15 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Staten Island, NY
1-star overall rating with 1-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
135 Vanderbilt Ave, Staten Island, NY
(718) 447-0701
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
320
Certified beds
Average residents
260
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-11-01
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
0.45
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.71
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
3.38
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
9,189
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.90
Baseline 20.32% · Performance 19.62% · Measure score 3.90 · Achievement 3.90 · Improvement 1.62
Healthcare-associated infections
0
Baseline 7.71% · Performance 8.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.90
Baseline 18.28% · Performance 39.55% · Measure score 5.90 · Achievement 5.90 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.84 hours · Performance 2.72 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 238 · Observed rate 15.13% · Lower 95% interval 8.24% |
| Discharge to community | 36.48% |
50.57%
14.1 pts worse
|
Worse than the National Rate · Eligible stays 187 · Observed rate 22.99% · Lower 95% interval 28.63% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.55% |
95.27%
4.3 pts better
|
Numerator 222 · Denominator 223 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 4 · Denominator 223 |
| Discharge self-care score | 36.8% |
53.69%
16.9 pts worse
|
Numerator 46 · Denominator 125 |
| Discharge mobility score | 44.8% |
50.94%
6.1 pts worse
|
Numerator 56 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 4.04% |
2.29%
1.8 pts worse
|
Numerator 9 · Denominator 223 · Adjusted rate 3.06% |
| Healthcare-associated infections requiring hospitalization | 8.11% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 12.5% · Lower 95% interval 5.71% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 253 |
| Staff flu vaccination coverage | 53.47% |
42%
11.5 pts better
|
Numerator 131 · Denominator 245 |
| Discharge function score | 34.4% |
56.45%
22.1 pts worse
|
Numerator 43 · Denominator 125 |
| Transfer of health information to provider | 95.95% |
95.95%
About the same
|
Numerator 71 · Denominator 74 |
| Transfer of health information to patient | 91.49% |
96.28%
4.8 pts worse
|
Numerator 43 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 12.3% |
25.2%
12.9 pts worse
|
Numerator 15 · Denominator 122 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.7 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
91.2%
4.5 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 95.2% · Q3 99.6% · Q4 99.6% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
95.3%
3.6 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.0%
0.6 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.4% · Q3 3.1% · Q4 3.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 67.6% |
18.5%
49.1 pts worse
|
11.4%
56.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.5% · Q2 68.9% · Q3 60.7% · Q4 82.2% · 4Q avg 67.6% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.1%
0.4 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.8% · Q3 4.5% · Q4 5.6% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
13.5%
10.3 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 24.0% · Q3 24.8% · Q4 25.5% · 4Q avg 23.8% |
| Percentage of long-stay residents who were physically restrained | 0.9% |
0.2%
0.7 pts worse
|
0.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.6% · Q3 0.4% · Q4 0.4% · 4Q avg 0.9% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.2% |
15.1%
7.9 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 11.9% · Q3 2.6% · Q4 9.7% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
15.5%
7 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.7% · Q3 6.2% · Q4 11.4% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.6%
1.6 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.8% · Q3 2.0% · Q4 1.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.4%
0.8 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.2% · Q3 3.2% · Q4 0.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.0% |
20.8%
6.8 pts better
|
19.8%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 19.1% · Q3 9.0% · Q4 13.7% · 4Q avg 14.0% |
| Percentage of long-stay residents with pressure ulcers | 15.5% |
6.9%
8.6 pts worse
|
5.1%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 17.3% · Q3 15.2% · Q4 13.0% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
76.7%
14.9 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.0% · Q2 94.1% · Q3 99.4% · Q4 100.0% · 4Q avg 91.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
9.7%
2.5 pts worse
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 15.0% · Expected 13.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.2%
2.9 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.1% · Q3 7.5% · Q4 1.4% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.7% |
78.8%
15.9 pts better
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
20.6%
0.4 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 27.5% · Expected 32.4% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Resident Assessment and Care Planning (7 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-13
Fire Safety
Install proper backup exit lighting.
Corrected 2024-09-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-13
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-13
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-08-08
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-07-06
Fire Safety
Install proper backup exit lighting.
Corrected 2023-06-16
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-13
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-06
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 2023-06-15
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-07-06
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-20
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-08
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-26
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 2020-11-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-11-16
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-11-16
Fire Safety
Meet other general requirements that are deficient.
Corrected 2020-11-16
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-11-16
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-13
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-13
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 2024-09-13
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-09-13
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-09-13
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-13
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-09-13
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-13
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-13
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 2024-09-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-13
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 2024-09-13
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-13
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 2024-09-13
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 2024-09-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-13
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-09-13
Health
Dispose of garbage and refuse properly.
Corrected 2024-09-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-03
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-01-03
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-01-03
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 2023-08-01
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-08-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-01
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-08-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-08-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-01
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-08-01
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-08-01
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 2023-08-01
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-01
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-01
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-08-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
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