4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
East Elmhurst, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
100 17 23rd Avenue, East Elmhurst, NY
(718) 205-8100
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
240
Certified beds
Average residents
232
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-04-20
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
0.55
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
0.96
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.47
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
4,302
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.92
Baseline 17.61% · Performance 17.76% · Measure score 7.92 · Achievement 7.92 · Improvement 0
Healthcare-associated infections
0
Baseline 6.49% · Performance 8.24% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.28
Baseline 35.56% · Performance 29.85% · Measure score 8.28 · Achievement 8.28 · Improvement 4.83
Adjusted total nurse staffing
0
Baseline 2.84 hours · Performance 2.99 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 219 · Observed rate 10.5% · Lower 95% interval 8.12% |
| Discharge to community | 14.59% |
50.57%
36 pts worse
|
Worse than the National Rate · Eligible stays 168 · Observed rate 7.74% · Lower 95% interval 10.26% |
| Medicare spending per beneficiary | 1.39 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 89.16% |
95.27%
6.1 pts worse
|
Numerator 148 · Denominator 166 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 166 |
| Discharge self-care score | 66.96% |
53.69%
13.3 pts better
|
Numerator 75 · Denominator 112 |
| Discharge mobility score | 53.57% |
50.94%
2.6 pts better
|
Numerator 60 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 1.81% |
2.29%
0.5 pts better
|
Numerator 3 · Denominator 166 · Adjusted rate 1.41% |
| Healthcare-associated infections requiring hospitalization | 8.24% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 10.69% · Lower 95% interval 5.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 267 |
| Staff flu vaccination coverage | 34.11% |
42%
7.9 pts worse
|
Numerator 88 · Denominator 258 |
| Discharge function score | 70.54% |
56.45%
14.1 pts better
|
Numerator 79 · Denominator 112 |
| Transfer of health information to provider | 82.35% |
95.95%
13.6 pts worse
|
Numerator 42 · Denominator 51 |
| Transfer of health information to patient | 88.89% |
96.28%
7.4 pts worse
|
Numerator 24 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 21.95% |
25.2%
3.2 pts worse
|
Numerator 18 · Denominator 82 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
91.2%
5.1 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 98.1% · Q3 99.0% · Q4 99.5% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
95.3%
0.6 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.0%
2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.0% · Q3 1.0% · Q4 0.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 38.5% |
18.5%
20 pts worse
|
11.4%
27.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 30.7% · Q3 47.1% · Q4 47.2% · 4Q avg 38.5% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
6.1%
2.3 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.9% · Q3 2.2% · Q4 2.6% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
13.5%
1.7 pts worse
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 15.1% · Q3 16.4% · Q4 14.7% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
14.8%
0.2 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 14.1% · Q3 16.2% · Q4 13.4% · 4Q avg 14.6% · 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 | 10.9% |
15.1%
4.2 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 10.9% · Q3 13.5% · Q4 3.3% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
15.5%
0.3 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 18.3% · Q3 13.1% · Q4 11.1% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.6%
0.3 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.1% · Q3 1.3% · Q4 0.3% · 4Q avg 0.9% · 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 3.0% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.0% |
20.8%
11.8 pts better
|
19.8%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.9% · Q3 10.6% · Q4 4.3% · 4Q avg 9.0% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
6.9%
2.5 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.4% · Q3 9.9% · Q4 7.5% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.4% |
76.7%
13.3 pts worse
|
81.7%
18.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 68.4% · Q3 73.9% · Q4 66.7% · 4Q avg 63.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.5% |
9.7%
5.2 pts better
|
12.0%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 4.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 2.8% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.7% |
78.8%
0.9 pts better
|
79.7%
About the same
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.4% |
20.6%
8.2 pts better
|
23.9%
11.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 12.8% · Expected 24.7% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-08-19
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-08-19
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-22
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-22
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-22
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-22
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-12-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-31
Inspection history
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 2024-08-28
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 2024-08-28
Health
Post nurse staffing information every day.
Corrected 2024-08-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-28
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-08-28
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-10-31
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-10-31
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-31
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-31
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-12-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-12-06
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
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