West Haverstraw, NY

Helen Hayes Hospital T C U

5-star overall rating with 5-star inspections

51 N Route 9w, West Haverstraw, NY

(845) 786-4000

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

24

Certified beds

Average residents

22

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

State Of New York Comptroller's Office

Operator or chain grouping

Approved since

2016-08-10

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

6 facilities

Chain averages 5 overall / 5 health / 4 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

No

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

2.99

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.09

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

3.20

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

6.27

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

3.07

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

5.32

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

2.34

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.89

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

3.32

CMS adjusted RN staffing hours

Adjusted total hours

6.98

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

34%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

36

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

94.69

Composite VBP score used to determine payment impact.

Payment multiplier

1.0276

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

8.41

Baseline 19.13% · Performance 17.54% · Measure score 8.41 · Achievement 8.41 · Improvement 7.08

Healthcare-associated infections

10

Baseline 4.06% · Performance 4.31% · Measure score 10 · Achievement 10 · Improvement 0

Total nurse turnover

10

Baseline 3.70% · Performance 15.38% · Measure score 10 · Achievement 10 · Improvement 0

Adjusted total nurse staffing

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	7.94%	10.72% 2.8 pts better	Better than the National Rate · Eligible stays 553 · Observed rate 4.16% · Lower 95% interval 5.81%
Discharge to community	72.19%	50.57% 21.6 pts better	Better than the National Rate · Eligible stays 564 · Observed rate 85.64% · Lower 95% interval 70.68%
Medicare spending per beneficiary	0.51	1.02 0.5 pts better
Drug regimen review with follow-up	98.31%	95.27% 3 pts better	Numerator 290 · Denominator 295
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 294
Discharge self-care score	81.95%	53.69% 28.3 pts better	Numerator 227 · Denominator 277
Discharge mobility score	85.2%	50.94% 34.3 pts better	Numerator 236 · Denominator 277
Pressure ulcers or injuries, new or worsened	0.68%	2.29% 1.6 pts better	Numerator 2 · Denominator 294 · Adjusted rate 1.34%
Healthcare-associated infections requiring hospitalization	4.31%	7.12% 2.8 pts better	No Different than the National Rate · Eligible stays 248 · Observed rate 0.4% · Lower 95% interval 2.34%
Staff COVID-19 vaccination coverage	3.24%	8.2% 5 pts worse	Numerator 7 · Denominator 216
Staff flu vaccination coverage	58.6%	42% 16.6 pts better	Numerator 126 · Denominator 215
Discharge function score	74.73%	56.45% 18.3 pts better	Numerator 207 · Denominator 277
Transfer of health information to provider	91.43%	95.95% 4.5 pts worse	Numerator 32 · Denominator 35
Transfer of health information to patient	99.62%	96.28% 3.3 pts better	Numerator 259 · Denominator 260
Resident COVID-19 vaccinations up to date	40.97%	25.2% 15.8 pts better	Numerator 59 · Denominator 144

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.8%	76.7% 23.1 pts better	81.7% 18.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.5% · Q3 99.6% · Q4 100.0% · 4Q avg 99.8%
Percentage of short-stay residents who had an outpatient emergency department visit	4.7%	9.7% 5 pts better	12.0% 7.3 pts better	Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.0% · Expected 9.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	99.5%	78.8% 20.7 pts better	79.7% 19.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	12.0%	20.6% 8.6 pts better	23.9% 11.9 pts better	Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 8.0% · Expected 16.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-20 · Fire 2025-03-20

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-02-24 · Fire 2022-02-24

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2018-05-07 · Fire 2018-05-07

2 health deficiencies

Top issue: Resident Rights (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2022-02-24

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2022-03-22

D · Potential for more than minimal harm 2018-05-07

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2018-05-25

Inspection history

Recent health citations

D · Potential for more than minimal harm 2018-05-07

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 2018-06-27

D · Potential for more than minimal harm 2018-05-07

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 2018-06-27

Penalties and ownership

What sits behind the stars

Ownership

State Of New York Comptrollers Office

5% Or Greater Direct Ownership Interest · Organization

100% 6 facilities 2016-04-14

Begho, Nathalie