10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
21 fire-safety deficiencies
Top issue: Egress (7 deficiencies)
Monsey, NY
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
225 Maple Avenue, Monsey, NY
(845) 352-9000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
118
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1973-01-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.62
Registered nurse staffing
LPN hours / resident day
0.72
Licensed practical nurse staffing
Aide hours / resident day
2.23
Nurse aide staffing
Weekend hours
3.16
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
18%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.3
0.5 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.2%
8.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.3%
3.8 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.0%
0.7 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 71.8% |
18.5%
53.3 pts worse
|
11.4%
60.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.1%
2.5 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
13.5%
1.2 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.3% |
14.8%
3.5 pts worse
|
16.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.4% |
15.1%
11.7 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.7% |
15.5%
10.8 pts better
|
14.9%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.4%
0.9 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
20.8%
0.5 pts worse
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.9%
1.6 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
76.7%
20.5 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
9.7%
2.8 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
78.8%
17.5 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
20.6%
0.2 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Rights (3 deficiencies)
21 fire-safety deficiencies
Top issue: Egress (7 deficiencies)
Top issue: Nursing and Physician Services (1 deficiency)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-23
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-04
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-05
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-23
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 2024-08-23
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2024-08-23
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-23
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-08-23
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-23
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-23
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 2024-08-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-23
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-23
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-23
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-23
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-23
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-08-23
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-08-23
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 2022-01-25
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 2022-01-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-25
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-01-25
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-01-25
Fire Safety
Install proper backup exit lighting.
Corrected 2022-01-25
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-01-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-25
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2018-12-05
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-12-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-05
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-12-05
Fire Safety
Implement emergency and standby power systems.
Corrected 2018-12-05
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-12-05
Inspection history
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 2024-08-30
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 2024-08-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-30
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-30
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-30
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 2024-08-30
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-30
Health
Post nurse staffing information every day.
Corrected 2022-02-02
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2018-12-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-12-03
Penalties and ownership
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
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