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The Willows At Ramapo Rehab And Nursing Center

30 Cragmere Road, Suffern, NY 10901 · For profit - Corporation · 203 certified beds · (845) 357-1230 Medicare & Medicaid certified

Call the home — (845) 357-1230 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Nov 2023Resident-funds citation (F0567)Behavioral-health or dementia-care citations — no harm found (F0740, F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
Worth asking about
  • 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
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
255 Lafayette Ave · (845) 368-5000 · Call to confirm hours
Pharmacy
5 Indian Rock · (845) 357-1500 · Call to confirm hours
Grocery
125 Franklin Tpke · (201) 529-9775 · Call to confirm hours
Park
59 Campbell Ave · (845) 357-6100 · Typically dawn to dusk
Place of worship

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 fell from 4 to 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.7%14.1%15.4%typical
Long-stay residents who lose too much weight8.3%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.5%0.9%better
Long-stay residents with a urinary tract infection0.9%1.3%2.0%better
Long-stay residents with depressive symptoms4.9%19.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.3%3.1%3.3%typical
Long-stay residents whose ability to walk worsened11.4%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.9%13.2%18.9%worse
Long-stay residents given the seasonal flu vaccine83.5%95.3%95.3%worse
Long-stay residents with pressure ulcers5.1%6.5%4.7%typical
Long-stay residents with worsening bladder/bowel control25.3%19.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table6.8%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine50.6%78.8%79.4%worse
Short-stay residents rehospitalized after admission16.0%20.6%22.6%better
Short-stay residents with an outpatient ER visit10.8%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.421.701.67better
Long-stay outpatient ER visits per 1,000 resident days1.391.361.80better

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.

56.4% 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 454 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.4%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
62.5%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 62.5% 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 280 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.4%CMS range 50.3–61.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 8.0–13.110.7%Oct 2022–Sep 2024no 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 discharge62.5%56.6%Oct 2024–Sep 2025CMS 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 discharge58.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.6%50.0%Oct 2024–Sep 2025CMS 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 identified99.7%98.7%Oct 2024–Sep 2025CMS 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 setting97.7%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.3%CMS range 6.7–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.371.02Oct 2022–Sep 2024CMS 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

0.40
RN hours/ resident / day
0.91
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.24
Total nurse hours/ resident / day
0.25
RN hoursweekends
27.7%
Total nursing turnover
43.5%
RN turnover

How full it usually is: this home is certified for 203 beds and averages 186.0 residents a day — about 92% occupied, or roughly 17 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 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.37 on weekdays — 13% thinner on weekends. RN hours go from 0.46 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% 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

7
deficiencies at the latest standard inspection (2026-03-13)
6
at the previous standard inspection (2023-11-17)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2025-10-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interviews conducted during the abbreviated Survey #2637567, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one (1) of three (3) residents (Resident #1) reviewed for neglect. Specifically, Certified Nurse Aide #1 did not provide Resident #1 with staff assistance for meeting their activities of daily living needs during the evening shift on 10/06/2025, despite documenting such care was given. Subsequently, Resident #1 was last seen on 10/06/2025 at 9:12 PM in their room sitting fully clothed in their wheelchair and at 11:51 PM, Resident #1 was found in their room lying face down on the floor between the bed and wheelchair, with their head under the bed and their oxygen nasal cannula dislodged. Resident #1 was short of breath, non-verbal and had lacerations (cuts) on their forehead and neck. Resident #1 was pronounced deceased at 12:20 AM at the facility. This resulted in actual harm to Resident #1 that was not Immediate…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review conducted during the recertification survey from 03/08/2026 to 03/13/2026, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for one (1) (Resident #29) of two (2) residents reviewed for personal funds. Specifically, the facility restricted Resident #29 to receiving money on two (2) days a week and in an amount lower than the resident wanted.The findings are:Resident #29's diagnoses included surgical amputation of the left leg below the knee and partial right foot, congestive heart failure, and diabetes.The 01/14/2026 quarterly Minimum Data Set (a resident assessment tool) documented Resident #29 had intact cognition.The facility policy, Resident Funds, last approved on 10/02/2025, documents that residents have access to their personal funds 24 hours a day, seven (7) days a week.A 11/04/2025 memorandum from the resident's family member documented they would have no problem if the resident requested…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the recertification survey, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment for two (2) of eight (8) residents (Resident #126 and Resident #170) reviewed for the environment. Specifically, 1) Resident #126 was observed sitting in a wheelchair that was visibly soiled on the frame, cushion, and protective gauze; 2) Resident #170 was observed sitting in a wheelchair that was visibly soiled on the frame, body, and back of wheelchair. The findings included:The facility policy Wheelchair Cleaning Process, dated 10/03/2025, documented that all resident wheelchairs, cushions, and adaptive equipment are routinely cleaned in accordance with the Centers for Disease Control infection control guidelines to maintain a clean and sanitary environment and to prevent the transmission of infectious agents. Any equipment that is soiled will be added to the daily cleaning schedule. 1) Resident #126 had diagnoses 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the recertification survey, the facility did not ensure that residents unable to carry out activities of daily living received the necessary assistance with eating for one (1) of six (6) residents (Resident #128) reviewed for nutrition and one (1) of 19 residents (Resident #140) reviewed for dining. Specifically, 1) Resident #128, who had significant weight loss and required maximal assistance with eating was observed receiving only set up assistance during meals; 2) Resident #140, who had a history of weight loss and required moderate assistance with eating was observed receiving mostly only set up assistance during meals. The findings included:The Facility Activities of Daily Living Policy last reviewed 10/03/2025 documented that appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 reviews during the recertification survey, the facility did not ensure that the residents' environment remained as free of accident hazards as possible for one (1) of two (2) residents (Resident #72) reviewed for Accidents. Specifically, Resident #72 had a history of falls and multiple safety interventions in place including keeping the environment well lit and clutter free. Floor mats were determined to be a tripping hazard and not included as an intervention for their safety; however, floor mats were observed in the room and staff reported that they were in use. The findings included:The Facility Managing Fall Risk and Prevention policy dated 06/24/2025 documented based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident #72 had diagnoses that included dementia, obstructive uropathy…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, interview, and record review the facility did not ensure care consistent with professional standards of practice, and the comprehensive person-centered care plan was provided for one (1) of two (2) residents (Resident #69) reviewed for Respiratory Care. Specifically, Resident #69 was administered oxygen at a liter flow greater than the current physician's order.The findings included:An undated, untitled facility policy documented guidelines for safe oxygen administration included review the physician's orders or facility protocol for oxygen administration.Resident #69's diagnoses included dysphagia following other cerebrovascular disease, Alzheimer's disease and chronic obstructive pulmonary disease. The quarterly Minimum Data Set, dated [DATE] document Resident #69 had severe cognitive impairment, was short of breath when lying flat and received oxygen therapy. A physician order dated 03/03/2026 documented two (2) liters of oxygen via nasal cannula continuously every shift for chronic…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 interviews and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure a resident received behavioral health services to attain their highest practicable well-being, in accordance with the comprehensive assessment and plan of care. This was evident for one (1) (Resident #9) of one (1) resident reviewed for Behavioral/Emotional Status. Specifically, Resident #9 had a physician order for a psychiatry and psychology consultation after making an inappropriate sexual comment to another resident on [DATE]. Resident #9 was not evaluated by a psychiatrist or psychologist in accordance with the physician order. The findings included:A facility policy titled Behavior Health Services, revised 04/2024 documented the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure 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 observations and interviews during a recertification survey from 3/08/2026 to 3/13/2026, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, six (6) food items were not properly identified in the kitchen refrigerators, freezers, and food storage areas and one dietary cook was not wearing a beard net while actively preparing food.The findings include:The policy titled Food Receiving and Storage last approved 09/12/2025, documented that refrigerated foods are labeled, dated and monitored.On 3/08/2025 at 11:28 a.m., the initial inspection of the kitchen was conducted with the Dietary Supervisor, and the following were observed:One (1) tray of apple and pineapple cups not labeled with identification in the snack refrigerator.One (1) tray of cottage cheese cups, three (3) apples in cups and two (2) oranges in cups were not labeled with identification in the snack refrigerator.One (1) tray of pudding cups not labeled with identification in the portable tray rack.Three (3) peanut butter cups not labeled…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during abbreviated survey #2637567, the facility did not ensure accurate documentation of medical records in accordance with accepted professional standard and practice were maintained for one (1) (Resident #1) of three (3) residents reviewed for activity of daily living care. Specifically, Certified Nurse Aide #1 documented in the electronic medical record activity of daily living cares on [DATE] that had not been provided. Additionally, although Resident #1 expired on [DATE] at 12:20 AM and their remains were removed from the facility at approximately 3:00 AM, Licensed Practical Nurse #10 documented hourly rounding was completed for Resident #1 on [DATE] from 11:45 PM-6:45 AM.The findings included:Resident #1 was admitted to facility with diagnoses including but not limited to Pneumonia, Coronary Artery Disease, and Heart Failure.The [DATE] Five-day admission Minimum Data Set (MDS) documented Resident #1 had severe cognitive impairment, was dependent for toileting,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, interviews and record review completed during a complaint investigation (NY00374056) the facility did not maintain infection prevention and control practices in accordance with guidelines for enhanced barrier precautions for one (Resident #2) of three residents reviewed for infection control practices. Specifically, Resident #2 was on enhanced barrier precautions, as indicated by signage posted on the wall outside of their room. On three separate occasions, staff provided hands-on care without wearing gowns.Record review:The facility policy titled Enhanced Barrier Precautions, dated 1/28/25 documented that enhanced barrier precautions are utilized to reduce the transmission of multi-drug-resistant organisms to residents. The policy listed examples of high contact resident care activities requiring gown and glove use one of which was device care or use, as well as dressing a resident.Resident #2's quarterly review minimum data set assessment dated [DATE] documented active diagnoses 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews conducted during abbreviated survey (NY00331188) the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1(Resident #2) of 4 residents reviewed for Abuse. Specifically, Resident #2's Behavior Care Plan initiated 4/22/22 documented that they were two assists with cares due to history of accusatory behaviors and the care plan was not reviewed and revised to populate these interventions onto Certified Nurse Aides tasks/documentation. Certified Nurse Aide #2 was unaware of Resident #2's plan of requiring two person assists and they provided care to Resident #2 without another staff member present. Resident #2 accused Certified Nurse Aide #2 of alleged abuse after cares were provided. The Findings are: The Facility policy titled Care Plans, Comprehensive Person-Centered last revised on 3/2022 documented that the comprehensive person-centered care plan describes the services that are furnished to attain or maintain 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Ecited before2023-11-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 observations and interviews conducted during the recent recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. Cold foods were stored in a soiled, unsanitary refrigerated unit, 2. Cold foods to be served at activities events were stored in an unsanitary manner in a refrigerated unit, 3. Unlabeled, defrosted, uncooked, ground beef was stored in a refrigerated unit, 4. cooling logs were being utilized to ensure that foods were cooled in a safe and timely manner, 5. 2 of 7 nourishment refrigerators were not maintained at safe temperatures for food safety, and 5. Two food service staff did not follow safe food handling practices while recording food temperatures. The findings are: The initial tour of the kitchen was conducted on 11/08/2023 at 10:23 AM and the following were noted: 1) A chest freezer was in use as a refrigerated unit. The chest freezer unit was observed with external soiling which included grimy, black-ish colored smears, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification and abbreviated surveys (NY 309477) conducted from 11/8/2023 through 11/17/2023, the facility did not ensure a thorough and complete investigation was conducted for 1 of 3 residents (Resident #70) reviewed for abuse/neglect. Specifically, for Resident #70 the facility did not conduct a complete and thorough investigation, including a root cause analysis to determine why physician recommended magnesium citrate scheduled for 1/10/2023 and 1/11/2023 was not administered for management of the residents' constipation. Subsequently on 1/12/2023 Resident #70 required manual dis-impaction. The findings are: An undated protocol titled Abuse and Neglect - Clinical Protocol documented that abuse included the deprivation by an individual, including a care taker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being, and neglect was defined as the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews conducted during the recertification survey from 11/8/23 to 11/17/23, the facility did not provide an ongoing program of activities for 1 of 4 residents (Resident #39) reviewed for activities. Specifically, Resident #39 was not provided opportunities to consistently participate in independent activities of their choice and to be regularly reassessed for their preferences. Findings include: Resident #39 was admitted with diagnoses including Multiple Sclerosis and optic neuritis. The annual Minimum Data Set (MDS: an assessment tool) dated 4/11/2023 documented the resident was cognitively intact for decision making. Preferences for daily activities included music, keeping up with the news, and getting fresh air. The MDS documented the resident was totally dependent on staff for activities of daily living except for eating, for which the resident received extensive assistance. The resident had participated in the assessment. The resident's Care Plan for Activities dated 7/14/2021, and updated 4/28/2023, documented the resident preferred…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observation, record review, and interviews conducted during the recertification and abbreviated surveys (#NY00326212 and NY00309477) from 11/8/23 to 11/17/23, the facility did not ensure 1 of 3 residents (Resident #70) reviewed for abuse/neglect and 1 of 3 (Resident #63) reviewed for medications, received care and treatment in accordance with professional standards. Specifically, 1) Resident #70's medications for constipation was not given timely, the physician and pharmacy were not notified when the medication was unavailable; and 2) Resident #63 was not provided their medication with meals as ordered. Findings include: 1) Resident #70 was admitted with diagnoses including anemia, anxiety disorder, and constipation. The 5-day Minimum Data Set (MDS: an assessment tool) dated 11/25/2022 documented the resident was cognitively intact for decision making. Functional status indicated total dependence with one person assist for toilet use. The resident was always incontinent of bowel and bladder and did 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 residents were provided the appropriate treatment to improve and/or prevent a further decline in range of motion (ROM) for 1 of 2 residents, (Resident #120) reviewed for positioning and limited mobility. Specifically, Resident # 120 was not provided soft booties as per physical therapy recommendations. Resident #120 was admitted with diagnoses and medical conditions including but not limited to encephalopathy, cerebral vascular accident (Stroke), and generalized muscle weakness. The 11/05/2020 risk for chronic pain related to contractures and impaired mobility care plan, revised 11/10/23, did not include use of soft booties or monitoring the effect(s) of their use. The 11/8/2020 alteration in musculoskeletal status related to contracture of bilateral hand and feet care plan, revised on 11/10/23, directed supportive devices as recommended. The 9/14/2021 Physical Therapy (PT) evaluation documented Resident # 120 was referred to skilled PT due to noted…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews conducted during the recertification survey conducted from 11/8/2023 to 11/17/2023, it was determined that for one of four (Resident #82) reviewed for respiratory care, the facility did not ensure that the resident received proper respiratory treatment and care consistent with professional standards of practice, and the comprehensive person-centered care plan. Specifically, Resident #82 did not receive continuous oxygen 3L/min via nasal cannula as per physician order. Findings include: Resident #82 was admitted to the facility with diagnoses including cerebral infarction, respiratory failure and anxiety. The 8/15/2023 Minimum Data Set Assessment documented Resident #82 had severely impaired cognition and required oxygen therapy. The 3/18/2023 physician order documented continuous oxygen 3L/min via nasal cannula. The November 2023 Medication Administration Record (MAR) documented continuous oxygen 3L/min was administered every shift from 11/1/2023 through the 11/15/2023 day shift. The 4/28/2023 revised Comprehensive Care Plan (CCP)…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation and interview during the 11/8/2023 -11/17/2023 recertification survey, it could not be ensured that for 3 of 3 residents (Resident # 35, #126 and #129) reviewed for dignity that the residents' rights and/or that care was provided in a dignified manner. Specifically, Residents #35, #126 and #129 were not provided a dignified dining experience. The findings are: Resident #35 was admitted with diagnoses including dementia. The Minimum Data Set (MDS, an assessment tool) dated 10/25/23 documented Resident #35 had severely impaired cognition. Resident #126 had diagnoses including Alzheimer's Disease, dysphagia, and muscle weakness. The Minimum Data Set (MDS, an assessment tool) dated 9/21/23 documented Resident #126 had severely impaired cognition. Resident #129 had diagnoses including depression and anxiety. The Minimum Data Set (MDS, an assessment tool) dated 9/15/23 documented Resident #129 had severely impaired cognition. During a meal observation on 11/15/23 from 9:30 AM to 9:45 AM, Residents #35, #126, and #129 were eating in the hallway. The 3…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-04-18 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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, the facility did not determine there had been a significant change in the residents mental or physical condition within 14 days for 1 resident (#104) reviewed for decline in Activities of Daily Living (ADLs). Specifically, a significant change Minimum Data Set (MDS: a resident assessment tool) was not completed to ensure all appropriate interventions were in place after a decline from extensive assist to total dependence was identified in two areas of ADLs. Specifically, the resident declined from extensive assistance to total dependence for toilet use and personal hygiene. The findings are: Resident #104 was admitted on [DATE] with diagnoses including but not limited to Cirrhosis, Hepatitis and Non-Alzheimer's dementia. The admission MDS dated [DATE] documented the resident's BIMS score (Brief Interview for Mental Status) was 3 out of 15 which indicated the resident had severe cognitive impairment and required extensive assistance…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-04-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that comprehensive person-centered care plans with measurable goals and interventions were developed to address the residents' respiratory and diabetic needs. Specifically, 1) 1 resident (Resident #28) reviewed for respiratory care did not have care plans in place to address her respiratory needs; and 2) 1 of 5 residents (Resident # 28) reviewed for unnecessary medications did not have care plans in place to address her diabetic needs. The findings are: 1. Resident # 28 was admitted to the facility with diagnoses including Parkinson Disease, Dementia, and Shortness of Breath. According to the 1/16/19 minimum data set (MDS- a resident assessment tool) the resident had severe cognitive impairment, was dependent on oxygen therapy for lung support, and required total staff assist for related to activities of daily living (ADLs). The 4/12/19 physician's orders had instructions for 4 Liters 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-04-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, interview and record review conducted during the recertification survey, the facility did not ensure that staff followed protocol for the care of a BI-PAP machine (a device to treat sleep apnea) for 1 resident (Resident # 28) who required respiratory support. The findings are: 1. Resident # 28 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia and Shortness of Breath. According to the 1/16/19 minimum data set (MDS- a resident assessment tool) the resident had severe cognitive impairment, was dependent on oxygen therapy for breathing support and required total staff assistance with activities of daily living (ADLs). The 4/12/19 physician's orders had instructions for 4 L of oxygen via nasal cannula continuously every shift and BI-PAP therapy at bedtime. Review of the 11/18/16 policy on BI-PAP/CPAP administration revealed instructions that included but were not limited to: 1) follow manufacturer's instructions and guidelines for cleaning 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-04-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 interviews and record review conducted during the recertification survey, it was determined that for one of five residents reviewed for unnecessary medications, the facility did not ensure that the resident's drug regimen was reviewed at least once a month by a licensed pharmacist. Specifically, no drug regimen review was completed for Resident #104 for the month of February 2019. (Resident #104). The findings are: Resident # 104 was admitted on [DATE] with diagnoses including Non-Alzheimer's' Dementia, Depression, and Psychotic disorder. Review of the medical record revealed a Drug Regimen Review (DRR) was conducted on 1/31/19, and a subsequent DRR was conducted on 3/17/19. No DRR was found for February 2019 and a time frame of 45 days lapsed between DRRs. The facility Drug Regimen Review policy and procedure dated 11/16/18 documented the consultant pharmacist performs a comprehensive Drug Regimen Review (DRR) at least monthly on all residents of the facility. The Director of Nursing (DON) 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-04-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not ensure that each residents' medication regimen was free from unnecessary medications. Specifically, the Psychiatrist's recommendation to discontinue Cymbalta (antidepressant) was not communicated to the resident's primary medical doctor concurrent with a new order for a different antidepressant, resulting in the administration of duplicate medication therapies to the resident for a period of 12 days (4/4/19 to 4/15/19). This was evident for 1 of 5 residents reviewed for unnecessary medications (Resident #104). Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking. The finding is: Resident # 104 was admitted on [DATE] with diagnoses including Non-Alzheimer's' Dementia, Depression, and Psychotic disorder. The admission MDS (Minimum Data Set: a resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-04-18 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review conducted during a recent recertification survey, the facility did not ensure that its medication error rate 5% or less. This was evident for 1 of 5 residents observed during a medication pass (Resident # 4). This resulted in an error rate of 12% out of total of 25 opportunities observed. The findings are: Resident # 4 has diagnoses and conditions including Diabetes, Heart Failure, and Hypertension. A medication pass was conducted on 4/15/19 at 8:50AM on the Team 2 Unit. The Licensed Practical Nurse (LPN # 1) administered the resident's morning medications, including, but not limited to Vitamin C 500 mg tablet, Cetirizine HCL (antihistimine)10mg tablet, and one daily multivitamin tablet from the facility's supply of stock medications. Review of the physician's orders dated 3/29/19 revealed the resident should have received Vitamin C 1,000mg tablet oral daily for supplement, Thera-M (Multiple Vitamins-Minerals) tablet oral daily for supplement, and Claritin 10mg tablet oral daily for allergy. The resident did not receive the mineral…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-04-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that the facility staff followed proper hand hygiene, gloving, and proper cleansing of a blood glucose monitoring device to prevent the spread of infection. This was evident for 1 of 7 residents reviewed for pressure ulcer wound care (Resident #119) and 3 of 5 residents observed during medication administration (Resident #s 4, 98 and 105). The findings are: 1. Resident # 4 has diagnoses and conditions including Diabetes, Heart Failure, and Hypertension. A medication pass was conducted on 4/15/19 at 8:50AM on the Team 2 Unit and the following were observed: Prior to pouring the resident's medications, the Licensed Practical Nurse (LPN # 1) tested the resident's blood glucose level using a Glucometer device. LPN #1 removed the device from the storage pouch and placed it on the resident's over-bed table without cleansing the ovew-bed table or applying a protective barrier. LPN # 1 cleansed the resident's finger with an alcohol-based prep pad, then stuck 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-04-18 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview conducted during the recertification survey it was determined that residents were not aware of the location of the results of the most recent survey. Specifically, the signage indicating the location of the most recent survey and the actual survey results were placed together in an area not readily available to the public. The findings are: Upon entering the facility on 4/10/19 at 9:00 AM an attempt was made to locate the most recent survey results. A sign indicating the location of the survey results and the most recent survey were found together near a window by the front entrance behind a piano. This location eliminated easy access to the documents. The resident council meeting was held on 4/11/19 at 11:00 AM and had a representative from each of the nursing units(Teams) except Team 3. During the meeting, 7 of 7 residents stated that they did not know where the survey results were located. In an interview with the Administrator on 4/12/19 at 3:00 PM he stated that he didn't want to place a notice on the reception desk because the desk gets…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-04-18 · tag F0625 — widespread
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the recertification survey, the facility did not ensure that for 2 of 2 residents (Resident #119 and #183), reviewed for hospitalization, that the resident and/or their representatives received written notification of the facility bed hold policy. The findings are: 1. Resident #183 was admitted to the facility on [DATE] with diagnoses including major depression, hypertension and dementia. On 03/26/19 a nurse's note documented that the resident was alert but her appetite remained poor. Fluids by mouth were encouraged in addition to the resident being provided with a nutritional supplement. On 03/27/19 at 10:20 AM the resident's physician wrote an order for the resident to be transferred to the hospital for acute hyperkalemic renal failure. On 04/18/19 at 03:30pm the Director of Social Work (DSW) was interviewed and asked about the facility policy of providing written notification to residents or family representatives regarding bed hold upon discharge or…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-04-18 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews conducted during the recent recertification survey, the facility did not ensure that garbage and refuse were contained and disposed of in an appropriate manner. Specifically, the area surrounding the trash compactor was not maintained in a sanitary condition. The findings are: An observation of the trash compactor area was conducted on 4/16/19 at about 12:45 PM. The following was observed: -Three large, clear plastic bags containing empty beverage containers, Styrofoam and disposable serve ware and plastic straws, were observed behind the trash compactor. -Three small, clear plastic bags containing used disposable diapers were observed on the left side of the trash compactor. -Loose debris was strewn about the left side of and behind the compactor including used paper, plastic, and Styrofoam disposable serve ware, straws and empty milk and supplement containers. All the items were mixed in with dirty pieces of paper and leaves. An odor of garbage emanated from the area. The facility Policy and Procedure titled: Waste Handling, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2019-04-18 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 upon observations, interview and record review conducted during the recertification survey, the facility did not ensure that advance directives formulated for one resident (#104) were effectively implemented according to facility policy to identify the residents' written consent for Do Not Resuscitate (DNR). Specifically, an identifier (orange dot) indicating DNR was not found on the resident's identification (ID) band and on the paper chart spine. The facility is required to establish, maintain, and implement written policies and procedures regarding the residents' right to formulate an advance directive, refuse medical or surgical treatment. In addition, the facility management is responsible for ensuring that staff follow those policies and procedures. The finding is: Resident #104 was admitted on [DATE] with diagnoses including but not limited to Cirrhosis, Hepatitis and Non-Alzheimer's dementia. The admission MDS (Minimum Data Set: a resident assessment tool) dated 2/7/19 documented the residents'…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2019-04-18 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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 interview conducted during the recertification survey, the facility did not ensure that 1 of 6 residents (#62) was consistently invited to care plan meetings. Specifically, Resident # 62 stated during an interview that she attended one care plan meeting soon after admission but has not been invited to any further care plan meetings. Review of the Comprehensive Care Plan (CCP) Policy dated 02/19/2019 revealed that to ensure resident and family participation in the interdisciplinary treatment plan, residents (as they are able to) and families are invited to attend during an initial, annual or significant change CCP meetings. The findings are: Resident #62 was admitted to the facility on [DATE] with diagnoses including; Cellulitis of left lower limb, Type 2 Diabetes Mellitus and Hypertension. The Minimum Data Set (MDS - a resident assessment tool) dated 02/21/2019 documented that her Brief Interview for Mental Status (BIMS) score was 13 out of a possible 15, indicating she was cognitively…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARERITE CENTERS — 34 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.6-0.6 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 33 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Bethany Center For Rehabilitation And Healing LLCNashville, TN 1 of 5Quality Center For Rehabilitation And Healing LLCLebanon, TN 2 of 5Nashville Center For Rehabilitation And Healing LlNashville, TN 2 of 5Sans Souci Rehabilitation And Nursing CenterYonkers, NY 2 of 5The Grove At Valhalla Rehab And Nursing CenterValhalla, NY 2 of 5The Paramount At Somers Rehab And Nursing CenterSomers, NY 2 of 5Waters Edge at Port Jefferson for Rehabilitation aPort Jefferson, NY 3 of 5Coral Reef Subacute Care Center LLCMiami, FL 3 of 5Encore At Boca Raton Rehabilitation And Nursing CeBoca Raton, FL 3 of 5Glengariff Health Care CenterGlen Cove, NY 3 of 5Green Hills Center For Rehabilitation And HealingNashville, TN 3 of 5Pearl At Fort Lauderdale Rehabilitation And NursinFort Lauderdale, FL 3 of 5Savoy At Fort Lauderdale Rehabilitation And NursinFort Lauderdale, FL 3 of 5The Emerald Peek Rehabilitation And Nursing CenterPeekskill, NY 3 of 5The Grand Pavilion For Rehab & Nursing at RockvillRockville Centre, NY 3 of 5Trevecca Center For Rehabilitation And Healing LLCNashville, TN 4 of 5Chatham Hills Subacute Care CenterChatham, NJ 4 of 5Creekside Center For Rehabilitation And HealingMadison, TN 4 of 5Gallatin Center For Rehabilitation And HealingGallatin, TN 4 of 5Legacy At Boca Raton Rehabilitation And Nursing CeBoca Raton, FL 4 of 5Manchester Center For Rehabilitation And Healing LManchester, TN 4 of 5St James Rehabilitation & Healthcare CenterSt James, NY 5 of 5Cortlandt HealthcareCortlandt Manor, NY 5 of 5Lebanon Center For Rehabilitation And Healing, LLCLebanon, TN 5 of 5Luxor Nursing & Rehabilitation at Mills PondSt James, NY 5 of 5Palmetto Subacute Care CenterMiami, FL 5 of 5Sayville Nursing And Rehabilitation CenterSayville, NY 5 of 5The Chateau At Brooklyn Rehabilitation and NursingBrooklyn, NY 5 of 5The Enclave At Rye Rehab And Nursing CtrPort Chester, NY 5 of 5The Hamlet Rehabilitation and Healthcare Center atNesconset, NY 5 of 5The Monarch at Brooklyn Rehabilitation and NursingBrooklyn, NY 5 of 5The Phoenix Rehabilitation and Nursing CenterBrooklyn, NY 5 of 5The RiversideNew York, NY

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 / managerTypeRoleShareSince
AHUJA, SANJAYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF15%since 07/01/2012
EINHORN, NEALIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNF9%since 07/01/2012
EINHORN, SHARONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF9%since 07/01/2012
FRIEDMAN, DEVORAHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF9%since 07/01/2012
FRIEDMAN, MARKIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNF9%since 07/01/2012
MOHAN, NAMITAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF15%since 08/01/2006
MUDGIL, VANITAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF15%since 08/01/2006
ZIMILES, JOSEPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; ADP OF THE SNF15%since 07/01/2012
ZUCKER, YOSSIEIndividualDIRECT OWNERSHIP INTERESTsince 07/01/2012
GREEN-RIVERS, KELLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2016
HALON, JONATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/02/2016
SHAH, PARAGIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/05/2015

CMS files one row per role, so the 29 rows in the source record cover these 12 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.

$32.7M
Net patient revenuemost recent cost report
+4.2%
Operating marginrevenue minus expenses
$4.0M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 63%Medicare 21%Other / private 16%

This home reported $4.0M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$460per resident / day
operating cost
$13,988per month
≈ monthly operating cost
$480per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

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 335148. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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.

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