Clove Lakes Health Care And Rehabilitation Center,
25 Fanning Street, Staten Island, NY 10314 · For profit - Corporation · 576 certified beds · (718) 289-7900 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (35) — 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 (1/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 10.5% | 14.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.7% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.2% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 65.7% | 19.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.4% | 0.2% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 1.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.5% | 12.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.8% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 81.8% | 95.3% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 10.4% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.9% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 13.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 37.9% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.2% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.4% | 9.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 1.70 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.52 | 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.
52.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 565 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 441 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 0.04 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 52.6%CMS range 47.2–57.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 9.5–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.7% | 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 | 60.3% | 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 | 55.3% | 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 | 99.7% | 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 | 98.6% | 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 | 94.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.4% | 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 | 7.3%CMS range 5.7–9.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.45 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 576 beds and averages 543.5 residents a day — about 94% occupied, or roughly 32 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.11 hrs/resident/day on weekends vs 3.47 on weekdays — 10% thinner on weekends. RN hours go from 0.92 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. 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.
35 citations, most serious first. The 14 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Kcited before2026-04-27 · 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, record reviews, and interviews conducted during survey, the facility failed to ensure that five (5) of seven (7) residents (Resident #7, Resident #9, Resident #10, Resident #11 and Resident #12) received adequate supervision and interventions to prevent accidents. Specifically, 1) On 04/16/2026 at 1:30 PM Resident #7 was observed entering the smoking room while using oxygen. Smoking Monitor #1 did not prevent Resident #7 from entering the smoking room nor did they attempt to remove Resident #7's oxygen. Resident #7 also had three (3) known incidents of smoking in their room while using oxygen.2) On 04/17/2026, the facility conducted room searches for all 35 identified smokers and 19 were found with smoking materials. Four (4) out of 19 residents (Resident #9, Resident #10, Resident #11 and Resident #12) were found with lighters, and two (2) of them (Resident #9 and Resident #10) were found with continuous use oxygen order in their room. There was no documented evidence that a smoking…
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 before2026-04-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 reviews, and interviews conducted during survey, the facility failed to ensure that resident was free from neglect. This was evident for one (1) of five (5) residents (Resident #1) sampled. Specifically, the facility failed to ensure Registered Nurse #1 or other direct care service providers (Certified Nursing Assistant #1) provided Resident #1 with goods, services and care that were necessary to prevent physical harm. On [DATE], Registered Nurse #1 neglected to ensure that Resident #1, who had an order for continuous oxygen, received significant medications and treatments that were scheduled for 4:00 PM, 8:00 PM and 9:00 PM. In addition, Certified Nursing Assistant #1 neglected to provide hourly monitoring of Resident #1 who was assessed as at risk for falls and to ensure the resident had received and ate dinner. At 9:49 PM on [DATE], Resident #1 was found unresponsive on the floor face down with no pulse and no breathing. Cardiopulmonary resuscitation was initiated until Emergency…
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.
- Actual harm · Gcited before2026-04-27 · 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 record review, and interviews during survey, the facility failed to ensure that services provided or arranged by the facility met professional standards of quality. This was evident in one (1) of five (5) residents (Resident #1) sampled. Specifically, on [DATE], Registered Nurse #1 failed to administer Resident 1's significant medications and treatments that were ordered between the hours of 4:00PM and 9:00 PM including continuous oxygen as per Physician's orders. Registered Nurse #1 did not notify the physician and Registered Nurse Supervisor #1 when the medications were not administered. Additionally, from 4:15 PM to 9:49 PM on [DATE], Registered Nurse #1 and other direct care staff were unaware of Resident #1's whereabouts until Resident #1 was found unresponsive on the floor, face down with no pulse and no breathing. Cardiopulmonary resuscitation was initiated until Emergency Medical Services (911) arrived at 10:07 PM and assumed care. Resident #1 expired at 10:24 PM. This resulted in actual harm to…
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.
- Actual harm · Gcited before2026-04-27 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews conducted during survey, the facility failed to ensure that residents are free of significant medication errors. This was evident in one (1) out of five (5) residents sampled (Resident #1). Specifically, on [DATE], Registered Nurse #1 did not administer significant medications at 4:00 PM, 8:00 PM, and 9:00 PM to Resident #1 in accordance with Physician's orders. Additionally, Resident #1 did not receive ordered oxygen 3-Liters via nasal cannula continuously every shift for chronic obstructive pulmonary disease. From 4:15 PM to 9:49 PM on [DATE], Registered Nurse #1 and other direct care staff were unaware of Resident #1's whereabouts until Resident #1 was found unresponsive on the floor face down with no pulse and no breathing. Cardiopulmonary resuscitation was initiated until Emergency Medical Services arrived at 10:07 PM and assumed care. Resident #1 expired at 10:24 PM. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Cross Reference: F658 -…
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 · F2026-04-27 · tag F0835 — failed to run the facility competently — widespreadAdminister 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 observation, record review, and interviews, the facility failed to ensure the facility 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. Specifically, 1) The Administrator and the Director of Nursing failed to ensure that the residents were free from neglect. Immediate Jeopardy was determined on [DATE] when direct care and nursing staff failed to ensure that Resident #1 received medications, dinner meal, oxygen therapy and safety monitoring. This resulted in actual harm for Resident #1 who was found unresponsive and expired. 2) The Administrator and the Medical Director failed to ensure enforcement of smoking safety policies for residents with known unsafe smoking behavior and oxygen use. Immediate Jeopardy was determined on [DATE]. Cross Reference: F600 -Resident Neglect. F689- Free of Accident Hazards/Supervision/Devices The findings include: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 before2026-04-27 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident for five residents (Resident #6, # 7, #8, #10, and #11) out of seven total sampled residents. Specifically, the Minimum Data Set assessments for Residents #6, #7, #8, #10, and #11 did not reflect that the residents were active smokers. The findings are:The facility's policy titled Accuracy of Assessment'' with a last reviewed date of 10/2025 documented it is the policy of the facility to ensure accurate assessment of all residents in accordance with Federal and State Operations Manual. The policy stated the assessment will include direct observations, and communication with the residents, as well as communication with resident and direct care staff on all shifts. 1) Resident #6 was admitted to the facility with diagnoses including chronic obstructive disease, benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland),…
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 before2026-04-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, conducted during survey, the facility failed to ensure that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) of five (5) residents (Resident #1) sampled. Specifically, on [DATE], Registered Nurse #1 arrived in the unit at 4:15 PM and was informed by staff (unsure of staff) that Resident #1 had a visitor. Registered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-27 · 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 observation, record review, and interviews, the facility failed to ensure that alleged violations involving abuse were thoroughly investigated. This was evident for one (1) of five (5) residents (Resident #1) sampled. Specifically, on [DATE] Registered Nurse #1 arrived in the unit at 4:15 PM and was informed by staff (unsure of staff) that Resident #1 had a visitor. Registered Nurse #1 did not check for Resident #1 until 9:40 PM to give their medications and did not locate Resident #1. At 9:49 PM, Resident #1 was found unresponsive on the floor face down with no pulse and no breathing. Resident #1 was pronounced deceased by Emergency Medical Services. The facility did not conduct a thorough investigation to ascertain how Resident #1 was found to be unresponsive.The findings are:A review of the facility's policy on Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property with a reviewed date [DATE], documented Residents of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-27 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during the abbreviated survey the facility's assessment failed to address/include an evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population. This was evident for one (1) out of four (4) smoking monitors. Specifically, the facility designated the Activities staff to provide assessments of residents who smoke to identify residents who exhibit unsafe smoking practices. The Activities staff were also designated to conduct monitoring during residents smoking activity. A review of the Facility assessment dated 09/2025 revealed the position for Activity Aide did not identify the knowledge, training and /or skills required in safe smoking monitoring and oxygen safety. The findings include: The facility policy titled Facility assessment dated 09/2025 documented identifying resident's acuity levels will help evaluate level of care and services needed to provide sufficient care for facility's residents. The facility's vision is to provide continuous care through…
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 · D2025-11-18 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 an abbreviated survey (659849), the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences. This was evident for one (1) out of six (6) residents (Resident #6) sampled. Specifically, Resident #6, who was allergic to mushroom, ate mushrooms that was served to them on their meal tray on 06/05/2025 at 1:20 PM. Resident #6 had an allergic reaction and was immediately administered Solumedrol (used to treat allergic reaction) Intramuscular and Benadryl (used to relieve symptoms of allergies) 25 milligram every six (6) hours.The findings are:The facility's policy titled 'Resident with food allergies and intolerances' dated 01/2025 states that the facility will ensures that all residents who have allergies and/or food intolerances to food items will not receive them on their meal trays. The facility's policy titled 'Meal Delivery' dated 10/2024 states that food service personnel are…
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 before2025-02-13 · 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 conducted during the abbreviated survey (NY00361247), the facility failed to develop and implement a comprehensive person-centered care plan for the resident, consistent with the resident's rights. This was evident for one (1) out of ten (10) residents sampled. (Resident #1). Specifically, there was no documented evidence that a care plan was developed when Resident #1 was noted with macerated skin around the stoma on 11/21/2024. The Nurse Practitioner evaluated Resident #1 and ordered Maalox suspension to be applied to the affected area for 10 days. Findings are: The facility policy titled Comprehensive Person-Centered Care Planning, revised 11/2024, documented that Comprehensive Person-Centered Care planning is done to develop an individualized interdisciplinary care plan for each resident based on Care Area Assessment to ensure that residents receive treatment and care in accordance with perfectional standards of practice, the comprehensive person-centered care plan and the resident's choices. Resident #1 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 before2024-10-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 an Abbreviated Survey (NY00330767), the facility failed to protect the resident's right to be free from physical abuse by a nursing home staff. This was evident for one out of seven residents (Resident #4) sampled for abuse. Specifically, on 12/30/2023 at 2:44 AM, the facility's surveillance video recording showed Certified Nursing Assistant #2 roughly pulling some incontinent briefs away from Resident #4 who was sitting in their wheelchair in the hallway. Nurse Supervisor #2 assessed Resident #4 who did not sustain any visible injuries nor complained of pain. The findings are: The facility Policy and Procedure for Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property was last updated on 11/11/2022. The policy states that residents must not be subjected to abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property by anyone,…
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 before2024-10-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review during an abbreviated survey (NY00333881), the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. In addition, the facility did not ensure that violations involving sexual abuse was reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for 2 out of 10 residents sampled (Resident #2 and Resident #3). Specifically, On 02/18/2024…
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 · D2024-10-16 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification survey from 10/8/2024 to 10/16/2024, the facility did not ensure each resident had the right to be fully informed in a language that they can understand. This was evident for 1 (Resident #548) out of 41 total sampled residents. Specifically, Resident #548 was not fully informed of their health care status in a language the resident understood, and communication tools were not used by direct care staff to determine the resident's needs. The findings are: The facility's policy and procedure titled Language Policy dated 1/2024 documented that facility will make every effort to provide interpretive services for residents who primary language is other than English. Resources available for language access service during hours of facility operation, include language interpreting services, communication boards and bilingual staff members who are able to interpret during working hours. Resident #548 was admitted to the facility with End Stage…
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 21 citations
- Potential for harm · Dcited before2024-10-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the Recertification Survey from 10/08/24 to 10/16/24 the facility did not ensure residents' person-centered comprehensive care plans were developed and implemented to meet residents' needs. This was evident for 2 out of 40 sampled residents investigated for area of potential concerns. (Resident #147 and #391). Specifically,1) Comprehensive care plans were not developed and implemented for resident #147 who was on Hemodialysis, Antipsychotic and Anticoagulant medications. 2.) Comprehensive Care plans were not developed and implemented for resident #391 who was assessed as a smoker. Findings are: The facility policy titled Care Plans - Comprehensive with a last revision date of 12/2023 documented that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed…
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 before2024-10-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during the Recertification survey and Complaint survey (NY00342693) from 10/08/2024 to 10/16/2024, the facility did not ensure that residents comprehensive care plans were reviewed and revised to reflect the resident's status. This was evident for 1 (Resident #748) of 1 resident reviewed for Advance Directives, 1 (Resident #58) of 1 resident reviewed for Physical Restraints, and 1 (Resident #58) of 2 residents reviewed for Respiratory Care out of 40 sampled residents. Specifically, 1). Resident #748's comprehensive care plan related to Advance Directives was not revised to reflect the change in Advance Directive orders, and 2). Resident #58's comprehensive care plan related to physical restraints and tracheostomy were not reviewed and revised after the Minimum Data Set Assessment was completed. The findings are: A facility policy titled Comprehensive Person-Centered Care Planning dated 12/2023 documented Social Services/Team Members reviews and updates 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 · D2024-10-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 10/08/2024 to 10/16/2024, the facility did not ensure that medications provided by the pharmacy were not expired. Specifically, a Serevent Diskus inhalation device with an expiration date of 09/2024 was delivered to the facility on [DATE] and opened for administration on 10/15/2024 (Resident #314). The findings are: The facility policy titled Medication Administration dated 11/23 did not address checking the expiration date on medications prior to accepting them or administering them. On 10/16/2024 at 01:34 PM, the Director of Nursing stated they did not have a policy that addressed reviewing medication expiration dates. Resident #314 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia. The Order Summary Report dated 10/16/2024 documented that Resident #314 was prescribed Serevant Diskus Inhalation Aerosol Powder Breath Activated 50 mcg/act, inhale 50…
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 before2024-10-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews conducted during the Recertification survey between 10/08/2024 and 10/16/2024, the facility did not ensure that Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status. Specifically, the most recent Minimum Data Set (MDS) 3.0 assessments did not reflect that a resident had psychiatric behaviors. This was evident for 1 of 1 residents reviewed for Assessment Accuracy out of a sample of 39 residents (Resident #228). The findings are: Resident #228 was admitted to the facility on [DATE] with diagnoses including Nondisplaced fracture of medial condyle of left tibia, Anxiety Disorder, and Depression. The Minimum Data Set admission assessment dated [DATE] documented that the Resident #228 did not have any hallucinations or delusions, did not display any physical or verbal behaviors directed at themselves or others, and did not reject care. The Minimum Data Set Quarterly assessment dated [DATE] and the Minimum Data Set Quarterly…
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 · D2024-10-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 staff interviews conducted during the recertification survey from 10/08/2024 to 10/16/2024, the facility did not ensure assessments were coordinated with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid. Specifically, a resident with a new diagnosis of a serious mental disorder was not referred for a PASARR Level II Evaluation. This was evident for 1 of 1 residents reviewed for PASARR services (Resident #228). The findings are: A facility Policy and Procedure titled Screen/Pre-admission Screen Resident Review (PASSR) Process did not include any procedure related to referring residents with new diagnoses of serious mental health disorders for a PASARR Level II evaluation. Resident #228 was admitted to the facility on [DATE] with diagnoses including Nondisplaced fracture of medial condyle of left tibia, Anxiety Disorder, and Depression. The Minimum Data Set admission assessment dated [DATE] documented that the resident did not have any…
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 before2024-10-16 · 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 record review, and interview conducted during the Recertification Survey and Abbreviated survey (NY00356497) from 10/08/2024 to 10/16/2024, the facility did not ensure services provided met professional standards of quality. This was evident for 1 (Resident #369) out of 40 total sampled residents. Specifically, Resident #369 did not receive Brivaracetam (medication for seizure) in accordance with Physician's Orders due to the medication not being available. Additionally, there was no documented evidence indicating the physician was notified that the medication was not available. The findings are: The facility policy and procedure titled Medication Administration revised 11/2023 states that it is the Standard of Practice that medications be administered as ordered by the physician. When medication cannot be administered, or is refused, it is documented electronically on the electronic- Medication Administration Record including the reason and physician notification. Resident #369 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 · D2024-10-16 · 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 record review and interviews conducted during a Recertification Survey initiated on 10/8/2024 and completed on 10/16/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #275) of two residents reviewed for quality of care related to drugs and medication. Specifically, Resident #275 with a diagnosis that includes Hyperlipidemia and Thyroid disorder had a physician's order to administer Levothyroxine Sodium tablet 112 mcg one tablet by mouth one time a day for low thyroxin hormone. The facility policy is to administer Levothyroxine Sodium at six in the morning. Resident #275 was given this medication on multiple days after seven in the morning. The finding is: The facility's policy dated 06/2024, titled Quality of Care Policy and Procedure documents the facility will ensure it identifies and provides needed care and services that are person centered, in accordance with the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview conducted during the Recertification and Abbreviated Survey ( NY00356497) from 10/08/2024 to 10/16/2024, the facility did not ensure residents were free of significant medication errors for 1 of 1 residents (Resident #369) reviewed for medications. Specifically, Resident #369 did not receive Brivaracetam (medication for seizure) in accordance with Physician's Orders due to the medication not being available. Additionally, there was no documented evidence indicating the physician was notified that the medication was not available. The findings are: The facility policy and procedure titled Medication Administration revised 11/2023 states that it is the Standard of Practice that medications be administered as ordered by the physician. When medication cannot be administered, or is refused, it is documented electronically on the electronic- Medication Administration Record including the reason and physician notification. Resident #369 was admitted with diagnoses including…
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 · E2022-11-10 · 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 observation, record review, and interviews conducted during the Recertification survey from 11/03/2022 to 11/10/2022, the facility did not ensure residents with respiratory care were provided such care consistent with professional standards of practice. This was evident for 3 (Residents #81, #84, #117) of 3 residents reviewed for respiratory care out of 35 sample residents. Specifically, residents were observed several times receiving oxygen via Nasal Cannula (NC) without a Medical Doctor's Order (MDO). The findings are: The facility policy titled Oxygen Administration dated 04/2022 documented oxygen administration preparation as follows; verify that there is a physician's order, review the physician order or facility protocol for oxygen administration. 1) Resident #81 had diagnoses of Infection, Atrial Fibrillation, and Atherosclerotic heart disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #81 had moderately impaired cognition with a Brief Interview of Mental Status…
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 · E2022-11-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview conducted during the Recertification and Complaint survey 11/3/22 - 11/10/22, the facility did ensure food was stored in accordance with professional standards for food service safety. This was evident for the Kitchen Observation Task. Specifically, expired food was observed in the meat walk-in refrigerator. The findings are: The undated Dietary Department Policy and Procedure titled Food Storage documented the length of time food may be kept satisfactorily depends on the quality of the product when stored, how well it is stored and the temperature of the storage area. The manager should be consulted in regard to any food that may be questionable before beginning food production or service. Cold Storage, Section B3. All items should be marked with a receiving date prior to shelving. On 11/3/22 at 9:44am, the meat walk-in refrigerator was observed with four boxes of Party Ham with a use by date of 9/2/22. An interview was conducted with Assistant Food Service Director (AFSD) on 11/10/22 at 1:05pm, who stated that the storeroom…
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 · D2022-11-10 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 11/03/22 to 11/10/22, the facility did not ensure each resident remained free from physical restraints for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This was evident for 1 resident (Resident #207) reviewed for Physical restraints out of a sample of 35 residents. Specifically, Resident #207 was observed with a Stay Seat Reminder (a velcro belt fastened to the wheelchair armrests that prevents rising) in use without an assessment, care plan, documented evidence of the symptoms it was being used to treat, medical justification, and on-going re-evaluation. The findings are: The facility policy titled Restraints/Devices Physical dated 9/2022 documented a physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the Resident's body that the Resident cannot remove easily and restricts freedom of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) The facility policy and procedure titled Comprehensive Resident-Centered Care Planning revised 1/22 documented that comprehensive resident-centered care planning is done to develop an individualized interdisciplinary care plan for each resident based on Care Area Assessment to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan and the resident's choices. Resident #311 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease, and Heart failure. The Minimum Data Set (MDS) dated [DATE] documented that Resident #311 had moderately impaired cognition. Required limited assistance with one person assist for bed mobility, transfer, toilet use and total dependence with one person for locomotion on and off the unit. The resident was always continent of bowel and bladder. The Comprehensive Care Plan (CCP) for Fall initiated 6/4/22, revised 10/29/22 documented that…
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 before2022-11-10 · 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 record review and interviews conducted during the Recertification survey from 11/03/2022 to 11/10/2022, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident for 2 (Resident #290 and # 311) of 5 residents reviewed for Accidents out of a sample of 35 residents. Specifically, 1) Resident #290, a cognitively impaired resident, did not receive adequate supervision and interventions to prevent eleven falls in six months. 2) Resident #311, a resident identified as risk for fall/injury, with moderately impaired cognition, had multiple falls while trying to use the bathroom. The facility did not determine the causes of the falls, nor reviewed the effectiveness of interventions implemented for falls nor developed new individualized interventions to reduce the risk of further falls. The findings are: The facility's policy and procedure titled Residents High Risk for Falls with the last revised date 08/2022 documented that all residents will receive…
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 · D2022-11-10 · 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 reviews and staff interviews conducted during the Recertification and Complaint survey from 11/3/22 to 11/10/22, the facility did not ensure that the attending physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident for 1 (Resident #292) of 5 residents reviewed for Unnecessary Medications Review out of 35 sample residents. Specifically, there was no documented evidence that the attending physician followed-up on ordered a Hemoglobin A1C (HbA1C) ordered upon admission for Resident #292. In addition, the physician agreed to order the HbA1C after the pharmacist recommended the lab be completed, but the physician never re-ordered the lab. The findings are: The facility policy and procedure titled Physician Services revised 1/22 documented the medical care of each resident of the facility is under the supervision of a Licensed Physician. It further documented the Attending Physician will perform pertinent, timely medical…
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 · D2022-11-10 · 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 interviews conducted during the Recertification survey from 11/3/22 to 11/10/22, the facility did not ensure that a medication regimen review (MRR) performed by the consultant pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 1 (Resident #292) of 5 residents reviewed for Unnecessary Medications Review out of a total of 35 sampled residents. Specifically, a pharmacy recommendation to perform a Hemoglobin A1C (HbA1C) test for Resident #292 was agreed to by the Attending Physician (AP), but the test was not completed in a timely manner. The findings are: The facility policy and procedure titled Drug Regimen Review/Unnecessary Drugs revised 01/22 documented the consultant pharmacist reviews each resident regimen of medication at least monthly or upon a resident's change in conditions, such as falls, re-admission, return from bed hold and resident stays less than 30 days, and any area the QAPI Committee 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 · Dcited before2022-11-10 · 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 conducted during the recertification survey, the facility did not consistently maintain an infection control program designed to prevent the development and transmission of disease and infection. This was evident for 2 of 8 units observed for infection control. Specifically, a staff member caring for a COVID-19 positive resident did not wash hands after interacting with the resident's environment, and a staff member caring for a COVID-19 positive resident did not wear full personal protective equipment (PPE) when providing direct care. The findings are: The facility policy titled Infection control program, last updated on 8/2022, documented its primary goal was the provision of a safe and sanitary environment for residents, family members, visitors and employees. The program included environmental, clinical, employee health, and tuberculosis surveillance, vaccination programs, and education of employees, residents and family members. The policy further…
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 before2020-01-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, oxygen tubing going to residents' nares were observed touching the floor on several occasions. This was evident for 3 of 35 residents (Resident # 70 and 253 and #44) reviewed in the investigation sample. The findings are: Oxygen Tubing Policy last updated on October 2019 documented oxygen tubing/supplies is stored in a mesh bag or plastic bag when not in use. Oxygen tubing or equipment should be changed if found on the floor. 1) Resident # 70 was admitted on [DATE] with diagnoses which include chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia HTN, obesity, and chronic kidney disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident needs extensive assistance and two person assist for most activities of daily living. On 01/15/20 at,10:01 AM, on 01/16/20 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-23 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the recertification survey, the facility did not provide the appropriate liability notice to Medicare beneficiaries. Specifically, the facility did not provide residents/representatives with Notice of Medicare Non-Coverage (NOMNC) at the termination of Medicare Part A benefits. This was evident for 2 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 42 residents (Resident #570 and #177). The findings are: The facility policy and procedure for Medicare and Managed Medicare Notification of Non-Coverage (NOMNC), revised 10/2019, documented that it is the policy of the facility to follow CMS Guidelines for a resident who will no longer receive skilled services by providing them with a letter of non-coverage either in person or via telephone two (2) days prior to the effective date. A copy of the letter or the original is then mailed certified mail/return receipt requested on the same day that the phone call…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-01-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, during the recertification survey, the facility did not ensure that resident assessment accurately reflected the resident's status. Specifically, a resident's diagnosis of Neurogenic bladder was not captured on the Minimum Data Set {MDS} assessments. This was evident for 1 of 4 residents reviewed for Urinary Catheter/UTI out of a total sample of 38 residents (Resident #21). The findings are: The facility policy titled MDS 3.0 Guidelines dated 3/2018 documented, MDS coordinators are responsible for reviewing: timeliness, accuracy, interviews when assessing resident and completing MDS sections. Resident #21 was admitted to the facility with diagnoses which include Alzheimer's, Disease, Chronic Kidney Disease, and Benign Prostatic Hypertrophy. On 1/16/20 at 4:16 PM, the resident was observed sitting in room watching TV, cheerful and responsive. A Suprapubic Catheter drainage bag was placed in a privacy bag that was not visible upon entering room. The Annual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-23 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that pain management, consistent with professional standards of practice and the comprehensive person-centered care plan was provided. Specifically, staff did not conduct a pain assessment when a resident showed signs of pain during wound care. This was evident for 1 of 1 resident reviewed for Pain (Resident #394). The finding is: The Policy and Procedure for Pain Management, revised 10/2019, documented the experience of pain is subjective, and individual based upon many factors, i.e. culture, role, self-image, fear of pain, etc. Pain can be assessed using a Numeric or Verbal Descriptor scale as described in the EMR scale (Numeric scale (0-10 or 99 if unable to respond), (Verbal descriptor (e.g. mild, moderate, severe, very severe-horrible, unable to answer). Indications of pain or possible pain include non-verbal sounds (e.g. crying, whining, moaning or groaning) and verbal complaints of pain, facial expressions, protective movements. The Licensed Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-23 · 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 FACILITY Medication Storage and Labeling Based on observations and staff interviews conducted during a recertification survey, the facility did not ensure that all medications and biologicals were stored and appropriately labeled or discarded. Specifically, 1) A 5% Dextrose Injection 1000ml(milliters) bag and safety needle was not discarded after the manufacturer's expiration date. 2) One Artificial Tears (polyvinyl Alcohol) 1.4.% eye drops Visine tears drops was not dated when opened, This was evident during the observation conducted for the medication cart and room storage cabinet (5A unit Cart #2 and 6th floor storage cabinet). 1) During an observation on 01/22/20 at 12:51 PM with Registered Nurse (RN #4) present the following expired medication and biologicals were observed in the medication storage cabinet on 6th Floor Building B: 1) a 5% Dextrose Injection 1000ml with an expiration date of 10/18; 2) a [NAME] Monoject Magellan safety needle 23 G x 1 with a use by date of 7/2016 was observed in the storage…
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 INFINITE CARE — 8 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 | 2.0 | ≈ chain avg |
| Health inspection | 1 of 5 | 1.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 7 homes this chain runs (chain average 2.0★, 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 |
|---|---|---|---|---|
| DEMISAY, BERNADETTE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10% | since 02/15/2017 |
| DEMISAY, HELENE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 70% | since 02/15/2017 |
| DEMISAY, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 10% | since 02/15/2017 |
| KLEIN, SOLOMON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10% | since 02/01/2021 |
| SENK, LORRI | Individual | W-2 MANAGING EMPLOYEE | — | since 06/15/2012 |
CMS files one row per role, so the 6 rows in the source record cover these 5 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 $1.5M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335239. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-16, 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.