Cycle 1
Health 2025-01-14 · Fire 2025-01-14
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Valley Cottage, NY
Nyack Ridge Rehabilitation And Nursing Center
1-star overall rating with 1-star inspections with $39,130 in total fines with 21 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
476 Christian Herald Road, Valley Cottage, NY
(845) 268-6861
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
149
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
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,114
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.60
Baseline 21.14% · Performance 20.23% · Measure score 2.60 · Achievement 2.60 · Improvement 1.73
Healthcare-associated infections
2.32
Baseline 11.73% · Performance 9.83% · Measure score 2.32 · Achievement 0 · Improvement 2.32
Total nurse turnover
8.50
Baseline 21.93% · Performance 28.93% · Measure score 8.50 · Achievement 8.50 · Improvement 0
Adjusted total nurse staffing
1.52
Baseline 3.35 hours · Performance 3.51 hours · Measure score 1.52 · Achievement 1.52 · Improvement 0.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.03% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 234 · Observed rate 11.11% · Lower 95% interval 8% |
| Discharge to community | 47.77% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 207 · Observed rate 39.13% · Lower 95% interval 40.54% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 191 · Denominator 191 |
| Falls with major injury | 0.52% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 191 |
| Discharge self-care score | 43.02% |
53.69%
10.7 pts worse
|
Numerator 37 · Denominator 86 |
| Discharge mobility score | 47.67% |
50.94%
3.3 pts worse
|
Numerator 41 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 5.24% |
2.29%
3 pts worse
|
Numerator 10 · Denominator 191 · Adjusted rate 3.83% |
| Healthcare-associated infections requiring hospitalization | 9.83% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 154 · Observed rate 14.94% · Lower 95% interval 7.1% |
| Staff COVID-19 vaccination coverage | 20.71% |
8.2%
12.5 pts better
|
Numerator 41 · Denominator 198 |
| Staff flu vaccination coverage | 88.11% |
42%
46.1 pts better
|
Numerator 289 · Denominator 328 |
| Discharge function score | 47.67% |
56.45%
8.8 pts worse
|
Numerator 41 · Denominator 86 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 103 · Denominator 103 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 25.77% |
25.2%
0.6 pts better
|
Numerator 25 · Denominator 97 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.7
1.1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.0%
0.5 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 1.7% · Q4 1.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.9% |
18.5%
11.6 pts better
|
11.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 4.0% · Q3 5.8% · Q4 3.2% · 4Q avg 6.9% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
6.1%
3.5 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.8% · Q3 10.6% · Q4 9.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
13.5%
3.5 pts worse
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 16.4% · Q3 16.4% · Q4 19.3% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
14.8%
0.9 pts better
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 13.9% · Q3 15.0% · Q4 11.8% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.3% |
15.1%
8.8 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 4.0% · Q3 5.3% · Q4 8.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
15.5%
5.4 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.8% · Q3 10.0% · Q4 12.2% · 4Q avg 10.1% · 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 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.4%
1.8 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.6% · Q3 4.3% · Q4 2.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.9% |
20.8%
11.9 pts better
|
19.8%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.3% · Q3 7.6% · Q4 11.1% · 4Q avg 8.9% |
| Percentage of long-stay residents with pressure ulcers | 10.0% |
6.9%
3.1 pts worse
|
5.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 13.2% · Q3 11.2% · Q4 5.6% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
76.7%
18.5 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 97.9% · Q3 95.2% · Q4 88.8% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
9.7%
0.8 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.2%
2.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 6.3% · Q4 4.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
78.8%
19.8 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
20.6%
1.8 pts worse
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 25.0% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-25 · Fire 2023-09-25
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2020-02-19 · Fire 2020-02-19
5 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-14
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-14
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 2025-03-12
D · Potential for more than minimal harm
2025-01-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-12
E · Potential for more than minimal harm
2023-09-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
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 2023-11-01
D · Potential for more than minimal harm
2023-09-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-11-01
C · Minimal harm
2023-09-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-01
D · Potential for more than minimal harm
2020-02-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-15
Inspection history
Recent health citations
G · Actual harm
2025-11-04
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 2025-12-29
E · Potential for more than minimal harm
2025-01-14
F584 · Resident Rights Deficiencies
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 2025-03-13
E · Potential for more than minimal harm
2025-01-14
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-01-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-01-14
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 2025-03-13
E · Potential for more than minimal harm
2025-01-14
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 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
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 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
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 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
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 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-01-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-13
B · Minimal harm
2025-01-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-13
D · Potential for more than minimal harm
2024-04-25
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 2024-06-18
D · Potential for more than minimal harm
2024-04-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-04-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-18
J · Immediate jeopardy
2023-09-25
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 2023-10-23
E · Potential for more than minimal harm
2023-09-25
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 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F758 · Pharmacy Service Deficiencies
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 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F803 · Nutrition and Dietary Deficiencies
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 2023-11-01
D · Potential for more than minimal harm
2023-09-25
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 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-25
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-06-12
F584 · Resident Rights Deficiencies
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 2023-09-01
E · Potential for more than minimal harm
2023-06-12
F690 · Quality of Life and Care Deficiencies
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 2023-09-01
D · Potential for more than minimal harm
2023-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-06-12
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-06-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-01
Penalties and ownership
What sits behind the stars
$39,130
2023-09-25
Fine
Fine · fine $39,130
Fine
Ownership
Braunstein, Edward
5% Or Greater Direct Ownership Interest · Individual
Braunstein, Michael
5% Or Greater Direct Ownership Interest · Individual
Einhorn, Benjamin
5% Or Greater Direct Ownership Interest · Individual
Diamond, Jessica
5% Or Greater Direct Ownership Interest · Individual
Gellis, Cheryl
5% Or Greater Direct Ownership Interest · Individual
Hirsch, Daniel
5% Or Greater Direct Ownership Interest · Individual
Beller, Steven
Operational/Managerial Control · Individual
Braunstein, Edward
Corporate Officer · Individual
Braunstein, Michael
Corporate Officer · Individual
Diamond, Jessica
Corporate Officer · Individual
Einhorn, Benjamin
Corporate Officer · Individual
Gellis, Cheryl
Corporate Officer · Individual
Hirsch, Daniel
Corporate Officer · Individual
Silberberg, Chaim
Operational/Managerial Control · Individual
Zyskind, Israel
5% Or Greater Direct Ownership Interest · Individual
Zyskind, Israel
Corporate Officer · Individual
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#3
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