Cycle 1
Health 2024-09-17 · Fire 2024-09-17
30 health deficiencies
Top issue: Resident Rights (7 deficiencies)
27 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Hyde Park, NY
The Eleanor Nursing Care Center
1-star overall rating with 1-star inspections with Special Focus status with $132,957 in total fines with 30 recent health deficiencies with 27 fire-safety deficiencies in the latest cycle
419 North Quaker Lane, Hyde Park, NY
(845) 229-9177
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-03-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.80
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,419
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.04% · Performance 21.74% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.66% · Performance 8.98% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.72
Baseline 37.68% · Performance 36.21% · Measure score 6.72 · Achievement 6.72 · Improvement 0.65
Adjusted total nurse staffing
0
Baseline 2.85 hours · Performance 2.63 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 10.6% · Lower 95% interval 7.38% |
| Discharge to community | 35.63% |
50.57%
14.9 pts worse
|
Worse than the National Rate · Eligible stays 154 · Observed rate 26.62% · Lower 95% interval 28.1% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 20.73% |
95.27%
74.5 pts worse
|
Numerator 17 · Denominator 82 |
| Falls with major injury | 1.22% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 82 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 20 · Denominator 48 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 24 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.22% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 82 · Adjusted rate 1.01% |
| Healthcare-associated infections requiring hospitalization | 8.98% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 12.94% · Lower 95% interval 5.65% |
| Staff COVID-19 vaccination coverage | 3.51% |
8.2%
4.7 pts worse
|
Numerator 4 · Denominator 114 |
| Staff flu vaccination coverage | 29.91% |
42%
12.1 pts worse
|
Numerator 35 · Denominator 117 |
| Discharge function score | 60.42% |
56.45%
4 pts better
|
Numerator 29 · Denominator 48 |
| Transfer of health information to provider | 83.33% |
95.95%
12.6 pts worse
|
Numerator 25 · Denominator 30 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 5.26% |
25.2%
19.9 pts worse
|
Numerator 2 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
95.3%
3.7 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.0%
1.6 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 2.2% · Q4 2.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
18.5%
17.3 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.4% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.1%
2.1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.6% · Q3 2.2% · Q4 4.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.2% |
13.5%
16.7 pts worse
|
19.6%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 33.0% · Q3 27.8% · Q4 29.3% · 4Q avg 30.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.0% |
14.8%
19.2 pts worse
|
16.7%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 31.9% · Q3 35.7% · Q4 31.7% · 4Q avg 34.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.0% |
15.1%
13.9 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 30.2% · Q3 30.5% · Q4 23.6% · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
15.5%
8.1 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 18.8% · Q3 27.7% · Q4 21.4% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.6%
0.1 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 1.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.4% |
20.8%
11.6 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 39.8% · Q3 34.0% · Q4 17.2% · 4Q avg 32.4% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
6.9%
1 pts better
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 2.0% · Q3 6.0% · Q4 6.6% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
76.7%
22.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
9.7%
1.7 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 8.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.2%
1.5 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 6.1% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.8% |
78.8%
11 pts better
|
79.7%
10.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
20.6%
4.2 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 27.7% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-02 · Fire 2022-08-02
15 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2019-09-16 · Fire 2019-09-16
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2024-09-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-09-17
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-09-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-09-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-09-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-09-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-09-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-02
C · Minimal harm
2024-09-17
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-12-02
C · Minimal harm
2024-09-17
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-11-27
C · Minimal harm
2024-09-17
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-11-27
C · Minimal harm
2024-09-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-02
C · Minimal harm
2024-09-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-02
E · Potential for more than minimal harm
2022-08-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-09-25
E · Potential for more than minimal harm
2022-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-25
E · Potential for more than minimal harm
2022-08-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-25
E · Potential for more than minimal harm
2022-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-08-02
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-08-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-08-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-09-25
C · Minimal harm
2022-08-02
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-09-25
C · Minimal harm
2022-08-02
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-09-25
C · Minimal harm
2022-08-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-25
C · Minimal harm
2022-08-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-09-25
C · Minimal harm
2022-08-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-09-25
C · Minimal harm
2022-08-02
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-09-25
E · Potential for more than minimal harm
2019-09-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-09-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-09-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-09-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-09-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-09-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-09-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-09-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-09-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-09-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-09-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-09-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-11-27
C · Minimal harm
2019-09-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-11-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Not marked corrected
D · Potential for more than minimal harm
2025-12-05
F584 · Resident Rights Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2025-12-05
F838 · Administration Deficiencies
Health
Conduct 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.
Not marked corrected
F · Potential for more than minimal harm
2025-05-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-07-05
E · Potential for more than minimal harm
2025-05-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-05-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-05-06
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-05-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-05
K · Immediate jeopardy
2024-09-17
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-16
E · Potential for more than minimal harm
2024-09-17
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-17
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-09-17
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-05-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-01-29
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-29
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-29
F838 · Administration Deficiencies
Health
Conduct 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.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-29
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-02
D · Potential for more than minimal harm
2023-10-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-06-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-04
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-07-20
E · Potential for more than minimal harm
2022-08-02
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-09-16
E · Potential for more than minimal harm
2019-09-16
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-11-14
E · Potential for more than minimal harm
2019-09-16
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2019-11-14
E · Potential for more than minimal harm
2019-09-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-14
E · Potential for more than minimal harm
2019-09-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-14
E · Potential for more than minimal harm
2019-09-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-09-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-09-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-14
B · Minimal harm
2019-09-16
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2019-11-14
Penalties and ownership
What sits behind the stars
$132,957
2024-09-17
Fine
Fine · fine $132,957
Fine
Ownership
Koschitzki, Jack
5% Or Greater Direct Ownership Interest · Individual
Albrecht, Barbara
Operational/Managerial Control · Individual
Imperati Ramsey, Alexandra
Operational/Managerial Control · Individual
Jones, Roxanne
Operational/Managerial Control · Individual
Koschitzki, Elliot
Operational/Managerial Control · Individual
Kovacs, Andrea
Operational/Managerial Control · Individual
Maus, Renee
Operational/Managerial Control · Individual
Negron, Christopher
Operational/Managerial Control · Individual
Patel, Deepesh
Operational/Managerial Control · Individual
Santiago, Ralph
Operational/Managerial Control · Individual
Tarazona, Fernando
Operational/Managerial Control · Individual
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#3
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