4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Jamaica, NY
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
91 31 175th Street, Jamaica, NY
(718) 657-6363
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
320
Certified beds
Average residents
307
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-05-01
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
0.42
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.95
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.07
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.62
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.91
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
49%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
1,103
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.90
Composite VBP score used to determine payment impact.
Payment multiplier
1.0151
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 20.00% · Performance 17.00% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.80
Baseline 11.38% · Performance 7.36% · Measure score 5.80 · Achievement 1.60 · Improvement 5.80
Total nurse turnover
7.52
Baseline 29.95% · Performance 32.95% · Measure score 7.52 · Achievement 7.52 · Improvement 0
Adjusted total nurse staffing
0.64
Baseline 2.88 hours · Performance 3.21 hours · Measure score 0.64 · Achievement 0 · Improvement 0.64
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 203 · Observed rate 10.34% · Lower 95% interval 7.78% |
| Discharge to community | 31.6% |
50.57%
19 pts worse
|
Worse than the National Rate · Eligible stays 185 · Observed rate 23.24% · Lower 95% interval 24.61% |
| Medicare spending per beneficiary | 1.77 |
1.02
0.8 pts worse
|
|
| Drug regimen review with follow-up | 99.68% |
95.27%
4.4 pts better
|
Numerator 313 · Denominator 314 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 3 · Denominator 314 |
| Discharge self-care score | 66.36% |
53.69%
12.7 pts better
|
Numerator 146 · Denominator 220 |
| Discharge mobility score | 70.91% |
50.94%
20 pts better
|
Numerator 156 · Denominator 220 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 5 · Denominator 314 · Adjusted rate 1.24% |
| Healthcare-associated infections requiring hospitalization | 7.36% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 7.45% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 3 · Denominator 273 |
| Staff flu vaccination coverage | 62.18% |
42%
20.2 pts better
|
Numerator 222 · Denominator 357 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 154 · Denominator 220 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 73 · Denominator 73 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 94 · Denominator 94 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 55 · Denominator 165 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.9 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
91.2%
7.7 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 99.7% · Q3 100.0% · Q4 98.9% · 4Q avg 98.9% |
| 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 | 1.1% |
3.0%
1.9 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.4% · Q3 1.1% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
18.5%
9.5 pts better
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 8.6% · Q3 9.5% · Q4 10.6% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
6.1%
0.7 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 9.0% · Q3 7.9% · Q4 6.5% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
13.5%
4.2 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.5% · Q3 10.3% · Q4 6.6% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
14.8%
3.6 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 11.7% · Q3 10.7% · Q4 9.9% · 4Q avg 11.2% · 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 | 24.5% |
15.1%
9.4 pts worse
|
16.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 27.4% · Q3 16.2% · Q4 16.8% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
15.5%
9.3 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 28.8% · Q3 18.4% · Q4 18.9% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.3% · Q3 0.3% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.4%
1.1 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
20.8%
3.2 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 24.9% · Q3 22.7% · Q4 21.7% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.9%
0.3 pts better
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.4% · Q3 5.8% · Q4 7.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.9% |
76.7%
10.2 pts better
|
81.7%
5.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.0% · Q2 86.3% · Q3 88.8% · Q4 88.8% · 4Q avg 86.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
9.7%
3.5 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 13.1% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.2%
1.1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.1% · Q3 2.9% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.7% |
78.8%
4.9 pts better
|
79.7%
4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
20.6%
2.9 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 18.4% · Expected 24.8% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-29
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-02-21
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-02-21
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-02-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-21
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-02-21
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-07-02
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-07-02
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 2019-07-02
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-02
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-05
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-05
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 2024-04-05
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-10
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-02-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-02-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-10
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 2022-02-10
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 2022-02-10
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 2022-02-10
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 2019-07-02
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 2019-07-02
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 2019-07-02
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-07-02
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-07-02
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-07-02
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-07-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-07-02
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
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