1 presented with fever, tachycardia (increased heart rate) hypotension (low blood pressure) and critical lab results including a HGB (hemoglobin) 4.9g/dl (normal range is 13.0-17.0g/dl). The resident's representative was not informed of the change in condition, or the interventions provided. The finding is: The facility's policy titled Change in Condition, last reviewed by the facility on 09/18/2024, documented the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical mental condition and/or status. 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 · Ecited before2025-01-22 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the Abbreviated Survey case #NY00369007 and initiated on 1/21/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. This was identified for six (Resident #1, Resident #2, and Resident #3, Resident #4, Resident #5, and Resident #6) of eighteen residents reviewed for Quality of Care and Treatment. Specifically, 1) Resident #1 had no documented bowel movement for eight consecutive days. 2) Resident #2 had no documented bowel movement for five consecutive days. 3) Resident #3 had no documented bowel movement for five consecutive days. The finding is: The facility's policy titled, Bowel Protocol dated 12/23/2024 documented the nurses shall assess and document/report the following: vital signs, quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount and consistency, etc.); change…
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 · E2024-02-15 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the Recertification and Abbreviated Survey (Complaint # NY00311574, NY00324554, NY00316227, and NY00331727) initiated on 2/07/2024 and completed on 2/15/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified during a review of the Payroll-Based Journal (PBJ) Staffing Data Report; a review of the Facility Assessment; and an observation during the Medication Administration. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report and the Facility Assessment (FA) identified that the facility did not ensure adequate staffing was available to meet the residents' needs on multiple days. Additionally, 2) during the survey medications were administered late due to short staffing on 2/07/2024, 2/09/2024, and 2/14/2024. 3) An anonymous staff member complained…
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 · E2024-02-15 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 observations, record review, and interviews, conducted during the Recertification Survey initiated on 2/07/2024 and completed on 2/15/2024, the facility did not ensure that pharmaceutical services including administration of all medications was provided to meet the needs of all residents. This was identified for four (Resident #35, Resident #164, Resident #15, and Resident# 99) of four residents observed during the medication pass observation. Specifically, 1) Resident #35 did not receive five of the 9:00 AM Physician ordered medications until 10:45 AM on 2/9/2024. 2) Resident #103 did not receive eight of the 9:00 AM Physician ordered medications until 11:00 AM on 2/9/2024, 3) Resident #99 did not receive nine of the 9:00 AM Physician ordered medications until 10:42 AM 2/7/2023. and 4) Resident # 15 did not receive two of the 9:00 AM Physician ordered medications until 10:17 AM on 2/7/2024. The findings include but are not limited to: The Facility's Policy for Administering Medications dated 6/20/2023…
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 · E2024-02-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated 2/07/2024 and completed 2/15/2024 the facility did not ensure that it maintained medical records that are complete and accurately documented in accordance with professional standards of practice. This was identified for 1) one (Resident #77) of three residents reviewed for Hydration, and 2) one (Resident #31) of one resident reviewed for Bladder and Bowel. Specifically, 1) Resident #77, had a Physician's order to check the Peripheral Intravenous Catheter insertion site for redness and infiltration every shift. There was no documented evidence that the Peripheral Intravenous Catheter was assessed for redness and infiltration as per the Physician's order. 2) Resident #31, had a Physician's order to flush the Nephrostomy tube. There was no documented evidence that the Nephrostomy tube was flushed as per the Physician's orders. The findings are: 1) The facility policy titled, Intravenous Administration last reviewed 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 · Ecited before2022-02-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 interviews during the Recertification Survey completed on 2/28/2022 the facility failed to ensure that each resident received care, consistent with professional standard of practice to prevent Pressure Ulcer (PU) development and to promote healing. This was identified for one (Resident #66) of three residents reviewed for PU. Specifically, Resident #66 was admitted with no PUs. The resident utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity. On 12/10/2021 Resident #66 was identified with a PU to the right heel. The facility staff did not consistently conduct weekly assessments. Timely assessments by the Physician were not completed. Resident #66's was identified with skin impairment and was not referred to the wound care team until 18 days after the PU was first identified. The finding is: The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol dated 2/22/2021 documented the nurse shall describe and document a full assessment of a pressure…
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 before2022-02-28 · 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 Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00253069) completed on 2/28/2022, the facility did not ensure that each resident representative was notified timely of a resident's transfer from the facility. This was identified for one (Resident #307) of two residents reviewed for Notification of Change. Specifically, Resident #307 was transferred to the hospital on 2/9/2020 to rule out Gastrointestinal Bleeding, however, there was no documented evidence that the resident's representative was notified of the change in the resident's condition resulting in a transfer to the hospital. The finding is: The facility policy and procedure dated 2/22/2021 for Acute Change in Condition documented nursing staff are responsible to notify the resident representative following the resident's transfer to the hospital. Resident #307 was admitted to the facility with diagnoses that include Essential (Primary) Hypertension, Bladder Neck Obstruction, and Acute Kidney…
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 · D2022-02-28 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00278230) completed on 2/28/2022, the facility did not ensure that a thorough investigation was completed to rule out neglect following a report of an incident. This was identified for one (Resident #303) of two residents reviewed for Accidents. Specifically, Resident #303 was found on the floor of their room on 6/20/2021, however, there was no documentation that an Occurrence Report investigation was completed. The finding is: The facility's policy titled Accident/Incident/Occurrence Reports (Patients/Residents) dated 9/2016 documented that all falls and/or lowered to the floor are to have an Occurrence Report completed for investigation and Quality Assurance (QA) review. Resident #303 was admitted with diagnoses which include Hydrocephalus and Bipolar Disorder. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score…
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 before2022-02-28 · 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, record review, and interviews conducted during the Recertification Survey completed on 2/28/2022 the facility did not ensure that services provided met professional standards. This was identified for one (Resident #17) of 5 residents reviewed for medication administration. Specifically, Licensed Practical Nurse (LPN) #1 administered a crushed Potassium Chloride (supplement) Extended-Release tablet to Resident #17. The Manufacturer's specifications for the Potassium supplement specified that the medication should not be crushed. The finding is: The undated facility policy and procedure for Crushing of Medications documented the Physician should order the crushing of medications. The physician must document the rationale why a medication must be crushed. The Medication Administration Record (MAR) or other documentation must indicate why it was necessary to crush the medication. Resident #17 was admitted with diagnoses of Depression and Hypertension. The Minimum Data Set (MDS) 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 · D2022-02-28 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's 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 review and interviews during the Recertification Survey completed on 2/28/2022, the facility did not ensure that the medical care of each resident was supervised by a Physician. This was identified for one (Resident #66) of three residents reviewed for Pressure Ulcer (PU). Specifically, Resident #66 utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity due to paralysis. On 12/10/21 the resident was identified with an open area to the right heel and there was no documented evidence that the resident's change in skin condition was evaluated or addressed by the attending Physician until 1/7/2022 after the wound had declined to a Stage 3 pressure ulcer. Additionally, there was no documented evidence in the Physician's monthly notes that the progress of the wound was monitored by the attending Physician. The finding is: The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol dated 2/22/2021 documented that during resident visits, the Physician will evaluate and document 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.
- No harm found · B2022-02-28 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of 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 staff interviews during the Recertification Survey completed on [DATE], the facility did not ensure that Minimum Data Set (MDS) assessment was encoded and transmitted timely for each resident including a subset of items upon a residents' transfer, reentry, discharge and or death. This was identified for one (Resident #1) of one resident reviewed for the Resident Assessment Task. Specifically, after Resident #1 expired on [DATE] there was no documented evidence that the MDS was encoded and transmitted to the Centers for Medicare & Medicaid Services (CMS) System. The finding is: Resident #1 was admitted with diagnoses including Hypertension, Chronic Obstructive Pulmonary Disease, and Compression Fracture of T5-T6 Vertebrae. The Entry MDS assessment dated [DATE] was in place and documented accepted in the CMS System. The admission MDS assessment dated [DATE] was in place and documented accepted in the CMS System. The MDS with an assessment reference date of [DATE] documented 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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
$153,911 in federal fines across 1 penalty.
- $153,911 — penalty dated 2025-08-11
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 | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 2.8 | -1.8 vs chain |
| Staffing | 1 of 5 | 2.2 | -1.2 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, NEAL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | 44% | since 08/10/2017 |
| FRIEDMAN, MARK | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | 44% | since 08/10/2017 |
| RUDNER, AKIVA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/10/2017 |
| SAX, STEVEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/10/2017 |
| MANDELBAUM, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/24/2025 |
| MARCENA, NADGEFFRENA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/17/2024 |
| WHANG, SUNG | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| ZUCKER, YOSSIE | Individual | ADP OF THE SNF | — | since 08/22/2017 |
CMS files one row per role, so the 13 rows in the source record cover these 8 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 $4.4M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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 335410. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-11, 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.