Staten Island, NY

Clove Lakes Health Care And Rehab Center, Inc

4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

25 Fanning Street, Staten Island, NY

(718) 289-7900

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

576

Certified beds

Average residents

472

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinite Care

Operator or chain grouping

Approved since

1969-06-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

20 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

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

0.94

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.51

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.14

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.59

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.20

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.69

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.76

CMS adjusted RN staffing hours

Adjusted total hours

2.89

CMS adjusted total nurse staffing hours

Case-mix index

1.70

Higher values indicate more complex resident acuity

RN turnover

35%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

30%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,372

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

Performance score

57.12

Composite VBP score used to determine payment impact.

Payment multiplier

1.0123

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

8.07

Baseline 22.67% · Performance 17.84% · Measure score 8.07 · Achievement 7.75 · Improvement 8.07

Healthcare-associated infections

5.42

Baseline 10.72% · Performance 7.33% · Measure score 5.42 · Achievement 1.68 · Improvement 5.42

Total nurse turnover

8.07

Baseline 25.00% · Performance 30.68% · Measure score 8.07 · Achievement 8.07 · Improvement 0

Adjusted total nurse staffing

1.29

Baseline 2.44 hours · Performance 3.04 hours · Measure score 1.29 · Achievement 0 · Improvement 1.29

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12%	10.72% 1.3 pts worse	No Different than the National Rate · Eligible stays 479 · Observed rate 12.53% · Lower 95% interval 9.54%
Discharge to community	52.61%	50.57% 2 pts better	No Different than the National Rate · Eligible stays 565 · Observed rate 44.6% · Lower 95% interval 47.16%
Medicare spending per beneficiary	1.45	1.02 0.4 pts worse
Drug regimen review with follow-up	99.82%	95.27% 4.5 pts better	Numerator 570 · Denominator 571
Falls with major injury	0.7%	0.77% 0.1 pts better	Numerator 4 · Denominator 571
Discharge self-care score	51.45%	53.69% 2.2 pts worse	Numerator 195 · Denominator 379
Discharge mobility score	50.92%	50.94% About the same	Numerator 193 · Denominator 379
Pressure ulcers or injuries, new or worsened	2.28%	2.29% About the same	Numerator 13 · Denominator 571 · Adjusted rate 1.48%
Healthcare-associated infections requiring hospitalization	7.33%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 372 · Observed rate 7.8% · Lower 95% interval 5.73%
Staff COVID-19 vaccination coverage	4.3%	8.2% 3.9 pts worse	Numerator 29 · Denominator 675
Staff flu vaccination coverage	53.02%	42% 11 pts better	Numerator 448 · Denominator 845
Discharge function score	57.26%	56.45% 0.8 pts better	Numerator 217 · Denominator 379
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 162 · Denominator 162
Transfer of health information to patient	92.95%	96.28% 3.3 pts worse	Numerator 224 · Denominator 241
Resident COVID-19 vaccinations up to date	8.33%	25.2% 16.9 pts worse	Numerator 26 · Denominator 312

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 2.0 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.3 0.2 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	68.5%	91.2% 22.7 pts worse	93.4% 24.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 75.8% · Q2 71.0% · Q3 66.4% · Q4 62.3% · 4Q avg 68.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	81.8%	95.3% 13.5 pts worse	95.5% 13.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 81.8%
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	3.0% 1.7 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.2% · Q3 1.1% · Q4 1.9% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	57.6%	18.5% 39.1 pts worse	11.4% 46.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 51.4% · Q2 50.5% · Q3 56.4% · Q4 70.2% · 4Q avg 57.6%
Percentage of long-stay residents who lose too much weight	5.7%	6.1% 0.4 pts better	5.4% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.6% · Q3 3.9% · Q4 5.7% · 4Q avg 5.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.9%	13.5% 1.4 pts worse	19.6% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 15.3% · Q3 13.9% · Q4 15.7% · 4Q avg 14.9%
Percentage of long-stay residents who received an antipsychotic medication	8.1%	14.8% 6.7 pts better	16.7% 8.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 8.4% · Q3 8.2% · Q4 7.6% · 4Q avg 8.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.6%	0.2% 0.4 pts worse	0.1% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.6% · Q4 0.5% · 4Q avg 0.6%
Percentage of long-stay residents whose ability to walk independently worsened	7.0%	15.1% 8.1 pts better	16.3% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 2.2% · Q3 7.3% · Q4 7.0% · 4Q avg 7.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.2%	15.5% 6.3 pts better	14.9% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.9% · Q3 10.3% · Q4 9.6% · 4Q avg 9.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.6% 0.3 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 0.6% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.1%	1.4% 0.3 pts better	1.7% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.6% · Q3 0.9% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.1%	20.8% 3.3 pts worse	19.8% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 26.6% · Q3 20.7% · Q4 18.0% · 4Q avg 24.1%
Percentage of long-stay residents with pressure ulcers	9.1%	6.9% 2.2 pts worse	5.1% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 9.2% · Q3 10.4% · Q4 9.8% · 4Q avg 9.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	28.7%	76.7% 48 pts worse	81.7% 53 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 31.2% · Q3 26.0% · Q4 23.2% · 4Q avg 28.7%
Percentage of short-stay residents who had an outpatient emergency department visit	10.4%	9.7% 0.7 pts worse	12.0% 1.6 pts better	Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 10.6% · 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 0.0% · Q2 0.3% · Q3 0.9% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	37.9%	78.8% 40.9 pts worse	79.7% 41.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 37.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.5%	20.6% 4.1 pts better	23.9% 7.4 pts better	Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 19.1% · Expected 27.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-16 · Fire 2024-10-16

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2022-11-10 · Fire 2022-11-10

16 health deficiencies

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

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2020-01-23 · Fire 2020-01-23

5 health deficiencies

Top issue: Infection Control (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-10-16

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-12-15

E · Potential for more than minimal harm 2022-11-10

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-01-09

C · Minimal harm 2022-11-10

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2023-01-09

C · Minimal harm 2022-11-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-01-09

C · Minimal harm 2022-11-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-01-09

E · Potential for more than minimal harm 2020-01-23

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2020-03-22

E · Potential for more than minimal harm 2020-01-23

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2020-03-22

C · Minimal harm 2020-01-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-03-22

C · Minimal harm 2020-01-23

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2020-03-22

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-18

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2026-01-09

D · Potential for more than minimal harm 2025-02-13

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 2025-04-05

D · Potential for more than minimal harm 2024-10-25

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 2024-12-20

D · Potential for more than minimal harm 2024-10-25

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 2024-12-20

D · Potential for more than minimal harm 2024-10-16

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

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 2024-12-08

D · Potential for more than minimal harm 2024-10-16

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 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

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 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-12-08

E · Potential for more than minimal harm 2022-11-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-01-09

E · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

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 2023-01-09

D · Potential for more than minimal harm 2022-11-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-01-09

E · Potential for more than minimal harm 2020-01-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

F582 · Resident Rights Deficiencies

Health

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

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

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 2020-03-22

Penalties and ownership