Cycle 1
Health 2023-09-01 · Fire 2023-09-01
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ghent, NY
Ghent Rehabilitation & Nursing Center
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1 Whittier Way, Ghent, NY
(518) 828-0800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
120
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1992-11-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.49
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.27
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,018
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.27
Baseline 19.51% · Performance 18.52% · Measure score 6.27 · Achievement 6.27 · Improvement 3.48
Healthcare-associated infections
0
Baseline 4.78% · Performance 8.06% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.59
Baseline 77.88% · Performance 50.91% · Measure score 4.59 · Achievement 3.12 · Improvement 4.59
Adjusted total nurse staffing
2.85
Baseline 2.66 hours · Performance 3.71 hours · Measure score 2.85 · Achievement 2.21 · Improvement 2.85
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.81% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 3.57% · Lower 95% interval 5.99% |
| Discharge to community | 40.13% |
50.57%
10.4 pts worse
|
Worse than the National Rate · Eligible stays 109 · Observed rate 35.78% · Lower 95% interval 32.47% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 106 · Denominator 106 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 106 |
| Discharge self-care score | 57.75% |
53.69%
4.1 pts better
|
Numerator 41 · Denominator 71 |
| Discharge mobility score | 59.15% |
50.94%
8.2 pts better
|
Numerator 42 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 106 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.06% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 8.43% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 66.2% |
56.45%
9.8 pts better
|
Numerator 47 · Denominator 71 |
| Transfer of health information to provider | 93.33% |
95.95%
2.6 pts worse
|
Numerator 28 · Denominator 30 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 42 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 1.67% |
25.2%
23.5 pts worse
|
Numerator 1 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| 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 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.3%
3.8 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.0%
1.9 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.1% · Q3 6.2% · Q4 7.2% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
18.5%
14.3 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.1% · Q3 3.6% · Q4 3.4% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 12.0% |
6.1%
5.9 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 14.6% · Q3 10.5% · Q4 6.2% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
13.5%
5.4 pts worse
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 20.8% · Q3 18.8% · Q4 16.5% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.6% |
14.8%
12.8 pts worse
|
16.7%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 29.3% · Q3 26.7% · Q4 23.7% · 4Q avg 27.6% · 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 | 7.3% |
15.1%
7.8 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 9.5% · Q3 1.8% · Q4 3.2% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
15.5%
10.2 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 4.7% · Q3 3.3% · Q4 2.1% · 4Q avg 5.3% · 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 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 29.1% |
20.8%
8.3 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 35.9% · Q3 21.1% · Q4 21.9% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
6.9%
3.5 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 14.5% · Q3 10.5% · Q4 7.0% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
76.7%
23.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
9.7%
2.1 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.4% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 3.1% · Q4 3.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
78.8%
19.3 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
20.6%
4 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 24.5% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-09 · Fire 2021-06-09
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2019-05-22 · Fire 2019-05-22
14 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-09-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-10
E · Potential for more than minimal harm
2023-09-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-09-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-16
F · Potential for more than minimal harm
2021-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-05
F · Potential for more than minimal harm
2021-06-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-05
E · Potential for more than minimal harm
2021-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-05
E · Potential for more than minimal harm
2021-06-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-05
E · Potential for more than minimal harm
2021-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-05
E · Potential for more than minimal harm
2019-05-22
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-22
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-07-28
E · Potential for more than minimal harm
2019-05-22
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-22
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2019-06-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-09-01
F584 · Resident Rights Deficiencies
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 2023-10-16
E · Potential for more than minimal harm
2023-09-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-09-01
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 2023-10-23
E · Potential for more than minimal harm
2023-09-01
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-01
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 2023-10-23
D · Potential for more than minimal harm
2023-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-07
E · Potential for more than minimal harm
2021-06-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-08-05
D · Potential for more than minimal harm
2021-06-09
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 2021-08-05
D · Potential for more than minimal harm
2021-06-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-08-05
D · Potential for more than minimal harm
2021-06-09
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 2021-08-05
C · Minimal harm
2021-06-09
F584 · Resident Rights Deficiencies
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 2021-08-05
E · Potential for more than minimal harm
2019-05-22
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-22
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-22
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 2019-06-21
E · Potential for more than minimal harm
2019-05-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-22
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-22
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 2019-06-21
D · Potential for more than minimal harm
2019-05-22
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 2019-06-21
D · Potential for more than minimal harm
2019-05-22
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 2019-06-21
D · Potential for more than minimal harm
2019-05-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-22
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-22
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 2019-06-21
D · Potential for more than minimal harm
2019-05-22
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 2019-06-21
Penalties and ownership
What sits behind the stars
Ownership
Zagelbaum, Ephraim
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
5% Or Greater Direct Ownership Interest · Individual
Walden, Yehudah
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
Corporate Officer · Individual
Oduwa, Felix
Operational/Managerial Control · Individual
Woodward, Xyier
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pine Haven Home
Philmont, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
The Grand Rehabilitation And Nursing At Barnwell
Valatie, NY
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $169,289 in total fines with 35 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
Greene Meadows Nursing And Rehabilitation Center
Catskill, NY
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out