Sunharbor Manor
255 Warner Avenue, Roslyn Heights, NY 11577 · For profit - Limited Liability company · 266 certified beds · (516) 621-5400 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- 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
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its 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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.8% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.6% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 4.1% | 1.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 47.4% | 19.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.8% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.3% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.2% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.9% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.2% | 19.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.0% | 78.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.7% | 20.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.0% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.16 | 1.70 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.41 | 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.
38.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 522 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.2% 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 245 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 38.2%CMS range 33.8–42.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.7–13.1 | 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 | 70.2% | 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 | 68.6% | 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 | 68.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.3% | 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 | 99.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 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 | 3.2% | 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 | 9.6%CMS range 6.7–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.41 | 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 266 beds and averages 255.0 residents a day — about 96% occupied, or roughly 11 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.12 hrs/resident/day on weekends vs 3.58 on weekdays — 13% thinner on weekends. RN hours go from 0.56 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Dcited before2024-03-21 · 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
Based on observation, record review, and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (Resident #246) of three residents reviewed for pain management. Specifically, Resident # 246 had a physician's order for a Lidocaine (a medication used to treat pain) patch to be applied to the resident's lumbar area (lower back). On 3/15/2024 during the medication pass observation, the medication nurse applied a Menthol patch to the resident's lower back instead of the Lidocaine patch. The finding is: The facility's policy titled Medication Administration, last revised 5/2023, documented that medication shall be administered as prescribed by the attending physician. Medication must be administered in accordance with the written orders of the attending physician. Prior to administering 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 · D2024-03-21 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint # NY 00320409) initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that they developed and implemented an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition the resident to post-discharge care. This was identified for one (Resident #466) of one resident reviewed for Discharge. Specifically, Resident #466 was discharged from the facility on 7/17/2023 with no confirmation of acceptance from a Home Care Agency. On 7/18/2023 the referred Home Care Agency denied Home Healthcare Services for Resident #466. Consequently, Resident #466 did not receive acceptance for Home Healthcare Services until 7/25/2023, eight days after they were discharged from the facility. The finding is: The facility policy titled, Discharge Plan dated 11/2017 documented the post-discharge plan will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
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 on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. This was identified for one (Resident #155) of four residents reviewed for communication. Specifically, Resident #155 required hearing aid devices for both ears. Resident #155 lost the left ear hearing aid. The resident had multiple physician orders on 1/18/2024, 1/23/2024, 2/03/2024, 2/20/2024, 3/11/2024, and 3/19/2024 for an Audiology Consult. The Audiology appointment was not confirmed until 3/19/2024, two months after the first physician's order was written. The finding is: Resident #155 was admitted with diagnoses that included Type 2 Diabetes, Hypertension, and Congestive Heart Failure. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15 which indicated the resident had intact…
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 · D2024-03-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observations, interviews, and record review during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for two (Resident #240 and Resident #101) of seven residents reviewed for Accidents. Specifically, 1) on 3/15/2024 Resident #240 was observed unsupervised outside of the building on the front sidewalk in the facility's designated smoking area. The resident was smoking but was not one of the residents that had been assessed and determined to be a safe smoker. The facility was not aware the resident had exited the building; and 2) Resident #101 was observed with multiple medication tablets in a medication cup and an inhaler on their overbed table on 3/14/2024 and 3/20/2024. There were no staff members in the vicinity. Resident #101 was not assessed to safely self-administer medications. The findings are: 1) The facility's policy titled Out on Pass, dated 7/2022,…
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 · D2024-03-21 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. This was identified for one (Resident #161) of one resident reviewed for Tube Feeding. Specifically, on 3/15/2024 at 12:03 PM, Resident #161's tube feeding and hydration (water) bags were observed hanging without labels including the resident's name, and the time the tube feeding was initiated. The finding is: The facility's Gastrostomy Tube Feeding policy dated 5/2023 documented that the facility will provide gastrostomy tube feedings to residents according to Physician's orders. Step 11 of the procedure documented to fill out the label that is included with the pouch to affix to both the feeding bag and the water bag. Resident #161 was admitted with diagnoses of Cerebral Infarction, Aphasia, and Hemiplegia.…
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 · D2024-03-21 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 review, and interviews conducted during the Recertification Survey initiated on 03/14/2024 and completed on 03/21/2024, the facility did not ensure that each resident received care and services for the provision of parenteral fluids consistent with professional standards of practice and in accordance with physician orders and the comprehensive person-centered care plan. This was identified for one (Resident #216) of one resident reviewed for Hydration. Specifically, on three separate occasions, 03/14/2024 at 10:02 AM, 03/15/2024 at 10:30 AM, and 03/18/2024 at 09:12 AM, Resident #216 was observed with a Peripheral Intravenous Catheter in their left hand; however, there was no Physician's order for the placement and the care of the Intravenous Catheter. The finding is: The facility policy's titled Guidelines for Preventing Parenteral/Intravenous Catheter-Related Infections documented that residents receiving Parenteral/Intravenous therapy will receive therapies safely, timely, 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 · D2024-03-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that for each resident, as-needed orders for psychotropic drugs were limited to 14 days, and there was a rationale and indication for the duration of the medication. This was identified for one (Resident #68) of one resident reviewed for Choices. Specifically, on 2/9/2024 Resident #68 was prescribed Ambien (a sedative medication to help people sleep) 10 milligrams to be taken as needed. The order was not limited to 14 days and there was no rationale and indication for the continued use of the medication documented in the physician's notes. The finding is: The facility's undated policy titled Use of Psychoactive Medications and Gradual Dose Reductions documented psychoactive medications will be used in accordance with F758 of the State Operations Manual and shall minimize use of as-needed psychoactive medications whenever possible and ensure use is in accordance with F758 of the State Operations Manual. Resident #68 was admitted with…
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 before2024-03-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that all drugs used were labeled in accordance with professional standards including expiration dates, and that the medications were stored at proper temperatures. This was identified for three of twelve medication carts reviewed during the Medication Storage task. Specifically, 1a) an open Lantus Solostar insulin pen for Resident #194 was observed on 3/19/2024 in the medication cart with an open date of 2/23/2024, more than 28 days. 1b) Resident # 518's unopened Admelog insulin pen was observed stored in the medication cart which was supposed to be stored in the refrigerator at a temperature range of 36-46 degrees Fahrenheit 1 c) Resident #3's unopened Humalog insulin pen was observed stored in the medication cart which was supposed to be stored in the refrigerator at a temperature range of 36-46 degrees Fahrenheit. The finding is: The facility's policy titled, Medication Storage revised on 12/2008 documented…
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 · D2024-03-21 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for 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 record review and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that residents were assisted in obtaining routine dental care. This was identified for one (Resident #2) of one resident reviewed for Dental. Specifically, Resident #2 had a Physician's Order for a dental consult dated 7/6/2023; however, the resident was not seen by the Dentist until 2/4/2024. Additionally, during a subsequent dental visit on 2/16/2024, the Dentist made a recommendation for the resident to have six tooth extractions so that a full upper and lower denture could be made. These recommendations were never addressed by the facility until it was brought to the facility's attention on 3/19/2024 by the Surveyor. The finding is: The facility's undated policy for Dental Department documented that residents will be assisted to obtain regular and emergency dental care. Resident #2 has diagnoses which include Type 2 Diabetes Mellitus and Peripheral Vascular…
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 before2024-03-21 · 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 3/14/2024 and completed on 3/21/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #252) of four residents reviewed for Infection Control. Specifically, Resident #252 had a physician's order for Contact Precautions for an infection of Clostridium Difficile(C-Diff). During an observation on 3/14/2024 of the resident's room, the Contact Precaution signage that included instructions for the use of specific Personal Protective Equipment was not posted in a conspicuous location outside of the resident's room. There was a Droplet Precaution sign stored in the pocket of a caddy that was hanging outside the resident's door and the Droplet Precaution signage was not visible to the staff and visitors. The finding is: The facility's policy titled…
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 17 citations
- Potential for harm · E2022-05-25 · 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 record review and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident as determined by resident assessment and individual plans of care. This was identified through staff interviews, resident council task, review of Facility Assessment and staffing assignments. Specifically, 1) The facility nursing staffing assignments did not reflect the staffing needs as indicated in the Facility Assessment for the Certified Nursing Assistants (CNA), the Licensed Practical Nurses (LPN), and the Registered Nurses (RN); 2) Resident #94 did not receive floor ambulation twice a day as ordered; 3) during the Resident Council meeting held on 5/19/2022, six of eight (Resident #27, #53, #69, #85, #94, and #131) Resident Council members…
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 · E2022-05-25 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and staff interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility failed to have 100% vaccination compliance rate. Specifically, the staff matrix for staff vaccination documented that out of the 341 staff members employed by the facility, one staff member, a Licensed Practical Nurse (LPN) #1 was not fully vaccinated and provided resident care. The finding is: The Center for Medicaid and Medicare Services (CMS) QSO-22-07-ALL, dated 12/28/2021, CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute noncompliance under the rule. The facility policy for Covid-19 Staff Vaccination, revised on 2/24/2022, documented employees must be fully vaccinated unless any staff-member meets the criteria for a medical exemption. The Staff Vaccination Matrix titled Staff Vaccination Status, documented that there was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-25 · 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 interviews during the Recertification Survey and Abbreviated Survey (NY 00288885) initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that all injuries of unknown origin are thoroughly investigated. This was identified for one (Resident # 228) of four residents reviewed for Accidents. Specifically, Resident #228 sustained an unwitnessed displaced fracture of the distal femur (leg bone). The Accident/Incident (A/I) report lacked documented evidence that all statements were obtained from staff that cared for Resident #228 prior to the identification of the injury. The statements that were obtained were not complete to rule out abuse, neglect, and mistreatment. Additionally, there was no statement obtained from Resident #228, who was cognitively intact, to ascertain the cause of the fracture. The finding is: The Facility Accident/Incident (A/I) Policy dated 1/2013 documented that Injuries of Unknown origin will require staff interviews as far back as 24 hours…
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 · D2022-05-25 · 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
Based on observation, record review, and staff interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for 1 (Resident #66) of 4 residents reviewed during the medication administration task. Specifically, Registered Nurse (RN) #2 crushed and mixed 11 medications and supplements together and administered them simultaneously to Resident #66 with applesauce, including an extended-release heart medication (Metoprolol Succinate). The finding is: The facility's undated policy, titled Crushing Medications, documented long-acting or enteric-coated medications may not be crushed without a physician's order. The Vendor pharmacist will screen medications and notify the facility of medications that should not be crushed by placing a Do Not Crush label on the prescription packaging. Resident #66 was admitted with diagnoses including Hypertension, Cerebrovascular Accident, and Heart…
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 · D2022-05-25 · 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
Based on observations, record review, and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice and that interventions were implemented in accordance with the resident's Comprehensive Care Plan (CCP). This was identified for 1 (Resident #10) of 4 residents reviewed for Pressure Ulcers. Specifically, Resident #10 had a Stage 4 Pressure Ulcer to the sacral region and was utilizing an air mattress to offload the bony prominences and the sacral area. The physician ordered the air mattress setting to be set at 210 pounds. Upon two separate observations, the air mattress was observed at the firm setting. The finding is: The facility's undated policy titled Use of Low Air Loss Relieving Pressure Mattress documented physician orders will be entered according to the weight requirements, and the air mattress is set up and adjusted according to the resident's weight or by 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 · D2022-05-25 · 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, record review, and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that its medication error rates were not 5 percent or greater. This was identified for 11 of 26 opportunities during a medication pass observation resulting in a 42.3 % medication error rate. Specifically, during the medication administration observation for Resident #66, the Registered Nurse (RN) #2 crushed and mixed 11 medications and supplements together and administered them simultaneously to the resident with apple sauce. The finding is: The facility's undated policy, titled Crushing Medications, documented long-acting or enteric-coated medications may not be crushed without a physician's order. Vendor pharmacist will screen medications and notify the facility of medications which should not be crushed by placing a Do Not Crush label on the prescription packaging. Resident #66 was admitted with diagnoses including Hypertension, Cerebrovascular Accident, and Heart Failure. The 3/9/2022 Annual Minimum Data Set (MDS)…
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 · D2022-05-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that each resident remained free of significant medication errors. This was identified for 1 (Resident #66) of 4 residents reviewed during the medication administration task. Specifically, during the medication administration observation for Resident #66, the Registered Nurse (RN) #2, the medication administration nurse, crushed and mixed seven medications and four supplements (total of 11 items) together, including Metoprolol Succinate (heart medication) 25 milligram (mg) extended-release tablet. RN #2 then administered the medications simultaneously to the resident with apple sauce. The finding is: The facility's undated policy, titled Crushing Medications, documented long-acting or enteric-coated medications may not be crushed without a physician's order. Vendor pharmacist will screen medications and notify the facility of medications which should not be crushed by placing a Do Not Crush label on the prescription…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-05 · 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 staff interviews during the Recertification Survey the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident. This was identified for one (Resident #114) of three residents reviewed for Activities of Daily Living (ADLs). Specifically, Resident #114 had a physician's order for a nursing rehabilitation (rehab) standing program to be done twice a day; however, the resident consistently refused the standing program during the evening shift and there was no documented evidence that the Certified Nursing Assistant (CNA) reported the resident's refusals to the nurse. The finding is: The facility's policy titled Rehabilitative Nursing, dated 10/17/19, documented that the CNA is responsible to report to the charge nurse and complete the stop and watch notification for all refusals and changes in the resident's functional status. Resident #114 was admitted to the facility on [DATE] with diagnoses including Seizure Disorder, Major Depressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-05 · 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 staff interviews during the recertification survey, the facility did not ensure that each resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect the resident's current status. This was identified for one (Resident #62) of two residents reviewed for Communication-Sensory Care. Specifically, Resident #62 experienced double vision, had an Ophthalmology Consultation outside the facility, and wore an eye patch for three weeks without the resident's Vision Comprehensive Care Plan (CCP) being updated. The finding is: Resident #62 was admitted to the facility on [DATE] and has diagnoses which include Psychotic Disorder with Delusions and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident was understood and could understand and had a Brief Interview for Mental Status Score of 15 which indicated that the resident was cognitively intact. The MDS documented that the resident's vision ability to see in adequate light…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the recertification survey, the facility did not provide care and services to maintain acceptable parameters of nutritional status for one (Resident #157) of five residents reviewed for Nutrition. Specifically, Resident #157 had a significant weight loss of over 7.5% in a three month time period with no updates to the resident's plan of care to address this weight loss. The finding is: The undated Documentation of Weight Loss policy documented Nursing will report significant weight change upon discovery to the Physician and Dietitian. The Dietitian will review weights timely within one week of notification. The Dietitian must evaluate the resident with significant weight change, initiate the weight loss protocol if not already ordered by the Physician and change the resident's treatment plan. Resident #157 was admitted to the facility on [DATE] and has diagnoses which include Alzheimer's Disease and Insomnia. The Significant Change Minimum Data Set (MDS) 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 · D2019-11-05 · tag F0711 — isolatedEnsure 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 staff interview during the recertification survey, the facility did ensure that each resident's total program of care, including medications and treatments was reviewed at each visit. This was identified for one (Resident # 157) of five residents reviewed for Nutrition. Specifically, Resident #157 had a significant weight loss of over 7.5% in a three month time period which was not addressed by the Attending Physician and Physician's Assistant. There was no a physician's evaluation when a change in a resident's nutritional status was identified to address the medical and nutritional issues related to the significant weight loss. The finding is: The undated Documentation of Weight Loss policy documented that Nursing will report significant weight change upon discovery to the Physician and Dietitian. The Dietitian will review weights timely within one week of notification. The Dietitian must evaluate the resident with significant weight change, initiate the weight loss protocol if 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 · D2019-11-05 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 interview during the recertification survey, the facility did not ensure that the Attending Physician documented review of an identified irregularity as identified by the Pharmacist for one (Resident #62) of five residents reviewed for Unnecessary Medications. Specifically, the Pharmacist documented on 9/30/19 a recommendation for the Primary Physician to address. The Physician agreed to the recommendation on 10/4/19; however, never documented or addressed it in the resident's medical record. The finding is: The facility's undated Monthly Drug Regimen Review policy documented that the Prescriber/Licensed Designee (Physician) shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation and provide a brief clinical rationale if no change is to be made. Resident #62 was admitted to the facility on [DATE] and has diagnoses which include Psychotic Disorder with Delusions and Hypertension. The Annual 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 · Dcited before2019-11-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews during Recertification survey the facility did not ensure that medications were stored in accordance with currently accepted professional principles and under proper temperature controls on 1 of 5 nursing units. Specifically, the 2 North nursing unit refrigerator thermometer was observed at 50 degrees Fahrenheit (F). Insulin pens and Insulin vials, as well as a vial of Procrit, were observed in a plastic tray which contained a 1/2 inch of water that had collected from defrosting ice. In addition, there was one flu vaccine in the refrigerator. The finding is: The facility's undated policy, titled Refrigerator Policy-Nourishment and Medication, documented that refrigerator temperatures should be within the range of 36-46 degrees F. If the refrigerator temperature is above or below the acceptable temperature range, the maintenance department is to be notified. On 10/31/19 at 9:58 AM the unit 2 North medication refrigerator was observed with a unit Licensed Practical Nurse (LPN) medication nurse. The refrigerator thermometer was observed at 50 degrees…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-05 · 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 observation, record review, and interviews during the Recertification Survey the facility did not ensure that practices were in place to help prevent the development and transmission of communicable diseases and infections for one (Resident #142) of two residents reviewed for Pressure Ulcers. Specifically, during the wound care observation for Resident # 142, the Registered Nurse (RN) treatment nurse did not not wash his hands or change his gloves after cleansing the wound. The finding is: The facility's policy titled Aseptic Dressing, dated 4/4/18, documented that the nurse will remove gloves and wash hands after cleansing the wound. Resident #142 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, and Stage 4 Pressure Ulcer to the Sacral Region. The 9/22/19 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview of Mental Status (BIMS) of 15, indicating the resident was cognitively intact.…
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 · B2022-05-25 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that the nurse staffing data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, during a tour on 5/18/2022 and 5/19/2022, there was no posting of the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) observed in a prominent area such as the lobby, near the elevator, or on the individual nursing units. The finding is: A tour was made on 5/18/2022 between 9:30 AM and 11:00 AM of the lobby and the five nursing units. There was no staffing data posting visible that contained the number of staff providing care for each nursing shift: 7AM-3 PM, 3 PM-11PM, and 11 PM-7 AM. A tour was made on 5/19/2022 between 10:00 AM and 1:00 PM of the facility including the lobby and the five nursing units. There was no staffing data posting visible that contained the number of staff providing care for each…
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 · C2019-11-05 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview during the recertification survey, the facility did not ensure that their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption specifically included how facility staff would ensure that a resident is assisted in accessing and consuming the food, if the resident is not able to do so on his or her own. The finding is: The facility's Handling of Food from Outside Sources dated 3/12/18 was reviewed on 11/4/19 at 9:30 AM. The policy did not specifically include how the facility would ensure that a resident was assisted in accessing and consuming food brought in by family and other visitors, if the resident was not able to do so on his or her own. The Food Service Director (FSD) was interviewed on 11/4/19 at 9:45 AM and stated if a resident could not consume food brought in by a family or friend, a Certified Nursing Assistant (CNA) or a Nurse would feed them. The FSD stated that a Nurse would be the one calling for a resident's food to be…
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 · B2019-11-05 · 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 interview during the recertification survey, the facility did not meet the electronic transmittal requirements for a Minimum Data Set (MDS) Discharge Assessment to the Centers for Medicare and Medicaid Services (CMS) system within fourteen days after the completion of the assessment. This was evident for one of two residents reviewed in the Resident Assessment Facility Task. Specifically, Resident #1 was discharged to home on 6/6/19. The MDS Discharge Assessment with a completion date of 6/17/19, had not been transmitted within 14 days of the completion of the assessment, the MDS was transmitted to CMS on 11/5/19. The finding is: Resident #1, with diagnoses including Hypertension and Diabetes Mellitus, was admitted to the facility on [DATE] for short term rehabilitation. The Social Work progress note dated 6/6/19 documented the resident was discharged to home on 6/6/19. A MDS assessment dated [DATE] and completed 6/17/19 documented that the resident was discharged to the community. 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.
- 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.
Part of a chain
This home belongs to THE SHERMAN FAMILY — 7 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 | 2.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 3 of 5 | 2.1 | +0.9 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 6 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SHERMAN, ISRAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 03/27/2006 |
| ARYEH, ELLIOT | Individual | W-2 MANAGING EMPLOYEE | — | since 03/05/2010 |
| SHERMAN, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/28/2008 |
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.
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 335559. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.