Cycle 1
Health 2025-03-07 · Fire 2025-03-07
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Brooklyn, NY
Atrium Center For Rehabilitation And Nursing
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
630 E 104th Street, Brooklyn, NY
(718) 240-3100
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
380
Certified beds
Average residents
366
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
1992-08-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
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
0.69
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.01
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.67
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
14%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,250
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.03
Baseline 17.25% · Performance 20.03% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Healthcare-associated infections
0
Baseline 7.47% · Performance 11.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 27.95% · Performance 17.99% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0.37
Baseline 2.36 hours · Performance 2.66 hours · Measure score 0.37 · Achievement 0 · Improvement 0.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 257 · Observed rate 9.73% · Lower 95% interval 7.58% |
| Discharge to community | 40.62% |
50.57%
10 pts worse
|
Worse than the National Rate · Eligible stays 267 · Observed rate 33.71% · Lower 95% interval 33.64% |
| Medicare spending per beneficiary | 1.73 |
1.02
0.7 pts worse
|
|
| Drug regimen review with follow-up | 78.96% |
95.27%
16.3 pts worse
|
Numerator 349 · Denominator 442 |
| Falls with major injury | 0.23% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 442 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 189 · Denominator 297 |
| Discharge mobility score | 62.29% |
50.94%
11.4 pts better
|
Numerator 185 · Denominator 297 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 3 · Denominator 442 · Adjusted rate 0.58% |
| Healthcare-associated infections requiring hospitalization | 11% |
7.12%
3.9 pts worse
|
Worse than the National Rate · Eligible stays 147 · Observed rate 14.97% · Lower 95% interval 8.13% |
| Staff COVID-19 vaccination coverage | 0.22% |
8.2%
8 pts worse
|
Numerator 1 · Denominator 448 |
| Staff flu vaccination coverage | 35.07% |
42%
6.9 pts worse
|
Numerator 141 · Denominator 402 |
| Discharge function score | 61.95% |
56.45%
5.5 pts better
|
Numerator 184 · Denominator 297 |
| Transfer of health information to provider | 91.18% |
95.95%
4.8 pts worse
|
Numerator 124 · Denominator 136 |
| Transfer of health information to patient | 92.13% |
96.28%
4.2 pts worse
|
Numerator 117 · Denominator 127 |
| Resident COVID-19 vaccinations up to date | 14.16% |
25.2%
11 pts worse
|
Numerator 32 · Denominator 226 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.2 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.1% |
91.2%
10.1 pts worse
|
93.4%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.4% · Q2 82.9% · Q3 86.0% · Q4 86.4% · 4Q avg 81.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
95.3%
3.1 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.0%
2.1 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.9% · Q3 1.2% · Q4 1.3% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.7% |
18.5%
81.2 pts worse
|
11.4%
88.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.3% · Q3 99.7% · Q4 99.7% · 4Q avg 99.7% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
6.1%
0.2 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.8% · Q3 7.4% · Q4 6.6% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.5% |
13.5%
10 pts better
|
19.6%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.7% · Q3 3.1% · Q4 3.5% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
14.8%
4.3 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 10.5% · Q3 10.6% · Q4 8.9% · 4Q avg 10.5% · 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 | 9.6% |
15.1%
5.5 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 15.8% · Q3 8.6% · Q4 8.9% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
15.5%
3.9 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 17.1% · Q3 11.3% · Q4 11.8% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.2% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.4%
1.2 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.3% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.3% |
20.8%
18.5 pts better
|
19.8%
17.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.5% · Q3 1.2% · Q4 1.5% · 4Q avg 2.3% |
| 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 6.4% · Q2 6.5% · Q3 6.8% · Q4 3.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.2% |
76.7%
8.5 pts worse
|
81.7%
13.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.2% · Q2 63.2% · Q3 78.9% · Q4 74.7% · 4Q avg 68.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
9.7%
4.3 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.6% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.7% |
78.8%
8.1 pts worse
|
79.7%
9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
20.6%
5.5 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 16.0% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-12 · Fire 2023-04-12
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2020-03-11 · Fire 2020-03-11
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-04
D · Potential for more than minimal harm
2025-03-07
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-04
F · Potential for more than minimal harm
2023-04-12
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-12
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-12
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-12
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-04-12
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-04-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-04-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-30
E · Potential for more than minimal harm
2020-03-11
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-05-10
E · Potential for more than minimal harm
2020-03-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-05-10
E · Potential for more than minimal harm
2020-03-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-11
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 2020-05-10
D · Potential for more than minimal harm
2020-03-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-11
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2020-05-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-07
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 2025-05-05
D · Potential for more than minimal harm
2025-03-07
F560 · Resident Rights Deficiencies
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-07
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 2025-05-05
D · Potential for more than minimal harm
2025-03-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-07
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-07
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 2025-05-05
D · Potential for more than minimal harm
2025-03-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-07
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 2025-05-05
F · Potential for more than minimal harm
2023-04-12
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 2023-06-12
D · Potential for more than minimal harm
2023-04-12
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 2023-06-12
D · Potential for more than minimal harm
2023-04-12
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 2023-06-12
D · Potential for more than minimal harm
2023-04-12
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 2023-06-12
D · Potential for more than minimal harm
2023-04-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-12
B · Minimal harm
2023-04-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-12
D · Potential for more than minimal harm
2020-03-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-05-08
Penalties and ownership
What sits behind the stars
Ownership
Carrol, Lennox
Operational/Managerial Control · Individual
Excelsior Care Group
Operational/Managerial Control · Organization
Khabye-Hasbani, Shaya
Operational/Managerial Control · Individual
Leifer, Constance
5% Or Greater Direct Ownership Interest · Individual
Leifer, Joel
5% Or Greater Direct Ownership Interest · Individual
Leifer, Joel
Corporate Director · Individual
Leifer, Joel
Corporate Officer · Individual
Rubinstein, Steven
Operational/Managerial Control · Individual
Steinberg, Moshe
Operational/Managerial Control · Individual
Stern, Samuel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Four Seasons Nursing And Rehabilitation Center
Brooklyn, NY
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Spring Creek Rehabilitation & Nursing Care Center
Brooklyn, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Schulman And Schachne Inst For Nursing & Rehab
Brooklyn, NY
2-star overall rating with 2-star inspections with $15,646 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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