Cycle 1
Health 2025-04-03 · Fire 2025-04-03
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cohoes, NY
Eddy Village Green
1-star overall rating with 1-star inspections with abuse icon flag with $97,383 in total fines with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
421 W Columbia Street, Cohoes, NY
(518) 237-5630
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
192
Certified beds
Average residents
183
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1989-02-01
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
0.77
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
4.50
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.95
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
5.40
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
6.33
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,642
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0100
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.82
Performance 17.81% · Measure score 7.82 · Achievement 7.82 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.51
Performance 6.49% · Measure score 4.51 · Achievement 4.51 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.18
Performance 42.51% · Measure score 5.18 · Achievement 5.18 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.52
Baseline 5.47 hours · Performance 4.36 hours · Measure score 4.52 · Achievement 4.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 2.44% · Lower 95% interval 6.32% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 18.52% |
53.69%
35.2 pts worse
|
Numerator 5 · Denominator 27 |
| Discharge mobility score | 40.74% |
50.94%
10.2 pts worse
|
Numerator 11 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 13.33% |
2.29%
11 pts worse
|
Numerator 4 · Denominator 30 · Adjusted rate 10.45% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 300 · Denominator 300 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 22.22% |
56.45%
34.2 pts worse
|
Numerator 6 · Denominator 27 |
| 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 13 · 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 | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
91.2%
5.5 pts better
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 98.4% · Q3 92.1% · Q4 96.5% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.5% |
95.3%
4.2 pts better
|
95.5%
4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.0%
2.7 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.9% · Q3 5.5% · Q4 6.4% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
18.5%
18.1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.1%
1.3 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.7% · Q3 5.1% · Q4 2.8% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
13.5%
5.6 pts worse
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 18.3% · Q3 17.9% · Q4 20.1% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
14.8%
1 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 15.3% · Q3 16.5% · Q4 13.0% · 4Q avg 15.8% · 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 | 20.6% |
15.1%
5.5 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 30.7% · Q3 17.0% · Q4 6.4% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
15.5%
0.6 pts worse
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 24.3% · Q3 10.7% · Q4 5.8% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.6%
About the same
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.4%
0.5 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.2% · Q3 0.6% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.6% |
20.8%
10.8 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 38.4% · Q3 30.6% · Q4 28.0% · 4Q avg 31.6% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
6.9%
5.1 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 1.7% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
76.7%
13.5 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 96.0% · Q3 87.8% · Q4 83.8% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
9.7%
2.3 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 16.7% |
1.2%
15.5 pts worse
|
1.6%
15.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.8%
21.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.4% |
20.6%
11.2 pts better
|
23.9%
14.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 7.7% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-28 · Fire 2022-04-28
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-10-09 · Fire 2019-10-09
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 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
2025-04-03
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-03
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-03
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-03
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-15
F · Potential for more than minimal harm
2022-04-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-27
E · Potential for more than minimal harm
2022-04-28
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 2022-06-30
E · Potential for more than minimal harm
2022-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-27
E · Potential for more than minimal harm
2019-10-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
E · Potential for more than minimal harm
2019-10-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-12-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-03
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 2025-05-15
E · Potential for more than minimal harm
2025-04-03
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 2025-05-15
E · Potential for more than minimal harm
2025-04-03
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 2025-05-15
E · Potential for more than minimal harm
2025-04-03
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 2025-05-15
E · Potential for more than minimal harm
2025-04-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-03
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 2025-05-15
E · Potential for more than minimal harm
2025-04-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-03
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 2025-05-15
E · Potential for more than minimal harm
2025-04-03
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 2025-05-15
D · Potential for more than minimal harm
2025-04-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-03
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-03
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-12
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 2025-03-06
J · Immediate jeopardy
2025-02-24
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 2025-04-08
J · Immediate jeopardy
2025-02-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-02-24
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 2025-04-08
D · Potential for more than minimal harm
2023-06-22
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 2023-07-21
D · Potential for more than minimal harm
2023-06-22
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 2023-07-21
E · Potential for more than minimal harm
2022-04-28
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 2022-06-27
D · Potential for more than minimal harm
2022-04-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-27
E · Potential for more than minimal harm
2019-10-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-09
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 2019-12-06
D · Potential for more than minimal harm
2019-10-09
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 2019-12-06
D · Potential for more than minimal harm
2019-10-09
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 2019-12-06
C · Minimal harm
2019-10-09
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-12-06
Penalties and ownership
What sits behind the stars
$97,383
2025-02-24
Fine
Fine · fine $97,383
Fine
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
Dougherty, Samantha
Operational/Managerial Control · Individual
Farrell, Eric
Corporate Officer · Individual
Freda, Kyle
Operational/Managerial Control · 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
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
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $186,939 in total fines with 28 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
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3-star overall rating with 3-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Eddy Heritage House Nursing And Rehabilitation Ctr
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1-star overall rating with 1-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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