Cycle 1
Health 2024-09-09 · Fire 2024-09-09
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Albany, NY
Daughters Of Sarah Nursing Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
180 Washington Ave Ext, Albany, NY
(518) 456-7831
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
210
Certified beds
Average residents
200
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-03-01
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
0.42
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,661
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9962
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.23
Baseline 15.98% · Performance 19.47% · Measure score 4.23 · Achievement 4.23 · Improvement 0
Healthcare-associated infections
4.25
Baseline 5.16% · Performance 6.57% · Measure score 4.25 · Achievement 4.25 · Improvement 0
Total nurse turnover
5.79
Baseline 37.57% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
3.03
Baseline 3.87 hours · Performance 3.94 hours · Measure score 3.03 · Achievement 3.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.11% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 366 · Observed rate 9.29% · Lower 95% interval 8.06% |
| Discharge to community | 39.13% |
50.57%
11.4 pts worse
|
Worse than the National Rate · Eligible stays 389 · Observed rate 32.9% · Lower 95% interval 34.97% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.95% |
95.27%
2.7 pts better
|
Numerator 239 · Denominator 244 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 244 |
| Discharge self-care score | 69.15% |
53.69%
15.5 pts better
|
Numerator 139 · Denominator 201 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 134 · Denominator 201 |
| Pressure ulcers or injuries, new or worsened | 2.05% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 244 · Adjusted rate 2.41% |
| Healthcare-associated infections requiring hospitalization | 6.56% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 5.7% · Lower 95% interval 4.32% |
| Staff COVID-19 vaccination coverage | 1.56% |
8.2%
6.6 pts worse
|
Numerator 5 · Denominator 321 |
| Staff flu vaccination coverage | 61.31% |
42%
19.3 pts better
|
Numerator 244 · Denominator 398 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 134 · Denominator 201 |
| Transfer of health information to provider | 98.95% |
95.95%
3 pts better
|
Numerator 94 · Denominator 95 |
| Transfer of health information to patient | 99.07% |
96.28%
2.8 pts better
|
Numerator 106 · Denominator 107 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 35 · Denominator 119 |
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 1.3 · Expected 1.7 · 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 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
91.2%
5.8 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 96.2% · Q3 97.1% · Q4 98.2% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.1% |
95.3%
2.2 pts worse
|
95.5%
2.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.0%
0.3 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.1% · Q3 3.5% · Q4 4.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
18.5%
16.9 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.5% · Q3 1.3% · Q4 0.6% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.1%
1.9 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.5% · Q3 4.2% · Q4 4.5% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
13.5%
3.7 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 12.2% · Q3 6.9% · Q4 10.4% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
14.8%
0.7 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 14.7% · Q3 14.1% · Q4 11.7% · 4Q avg 14.1% · 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 | 17.6% |
15.1%
2.5 pts worse
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 17.8% · Q3 17.3% · Q4 9.7% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
15.5%
0.8 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 19.7% · Q3 12.3% · Q4 12.6% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.6%
0.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.4%
0.6 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.9% · Q3 0.0% · Q4 0.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
20.8%
4.4 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 31.6% · Q3 26.5% · Q4 20.3% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
6.9%
1.8 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 3.5% · Q3 4.3% · Q4 4.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
76.7%
21.1 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 97.2% · Q3 97.2% · Q4 98.0% · 4Q avg 97.8% |
| 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 6.6% · Expected 8.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 1.2% · Q4 1.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.4% |
78.8%
9.6 pts better
|
79.7%
8.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
20.6%
4.9 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 19.3% · Expected 18.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-18 · Fire 2021-10-18
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-05-24 · Fire 2019-05-24
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-10
E · Potential for more than minimal harm
2021-10-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-30
E · Potential for more than minimal harm
2019-05-24
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-07-22
E · Potential for more than minimal harm
2019-05-24
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-07-22
E · Potential for more than minimal harm
2019-05-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-07-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-09
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 2024-10-20
D · Potential for more than minimal harm
2024-09-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-09
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 2024-10-20
D · Potential for more than minimal harm
2024-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-20
D · Potential for more than minimal harm
2023-10-02
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 2023-11-20
D · Potential for more than minimal harm
2023-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
E · Potential for more than minimal harm
2021-10-18
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-10-18
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-10-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-10-18
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-11-30
E · Potential for more than minimal harm
2019-05-24
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 2019-07-22
E · Potential for more than minimal harm
2019-05-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-22
Penalties and ownership
What sits behind the stars
Ownership
Marrello, Lisa
Operational/Managerial Control · Individual
Mirza, Ali
Operational/Managerial Control · Individual
Mulson, Anne
Operational/Managerial Control · Individual
Mulson, Anne
Corporate Officer · Individual
Regan, Michael
Operational/Managerial Control · Individual
Smith, Samantha
Operational/Managerial Control · Individual
Stryker, Marcy
Operational/Managerial Control · Individual
Weisblatt, Samuel
Corporate Director · Individual
Yorker, Ruth
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Teresian House Nursing Home Co Inc
Albany, NY
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Eddy Village Green At Beverwyck
Slingerlands, NY
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
St Peters Nursing And Rehabilitation Center
Albany, NY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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