New York, NY

New Gouverneur Hospital S N F

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

227 Madison Street, New York, NY

(212) 441-5023

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

295

Certified beds

Average residents

287

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

New York City Health + Hospitals

Operator or chain grouping

Approved since

1975-07-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

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

1.46

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.35

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.76

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.58

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.81

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.83

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

1.03

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

1.60

CMS adjusted RN staffing hours

Adjusted total hours

5.02

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

28%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

249

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

Performance score

75.75

Composite VBP score used to determine payment impact.

Payment multiplier

1.0247

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

10

Baseline 18.11% · Performance 16.11% · Measure score 10 · Achievement 10 · Improvement 9

Healthcare-associated infections

6.25

Baseline 6.26% · Performance 5.97% · Measure score 6.25 · Achievement 6.25 · Improvement 1.81

Total nurse turnover

8.67

Baseline 32.87% · Performance 28.25% · Measure score 8.67 · Achievement 8.67 · Improvement 5.26

Adjusted total nurse staffing

5.38

Baseline 4.09 hours · Performance 4.61 hours · Measure score 5.38 · Achievement 5.38 · Improvement 2.56

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.11%	10.72% 1.6 pts better	No Different than the National Rate · Eligible stays 372 · Observed rate 6.99% · Lower 95% interval 7.39%
Discharge to community	63.85%	50.57% 13.3 pts better	Better than the National Rate · Eligible stays 367 · Observed rate 57.77% · Lower 95% interval 58.17%
Medicare spending per beneficiary	0.99	1.02 About the same
Drug regimen review with follow-up	62.31%	95.27% 33 pts worse	Numerator 167 · Denominator 268
Falls with major injury	0.37%	0.77% 0.4 pts better	Numerator 1 · Denominator 268
Discharge self-care score	46.46%	53.69% 7.2 pts worse	Numerator 105 · Denominator 226
Discharge mobility score	56.19%	50.94% 5.2 pts better	Numerator 127 · Denominator 226
Pressure ulcers or injuries, new or worsened	3%	2.29% 0.7 pts worse	Numerator 8 · Denominator 267 · Adjusted rate 2.73%
Healthcare-associated infections requiring hospitalization	5.97%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 205 · Observed rate 4.88% · Lower 95% interval 4%
Staff COVID-19 vaccination coverage	11.06%	8.2% 2.9 pts better	Numerator 46 · Denominator 416
Staff flu vaccination coverage	73.28%	42% 31.3 pts better	Numerator 362 · Denominator 494
Discharge function score	57.08%	56.45% 0.6 pts better	Numerator 129 · Denominator 226
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 39 · Denominator 39
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 155 · Denominator 155
Resident COVID-19 vaccinations up to date	44.59%	25.2% 19.4 pts better	Numerator 70 · Denominator 157

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.7 0.3 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.5	1.3 0.8 pts better	1.8 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	91.2% 8.4 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.6%	95.3% 4.3 pts better	95.5% 4.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.6%
Percentage of long-stay residents experiencing one or more falls with major injury	1.2%	3.0% 1.8 pts better	3.3% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.9% · Q3 1.7% · Q4 1.2% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.8%	18.5% 17.7 pts better	11.4% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.2% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8%
Percentage of long-stay residents who lose too much weight	3.9%	6.1% 2.2 pts better	5.4% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.7% · Q3 2.1% · Q4 3.5% · 4Q avg 3.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	0.7%	13.5% 12.8 pts better	19.6% 18.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.5% · Q3 0.9% · Q4 0.4% · 4Q avg 0.7%
Percentage of long-stay residents who received an antipsychotic medication	3.8%	14.8% 11 pts better	16.7% 12.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.7% · Q3 3.0% · Q4 3.0% · 4Q avg 3.8% · 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	13.4%	15.1% 1.7 pts better	16.3% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 16.2% · Q3 12.9% · Q4 10.5% · 4Q avg 13.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.3%	15.5% 0.2 pts better	14.9% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 16.6% · Q3 14.4% · Q4 16.6% · 4Q avg 15.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.1%	0.6% 0.5 pts better	1.0% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.3% · 4Q avg 0.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.7%	1.4% 0.7 pts better	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.3% · Q3 0.4% · Q4 0.4% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.3%	20.8% 2.5 pts better	19.8% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 21.8% · Q3 14.3% · Q4 17.1% · 4Q avg 18.3%
Percentage of long-stay residents with pressure ulcers	12.5%	6.9% 5.6 pts worse	5.1% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 14.7% · Q3 9.0% · Q4 11.1% · 4Q avg 12.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.8%	76.7% 19.1 pts better	81.7% 14.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 94.6% · Q3 96.8% · Q4 96.9% · 4Q avg 95.8%
Percentage of short-stay residents who had an outpatient emergency department visit	6.3%	9.7% 3.4 pts better	12.0% 5.7 pts better	Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.4% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.1%	1.2% 1.1 pts better	1.6% 1.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.4% · 4Q avg 0.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.4%	78.8% 18.6 pts better	79.7% 17.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	15.1%	20.6% 5.5 pts better	23.9% 8.8 pts better	Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 13.5% · Expected 21.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-19 · Fire 2024-12-19

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2022-10-18 · Fire 2022-10-18

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-12-20 · Fire 2019-12-20

3 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-12-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-02-15

E · Potential for more than minimal harm 2024-12-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-02-15

D · Potential for more than minimal harm 2024-12-19

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2025-02-15

D · Potential for more than minimal harm 2024-12-19

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-02-15

D · Potential for more than minimal harm 2024-12-19

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-02-15

E · Potential for more than minimal harm 2022-10-18

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2022-12-28

D · Potential for more than minimal harm 2022-10-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-12-09

D · Potential for more than minimal harm 2022-10-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-12-09

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-12-19

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 2025-02-12

D · Potential for more than minimal harm 2024-12-19

F657 · Resident Assessment and Care Planning Deficiencies

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 2025-02-12

D · Potential for more than minimal harm 2024-12-19

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 2025-02-12

C · Minimal harm 2024-12-19

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-02-12

E · Potential for more than minimal harm 2022-10-18

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 2022-12-15

D · Potential for more than minimal harm 2022-10-18

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 2022-12-15

D · Potential for more than minimal harm 2022-10-18

F657 · Resident Assessment and Care Planning Deficiencies

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 2022-12-15

D · Potential for more than minimal harm 2022-10-18

F688 · Quality of Life and Care Deficiencies

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 2022-12-15

D · Potential for more than minimal harm 2022-10-18

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 2022-12-15

D · Potential for more than minimal harm 2019-12-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2020-02-14

D · Potential for more than minimal harm 2019-12-20

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2020-02-14

D · Potential for more than minimal harm 2019-12-20

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 2020-02-14

Penalties and ownership

What sits behind the stars

Ownership

Basquez, Florencio

Operational/Managerial Control · Individual

0% 5 facilities 2018-07-02

Calamia, Vincent