Brooklyn, NY

Boro Park Center For Rehabilitation And Healthcare

2-star overall rating with 2-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

4915 10th Ave, Brooklyn, NY

(718) 851-3700

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

510

Certified beds

Average residents

487

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Centers Health Care

Operator or chain grouping

Approved since

1976-03-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

35 facilities

Chain averages 2 overall / 2 health / 2 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

0.65

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.62

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.34

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.60

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.27

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.22

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.46

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

0.56

CMS adjusted RN staffing hours

Adjusted total hours

3.11

CMS adjusted total nurse staffing hours

Case-mix index

1.59

Higher values indicate more complex resident acuity

RN turnover

21%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

20%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,545

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29.47

Composite VBP score used to determine payment impact.

Payment multiplier

0.9855

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 23.95% · Performance 23.63% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0.91

Baseline 10.45% · Performance 9.68% · Measure score 0.91 · Achievement 0 · Improvement 0.91

Total nurse turnover

10

Baseline 31.55% · Performance 21.43% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

0.88

Baseline 3.18 hours · Performance 3.33 hours · Measure score 0.88 · Achievement 0.88 · Improvement 0.08

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.35%	10.72% 2.4 pts better	Better than the National Rate · Eligible stays 952 · Observed rate 7.25% · Lower 95% interval 6.83%
Discharge to community	58.49%	50.57% 7.9 pts better	Better than the National Rate · Eligible stays 1150 · Observed rate 51.3% · Lower 95% interval 54.65%
Medicare spending per beneficiary	1.48	1.02 0.5 pts worse
Drug regimen review with follow-up	98.03%	95.27% 2.8 pts better	Numerator 1047 · Denominator 1068
Falls with major injury	0.75%	0.77% About the same	Numerator 8 · Denominator 1068
Discharge self-care score	69.53%	53.69% 15.8 pts better	Numerator 502 · Denominator 722
Discharge mobility score	79.78%	50.94% 28.8 pts better	Numerator 576 · Denominator 722
Pressure ulcers or injuries, new or worsened	5.06%	2.29% 2.8 pts worse	Numerator 54 · Denominator 1068 · Adjusted rate 3.61%
Healthcare-associated infections requiring hospitalization	9.68%	7.12% 2.6 pts worse	Worse than the National Rate · Eligible stays 724 · Observed rate 10.22% · Lower 95% interval 7.87%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 604
Staff flu vaccination coverage	40.16%	42% 1.8 pts worse	Numerator 257 · Denominator 640
Discharge function score	72.85%	56.45% 16.4 pts better	Numerator 526 · Denominator 722
Transfer of health information to provider	99.13%	95.95% 3.2 pts better	Numerator 341 · Denominator 344
Transfer of health information to patient	99.64%	96.28% 3.4 pts better	Numerator 558 · Denominator 560
Resident COVID-19 vaccinations up to date	2.68%	25.2% 22.5 pts worse	Numerator 15 · Denominator 559

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.7 0.8 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.3 About the same	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.2%	91.2% 8 pts better	93.4% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 98.8% · Q3 99.1% · Q4 99.4% · 4Q avg 99.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.7%	95.3% 3.4 pts better	95.5% 3.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7%
Percentage of long-stay residents experiencing one or more falls with major injury	2.1%	3.0% 0.9 pts better	3.3% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.4% · Q3 2.6% · Q4 2.6% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	45.3%	18.5% 26.8 pts worse	11.4% 33.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 45.1% · Q2 45.7% · Q3 46.2% · Q4 44.5% · 4Q avg 45.3%
Percentage of long-stay residents who lose too much weight	3.7%	6.1% 2.4 pts better	5.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.1% · Q3 3.3% · Q4 3.1% · 4Q avg 3.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.0%	13.5% 5.5 pts better	19.6% 11.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.7% · Q3 7.9% · Q4 6.7% · 4Q avg 8.0%
Percentage of long-stay residents who received an antipsychotic medication	13.0%	14.8% 1.8 pts better	16.7% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 13.7% · Q3 14.8% · Q4 12.3% · 4Q avg 13.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.4%	0.2% 0.2 pts worse	0.1% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.6% · Q3 0.3% · Q4 0.3% · 4Q avg 0.4%
Percentage of long-stay residents whose ability to walk independently worsened	17.8%	15.1% 2.7 pts worse	16.3% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 19.8% · Q3 16.1% · Q4 9.6% · 4Q avg 17.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.6%	15.5% 7.1 pts worse	14.9% 7.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 27.2% · Q3 21.7% · Q4 15.4% · 4Q avg 22.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.6% 0.6 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.2% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.4% 1.1 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.3% · Q4 0.3% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.9%	20.8% 2.9 pts better	19.8% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 14.9% · Q3 23.6% · Q4 16.5% · 4Q avg 17.9%
Percentage of long-stay residents with pressure ulcers	8.1%	6.9% 1.2 pts worse	5.1% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.5% · Q3 8.4% · Q4 7.6% · 4Q avg 8.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.4%	76.7% 20.7 pts better	81.7% 15.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 95.8% · Q3 98.1% · Q4 99.0% · 4Q avg 97.4%
Percentage of short-stay residents who had an outpatient emergency department visit	9.7%	9.7% About the same	12.0% 2.3 pts better	Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 8.6% · Expected 10.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.2% 0.2 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.8% · Q3 1.2% · Q4 1.6% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.3%	78.8% 14.5 pts better	79.7% 13.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.9%	20.6% 7.3 pts worse	23.9% 4 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 30.4% · Expected 25.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-06 · Fire 2024-05-06

6 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2022-04-21 · Fire 2022-04-21

11 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2019-07-26 · Fire 2019-07-26

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

8 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-05-06

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-06-17

E · Potential for more than minimal harm 2024-05-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-17

C · Minimal harm 2024-05-06

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2024-06-20

C · Minimal harm 2024-05-06

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-06-17

E · Potential for more than minimal harm 2022-04-21

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2022-05-31

E · Potential for more than minimal harm 2022-04-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-05-31

D · Potential for more than minimal harm 2022-04-21

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-05-31

D · Potential for more than minimal harm 2022-04-21

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-05-31

D · Potential for more than minimal harm 2022-04-21

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2022-05-31

C · Minimal harm 2022-04-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-05-31

E · Potential for more than minimal harm 2019-07-26

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-09-20

E · Potential for more than minimal harm 2019-07-26

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2019-09-20

E · Potential for more than minimal harm 2019-07-26

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2019-09-20

E · Potential for more than minimal harm 2019-07-26

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2019-09-20

E · Potential for more than minimal harm 2019-07-26

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2019-09-20

E · Potential for more than minimal harm 2019-07-26

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-09-20

D · Potential for more than minimal harm 2019-07-26

K111 · Construction Deficiencies

Fire Safety

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Corrected 2019-09-20

D · Potential for more than minimal harm 2019-07-26

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2019-09-20

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-05-06

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2024-06-17

E · Potential for more than minimal harm 2024-05-06

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 2024-06-17

E · Potential for more than minimal harm 2024-05-06

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 2024-06-17

D · Potential for more than minimal harm 2024-05-06

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 2024-06-17

D · Potential for more than minimal harm 2024-05-06

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 2024-06-17

D · Potential for more than minimal harm 2024-05-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-06-17

E · Potential for more than minimal harm 2022-04-21

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 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2022-06-03

D · Potential for more than minimal harm 2022-04-21

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 2022-06-03

D · Potential for more than minimal harm 2022-04-21

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 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-06-03

D · Potential for more than minimal harm 2022-04-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-06-03

F · Potential for more than minimal harm 2019-07-26

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 2019-09-15

Penalties and ownership