Flushing, NY

Cypress Garden Center For Nursing And Rehab

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

139 66 35th Avenue, Flushing, NY

(718) 961-5300

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

278

Certified beds

Average residents

271

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Excelsior Care Group

Operator or chain grouping

Approved since

1975-07-01

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

0.61

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.32

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

2.90

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

0.93

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

2.66

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.45

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.53

CMS adjusted RN staffing hours

Adjusted total hours

2.53

CMS adjusted total nurse staffing hours

Case-mix index

1.56

Higher values indicate more complex resident acuity

RN turnover

51%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

24%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,896

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

Performance score

47.10

Composite VBP score used to determine payment impact.

Payment multiplier

1.0006

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

10

Baseline 18.94% · Performance 16.83% · Measure score 10 · Achievement 10 · Improvement 9

Healthcare-associated infections

0

Baseline 6.98% · Performance 8.01% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

8.84

Baseline 25.86% · Performance 27.55% · Measure score 8.84 · Achievement 8.84 · Improvement 0

Adjusted total nurse staffing

0

Baseline 2.83 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.21%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 191 · Observed rate 8.9% · Lower 95% interval 7.09%
Discharge to community	45.75%	50.57% 4.8 pts worse	No Different than the National Rate · Eligible stays 192 · Observed rate 40.1% · Lower 95% interval 38.71%
Medicare spending per beneficiary	1.7	1.02 0.7 pts worse
Drug regimen review with follow-up	54.52%	95.27% 40.7 pts worse	Numerator 163 · Denominator 299
Falls with major injury	1%	0.77% 0.2 pts worse	Numerator 3 · Denominator 299
Discharge self-care score	57.42%	53.69% 3.7 pts better	Numerator 120 · Denominator 209
Discharge mobility score	59.33%	50.94% 8.4 pts better	Numerator 124 · Denominator 209
Pressure ulcers or injuries, new or worsened	1%	2.29% 1.3 pts better	Numerator 3 · Denominator 299 · Adjusted rate 0.71%
Healthcare-associated infections requiring hospitalization	8.01%	7.12% 0.9 pts worse	No Different than the National Rate · Eligible stays 123 · Observed rate 8.94% · Lower 95% interval 4.97%
Staff COVID-19 vaccination coverage	1.2%	8.2% 7 pts worse	Numerator 4 · Denominator 332
Staff flu vaccination coverage	32.26%	42% 9.7 pts worse	Numerator 100 · Denominator 310
Discharge function score	65.07%	56.45% 8.6 pts better	Numerator 136 · Denominator 209
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 142 · Denominator 142
Transfer of health information to patient	85.42%	96.28% 10.9 pts worse	Numerator 41 · Denominator 48
Resident COVID-19 vaccinations up to date	8.38%	25.2% 16.8 pts worse	Numerator 14 · Denominator 167

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.7 0.3 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	1.3 0.7 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.0%	91.2% 6.8 pts better	93.4% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.6% · Q3 97.7% · Q4 94.6% · 4Q avg 98.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.0%	95.3% 2.7 pts better	95.5% 2.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.2%	3.0% 0.8 pts better	3.3% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.8% · Q3 2.7% · Q4 2.2% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	83.2%	18.5% 64.7 pts worse	11.4% 71.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 77.4% · Q2 79.8% · Q3 88.5% · Q4 87.2% · 4Q avg 83.2%
Percentage of long-stay residents who lose too much weight	8.3%	6.1% 2.2 pts worse	5.4% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.1% · Q3 7.8% · Q4 8.3% · 4Q avg 8.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.0%	13.5% 3.5 pts worse	19.6% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.0% · Q3 18.6% · Q4 13.4% · 4Q avg 17.0%
Percentage of long-stay residents who received an antipsychotic medication	10.4%	14.8% 4.4 pts better	16.7% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 9.6% · Q3 9.4% · Q4 10.3% · 4Q avg 10.4% · 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	4.8%	15.1% 10.3 pts better	16.3% 11.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.4% · Q3 3.5% · Q4 4.8% · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.7%	15.5% 9.8 pts better	14.9% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.6% · Q3 7.3% · Q4 5.3% · 4Q avg 5.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.1%	0.6% 0.5 pts better	1.0% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · 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 0.9% · Q2 0.0% · Q3 0.0% · 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	20.7%	20.8% 0.1 pts better	19.8% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 22.2% · Q3 20.8% · Q4 18.8% · 4Q avg 20.7%
Percentage of long-stay residents with pressure ulcers	4.2%	6.9% 2.7 pts better	5.1% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.9% · Q3 4.0% · Q4 3.7% · 4Q avg 4.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	60.1%	76.7% 16.6 pts worse	81.7% 21.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 74.2% · Q2 55.7% · Q3 54.2% · Q4 57.9% · 4Q avg 60.1%
Percentage of short-stay residents who had an outpatient emergency department visit	8.4%	9.7% 1.3 pts better	12.0% 3.6 pts better	Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 7.9% · Expected 10.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.8%	1.2% 0.4 pts better	1.6% 0.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 1.2% · Q4 0.6% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	67.7%	78.8% 11.1 pts worse	79.7% 12 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 67.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.1%	20.6% 2.5 pts better	23.9% 5.8 pts better	Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 19.1% · Expected 25.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-23 · Fire 2024-09-23

5 health deficiencies

Top issue: Environmental (1 deficiency)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2022-07-05 · Fire 2022-07-05

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-09-23 · Fire 2019-09-23

6 health deficiencies

Top issue: Resident Rights (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-09-23

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-09-23

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-11-22

B · Minimal harm 2024-09-23

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-11-22

F · Potential for more than minimal harm 2022-07-05

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2022-09-29

F · Potential for more than minimal harm 2022-07-05

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-07-05

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2022-07-11

D · Potential for more than minimal harm 2022-07-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-07-12

D · Potential for more than minimal harm 2022-07-05

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-08-02

D · Potential for more than minimal harm 2022-07-05

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-07-12

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-04-01

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 2025-03-23

E · Potential for more than minimal harm 2024-09-23

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 2024-11-22

E · Potential for more than minimal harm 2024-09-23

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-09-23

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-09-23

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 2024-11-22

D · Potential for more than minimal harm 2024-09-23

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-11-22

D · Potential for more than minimal harm 2022-07-05

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 2022-08-22

F · Potential for more than minimal harm 2019-09-23

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 2019-10-31

E · Potential for more than minimal harm 2019-09-23

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 2019-10-31

D · Potential for more than minimal harm 2019-09-23

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2019-10-31

D · Potential for more than minimal harm 2019-09-23

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2019-10-31

D · Potential for more than minimal harm 2019-09-23

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 2019-11-07

D · Potential for more than minimal harm 2019-09-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-10-31

Penalties and ownership