2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Brooklyn, NY
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2107 Ditmas Avenue, Brooklyn, NY
(718) 462-8100
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
200
Certified beds
Average residents
194
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-11-23
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
RN hours / resident day
1.25
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.91
Higher values indicate more complex resident acuity
RN turnover
34%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
3,216
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9987
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.15
Baseline 26.33% · Performance 21.08% · Measure score 5.15 · Achievement 0.77 · Improvement 5.15
Healthcare-associated infections
3.58
Baseline 10.77% · Performance 8.41% · Measure score 3.58 · Achievement 0 · Improvement 3.58
Total nurse turnover
8.66
Baseline 33.33% · Performance 28.28% · Measure score 8.66 · Achievement 8.66 · Improvement 5.46
Adjusted total nurse staffing
0.78
Baseline 3.30 hours · Performance 3.3 hours · Measure score 0.78 · Achievement 0.78 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 349 · Observed rate 11.17% · Lower 95% interval 7.12% |
| Discharge to community | 54.03% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 517 · Observed rate 34.24% · Lower 95% interval 47.09% |
| Medicare spending per beneficiary | 1.45 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 555 · Denominator 555 |
| Falls with major injury | 0.18% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 555 |
| Discharge self-care score | 67.4% |
53.69%
13.7 pts better
|
Numerator 184 · Denominator 273 |
| Discharge mobility score | 58.61% |
50.94%
7.7 pts better
|
Numerator 160 · Denominator 273 |
| Pressure ulcers or injuries, new or worsened | 0.18% |
2.29%
2.1 pts better
|
Numerator 1 · Denominator 555 · Adjusted rate 0.13% |
| Healthcare-associated infections requiring hospitalization | 8.41% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 288 · Observed rate 12.85% · Lower 95% interval 6.44% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 388 |
| Staff flu vaccination coverage | 73.11% |
42%
31.1 pts better
|
Numerator 242 · Denominator 331 |
| Discharge function score | 59.71% |
56.45%
3.3 pts better
|
Numerator 163 · Denominator 273 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 226 · Denominator 226 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 219 · Denominator 219 |
| Resident COVID-19 vaccinations up to date | 14.73% |
25.2%
10.5 pts worse
|
Numerator 43 · Denominator 292 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.7
1.6 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 4.9 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
91.2%
7.2 pts worse
|
93.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.6% · Q2 84.0% · Q3 80.0% · Q4 81.5% · 4Q avg 84.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.5% |
95.3%
6.8 pts worse
|
95.5%
7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| 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 | 9.2% |
18.5%
9.3 pts better
|
11.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.4% · Q3 5.2% · Q4 4.7% · 4Q avg 9.2% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.1%
1.2 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 6.0% · Q3 5.6% · Q4 6.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
13.5%
5 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.8% · Q3 8.2% · Q4 7.4% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.7% |
14.8%
10.1 pts better
|
16.7%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.9% · Q3 5.8% · Q4 4.3% · 4Q avg 4.7% · 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 | 16.2% |
15.1%
1.1 pts worse
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
15.5%
0.8 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 15.2% · Q3 13.6% · Q4 9.1% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.6%
0.2 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.4%
0.5 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.9% |
20.8%
12.9 pts better
|
19.8%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.4% · Q3 5.9% · Q4 24.8% · 4Q avg 7.9% |
| Percentage of long-stay residents with pressure ulcers | 12.9% |
6.9%
6 pts worse
|
5.1%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 15.4% · Q3 12.6% · Q4 10.6% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.8% |
76.7%
36.9 pts worse
|
81.7%
41.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 48.4% · Q3 31.5% · Q4 32.7% · 4Q avg 39.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
9.7%
0.9 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.4% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.6% |
78.8%
31.2 pts worse
|
79.7%
32.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
20.6%
0.3 pts worse
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 28.2% · Expected 32.2% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-10
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 2024-10-10
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-06-28
Fire Safety
Use approved construction type or materials.
Corrected 2022-06-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-28
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-06-28
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-06-28
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 2022-06-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-06-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-28
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-06-28
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 2022-06-28
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-06-28
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-28
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-28
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-28
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-06-28
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-10-11
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 2019-10-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-10-11
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2019-10-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-11
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-10
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-10
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-06-01
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 2022-06-01
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 2022-06-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-10-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Nearby options
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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