Cycle 1
Health 2023-07-27 · Fire 2023-07-27
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Montrose, NY
New York State Veterans Home At Montrose
2-star overall rating with 1-star inspections with $29,153 in total fines with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2090 Albany Post Road, Montrose, NY
(914) 788-6000
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
252
Certified beds
Average residents
202
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-10-05
CMS approved date
Coverage
Medicare
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
Hours and turnover
RN hours / resident day
1.04
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.70
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
1.22
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,000
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.38
Composite VBP score used to determine payment impact.
Payment multiplier
1.0069
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.44
Baseline 18.70% · Performance 19.38% · Measure score 4.44 · Achievement 4.44 · Improvement 0
Healthcare-associated infections
3.08
Baseline 5.77% · Performance 6.91% · Measure score 3.08 · Achievement 3.08 · Improvement 0
Total nurse turnover
10
Performance 21.13% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.43
Baseline 4.70 hours · Performance 4.05 hours · Measure score 3.43 · Achievement 3.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 12.26% · Lower 95% interval 7.69% |
| Discharge to community | 22.38% |
50.57%
28.2 pts worse
|
Worse than the National Rate · Eligible stays 37 · Observed rate 2.7% · Lower 95% interval 13.16% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 50 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 32.26% |
53.69%
21.4 pts worse
|
Numerator 10 · Denominator 31 |
| Discharge mobility score | 38.71% |
50.94%
12.2 pts worse
|
Numerator 12 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 2 · Denominator 50 · Adjusted rate 2.79% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 13.24% |
8.2%
5 pts better
|
Numerator 45 · Denominator 340 |
| Staff flu vaccination coverage | 33.44% |
42%
8.6 pts worse
|
Numerator 107 · Denominator 320 |
| Discharge function score | 32.26% |
56.45%
24.2 pts worse
|
Numerator 10 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 53.57% |
25.2%
28.4 pts better
|
Numerator 15 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| 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 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.0% |
91.2%
12.2 pts worse
|
93.4%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.0% · Q2 92.1% · Q3 80.3% · Q4 55.1% · 4Q avg 79.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
95.3%
2.8 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.0%
2.2 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.3% · Q3 5.1% · Q4 6.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
18.5%
16.3 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 4.4% · Q4 3.4% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.1%
0.1 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.8% · Q3 8.5% · Q4 4.6% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
13.5%
1.6 pts worse
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 14.4% · Q3 14.4% · Q4 16.7% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
14.8%
2 pts worse
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 18.5% · Q3 17.6% · Q4 12.2% · 4Q avg 16.8% · 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 | 22.1% |
15.1%
7 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 29.0% · Q3 17.0% · Q4 16.9% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.2% |
15.5%
11.7 pts worse
|
14.9%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.3% · Q2 35.8% · Q3 24.2% · Q4 12.6% · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.6%
0.8 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.8% · Q3 1.5% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
1.4%
3.1 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.9% · Q3 4.2% · Q4 1.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
20.8%
6.7 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 32.1% · Q3 25.4% · Q4 20.0% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 9.6% |
6.9%
2.7 pts worse
|
5.1%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 10.5% · Q3 9.0% · Q4 8.5% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.7% |
76.7%
20 pts worse
|
81.7%
25 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.0% · Q2 50.0% · Q3 50.0% · Q4 57.5% · 4Q avg 56.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
9.7%
2.4 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 6.8% · Expected 10.5% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
78.8%
15.8 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
20.6%
6.4 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 13.7% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-22 · Fire 2019-06-22
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-07-13 · Fire 2018-07-13
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-07-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-07-27
K321 · Smoke Deficiencies
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 2023-09-19
E · Potential for more than minimal harm
2023-07-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-07-27
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-07-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-20
E · Potential for more than minimal harm
2019-06-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-08-18
E · Potential for more than minimal harm
2019-06-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-06-22
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2019-08-18
D · Potential for more than minimal harm
2019-06-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-08-18
E · Potential for more than minimal harm
2018-07-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2018-09-14
E · Potential for more than minimal harm
2018-07-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2018-09-14
D · Potential for more than minimal harm
2018-07-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-09-14
D · Potential for more than minimal harm
2018-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-09-14
C · Minimal harm
2018-07-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-09-14
C · Minimal harm
2018-07-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-09-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-04
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 2025-07-31
D · Potential for more than minimal harm
2025-06-04
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 2025-07-31
G · Actual harm
2025-04-03
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 2025-05-23
G · Actual harm
2025-04-03
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-03
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 2025-05-23
D · Potential for more than minimal harm
2025-04-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-23
D · Potential for more than minimal harm
2023-07-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-07-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-07-27
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 2023-09-12
D · Potential for more than minimal harm
2023-07-27
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 2023-09-12
D · Potential for more than minimal harm
2023-07-27
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 2023-09-12
D · Potential for more than minimal harm
2023-07-27
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 2023-09-12
D · Potential for more than minimal harm
2023-07-27
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-07-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-12
D · Potential for more than minimal harm
2019-06-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-06-22
F578 · Resident Rights Deficiencies
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 2019-08-15
D · Potential for more than minimal harm
2018-07-13
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 2018-09-12
Penalties and ownership
What sits behind the stars
$29,153
2025-04-03
Fine
Fine · fine $29,153
Fine
Ownership
Leahy, John
Operational/Managerial Control · Individual
Leahy, John
Corporate Director · Individual
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#3
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