Based on observations, record review, and interviews during the survey, the facility failed to develop, implement, and maintain an effective compliance and ethics program that is likely to be effective in preventing and detecting criminal, civil, and administrative violations and promoting quality of care. Specifically, the facility failed to create and promote a program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution. …
F895 citations in New York
Administration Deficiencies
Have a Compliance and Ethics Program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New York cites F895 more often than its own record predicts
4.41 times the share F895 takes of citations nationally.
Of every deficiency written in New York in 2025, this is the portion that was F895.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New York surveyors wrote
F895 findings written in New York, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 3.02× |
| 2025 | 0.04% | 4.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction