Cycle 1
Health 2025-03-21 · Fire 2025-03-21
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Ossining, NY
Bethel Nursing Home Company Inc
4-star overall rating with 2-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
17 Narragansett Avenue, Ossining, NY
(914) 941-7300
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
43
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-04-01
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
1.34
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
1.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.36
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.49
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,223
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.47% · Performance 21.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.74% · Performance 7.98% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.23
Baseline 7.14% · Performance 54.55% · Measure score 2.23 · Achievement 2.23 · Improvement 0
Adjusted total nurse staffing
0.71
Baseline 3.79 hours · Performance 3.28 hours · Measure score 0.71 · Achievement 0.71 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 9.76% · Lower 95% interval 6.86% |
| Discharge to community | 49.03% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 43.06% · Lower 95% interval 36.79% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 33 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 77.78% |
53.69%
24.1 pts better
|
Numerator 21 · Denominator 27 |
| Discharge mobility score | 81.48% |
50.94%
30.5 pts better
|
Numerator 22 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 7.98% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 4.61% |
| Staff COVID-19 vaccination coverage | 8.11% |
8.2%
0.1 pts worse
|
Numerator 6 · Denominator 74 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 88.89% |
56.45%
32.4 pts better
|
Numerator 24 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 21 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 45% |
25.2%
19.8 pts better
|
Numerator 9 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
91.2%
0.4 pts worse
|
93.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 93.5% · Q3 86.7% · Q4 88.5% · 4Q avg 90.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.0%
3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.9% |
18.5%
17.6 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.1%
1.1 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.5% · Q3 3.3% · Q4 8.0% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
13.5%
8.2 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 19.4% · Q3 23.3% · Q4 23.1% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
14.8%
3.6 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 20.0% · Q3 21.7% · Q4 23.8% · 4Q avg 18.4% · 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 | 20.9% |
15.1%
5.8 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.3% |
15.5%
10.8 pts worse
|
14.9%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 20.8% · Q3 23.1% · Q4 27.3% · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.6%
1.4 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.6% · Q4 3.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.2% |
1.4%
7.8 pts worse
|
1.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 9.7% · Q3 10.0% · Q4 0.0% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
20.8%
1.7 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 23.2% · Q3 25.5% · Q4 16.2% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
6.9%
4.2 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 2.6% · Q4 3.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.1% |
76.7%
17.6 pts worse
|
81.7%
22.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.1% · Q2 59.4% · Q3 48.0% · Q4 46.2% · 4Q avg 59.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
9.7%
2.2 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 10.3% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.1% |
78.8%
0.7 pts worse
|
79.7%
1.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.6% |
20.6%
6 pts better
|
23.9%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.8% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-08 · Fire 2023-08-08
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-07-27 · Fire 2021-07-27
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-24
F · Potential for more than minimal harm
2025-03-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-24
F · Potential for more than minimal harm
2025-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-03-21
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 2025-05-24
C · Minimal harm
2025-03-21
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-05-24
C · Minimal harm
2025-03-21
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-05-24
C · Minimal harm
2025-03-21
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-05-24
E · Potential for more than minimal harm
2023-08-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-08-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-08-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-10
C · Minimal harm
2023-08-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-10
E · Potential for more than minimal harm
2021-07-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-09-25
E · Potential for more than minimal harm
2021-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-25
E · Potential for more than minimal harm
2021-07-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-25
E · Potential for more than minimal harm
2021-07-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-25
D · Potential for more than minimal harm
2021-07-27
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 2021-09-25
D · Potential for more than minimal harm
2021-07-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-09-25
D · Potential for more than minimal harm
2021-07-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-25
C · Minimal harm
2021-07-27
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2021-09-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-03-21
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 2025-05-20
E · Potential for more than minimal harm
2025-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-03-21
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
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 2025-05-20
D · Potential for more than minimal harm
2025-03-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
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 2025-05-20
D · Potential for more than minimal harm
2023-09-01
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 2023-12-28
D · Potential for more than minimal harm
2023-08-08
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-08
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 2023-10-02
D · Potential for more than minimal harm
2023-08-08
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 2023-10-02
D · Potential for more than minimal harm
2023-08-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-08
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 2023-10-02
D · Potential for more than minimal harm
2023-08-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-08
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 2023-10-02
D · Potential for more than minimal harm
2023-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-02
D · Potential for more than minimal harm
2021-07-27
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 2021-09-24
D · Potential for more than minimal harm
2021-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-24
Penalties and ownership
What sits behind the stars
Ownership
Alexander, Jennifer
W-2 Managing Employee · Individual
Goldstein, Beth
Corporate Officer · Individual
Markopoulos, Anastasios
Operational/Managerial Control · Individual
Markopoulos, Anastasios
Corporate Director · Individual
Markopoulos, Anastasios
W-2 Managing Employee · Individual
The Bethel Methodist Home
Operational/Managerial Control · Organization
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