Cycle 1
Health 2024-08-09 · Fire 2024-08-09
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Troy, NY
Eddy Memorial Geriatric Center
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2256 Burdett Avenue, Troy, NY
(518) 274-9890
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
78
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1985-02-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 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
0.57
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.20
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
3.75
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,271
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 49.38% · Performance 65.26% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.62
Baseline 4.09 hours · Performance 3.82 hours · Measure score 2.62 · Achievement 2.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 66.43% |
8.2%
58.2 pts better
|
Numerator 93 · Denominator 140 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
91.2%
2.2 pts better
|
93.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 96.0% · Q3 82.7% · Q4 98.7% · 4Q avg 93.4% |
| 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 | 5.0% |
3.0%
2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 5.3% · Q3 5.3% · Q4 7.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
18.5%
17.8 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
6.1%
3.9 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 4.7% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
13.5%
1.2 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 12.7% · Q3 15.4% · Q4 15.9% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.5% |
14.8%
7.7 pts worse
|
16.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 26.1% · Q3 17.3% · Q4 19.6% · 4Q avg 22.5% · 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 | 21.3% |
15.1%
6.2 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 34.2% · Q3 16.9% · Q4 11.2% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
15.5%
6.8 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 38.6% · Q3 10.0% · Q4 9.7% · 4Q avg 22.3% · 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 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.4%
0.7 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
20.8%
5.5 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 31.2% · Q3 19.0% · Q4 28.5% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
6.9%
4.8 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.2% · Q3 2.4% · Q4 2.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
76.7%
11.1 pts better
|
81.7%
6.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.0% · 4Q avg 87.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-17 · Fire 2022-05-17
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2019-12-10 · Fire 2019-12-10
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-09
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-10-07
F · Potential for more than minimal harm
2024-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-07
F · Potential for more than minimal harm
2024-08-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-08-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-08-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-08-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-07
E · Potential for more than minimal harm
2022-05-17
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-05-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-05-17
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-07-15
E · Potential for more than minimal harm
2019-12-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-02-07
E · Potential for more than minimal harm
2019-12-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-02-18
E · Potential for more than minimal harm
2019-12-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-09
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 2024-10-07
D · Potential for more than minimal harm
2024-08-09
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 2024-10-07
D · Potential for more than minimal harm
2024-08-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-09
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 2024-10-07
D · Potential for more than minimal harm
2024-08-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-09
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 2024-10-07
D · Potential for more than minimal harm
2024-08-09
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 2024-08-29
D · Potential for more than minimal harm
2024-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-07
E · Potential for more than minimal harm
2022-05-17
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 2022-07-15
D · Potential for more than minimal harm
2022-05-17
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 2022-07-15
D · Potential for more than minimal harm
2022-05-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-15
E · Potential for more than minimal harm
2019-12-10
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 2020-02-07
E · Potential for more than minimal harm
2019-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-10
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 2020-02-07
Penalties and ownership
What sits behind the stars
Ownership
St Peters Health Partners
5% Or Greater Direct Ownership Interest · Organization
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Bala, Guha
Corporate Director · Individual
Burke, Michael
Operational/Managerial Control · Individual
Farrell, Eric
Corporate Officer · Individual
Hanks, Steven
Corporate Director · Individual
Isacksen, Daniel
Corporate Director · Individual
Jimino, Kathleen
Corporate Officer · Individual
Lapczynski, Patricia
Corporate Director · Individual
Marshall, John
Corporate Officer · Individual
Mazzacco, Michelle
Operational/Managerial Control · Individual
Mccormick, Robert
Corporate Director · Individual
Meath, Michael
Corporate Director · Individual
Myers, Gina
Corporate Director · Individual
Pollard, Merriette
Corporate Director · Individual
Signor, Kristin
Operational/Managerial Control · Individual
Signor, Kristin
Corporate Officer · Individual
Smith, Alexandra
Operational/Managerial Control · Individual
St Peters Health Partners
Operational/Managerial Control · Organization
Sullivan, Marguerite
Corporate Director · Individual
Sweet Zavaglia, Kerri
Corporate Director · Individual
Tofade, Oluwatoyin
Corporate Director · Individual
Trinity Health Corporation
Operational/Managerial Control · Organization
Wildridge, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Eddy Heritage House Nursing And Rehabilitation Ctr
Troy, NY
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Troy Center For Rehabilitation And Nursing
Troy, NY
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Van Rensselaer Manor
Troy, NY
1-star overall rating with 1-star inspections with abuse icon flag with $21,645 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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