Cycle 1
Health 2024-10-03 · Fire 2024-10-03
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bayside, NY
Ozanam Hall Of Queens Nursing Home Inc
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
42 41 201st Street, Bayside, NY
(718) 423-2000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
432
Certified beds
Average residents
372
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Carmelite Sisters For The Aged And Infirmed
Operator or chain grouping
Approved since
1972-09-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 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
0.89
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.40
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
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,871
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.81
Baseline 20.08% · Performance 21.06% · Measure score 0.81 · Achievement 0.81 · Improvement 0
Healthcare-associated infections
0.87
Baseline 7.95% · Performance 7.57% · Measure score 0.87 · Achievement 0.87 · Improvement 0.78
Total nurse turnover
7.65
Baseline 23.00% · Performance 32.41% · Measure score 7.65 · Achievement 7.65 · Improvement 0
Adjusted total nurse staffing
2.09
Baseline 2.97 hours · Performance 3.67 hours · Measure score 2.09 · Achievement 2.09 · Improvement 2
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.18% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 565 · Observed rate 7.79% · Lower 95% interval 7.23% |
| Discharge to community | 57.12% |
50.57%
6.5 pts better
|
Better than the National Rate · Eligible stays 623 · Observed rate 48.15% · Lower 95% interval 51.85% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.07% |
95.27%
1.8 pts better
|
Numerator 397 · Denominator 409 |
| Falls with major injury | 0.98% |
0.77%
0.2 pts worse
|
Numerator 4 · Denominator 409 |
| Discharge self-care score | 38.54% |
53.69%
15.1 pts worse
|
Numerator 79 · Denominator 205 |
| Discharge mobility score | 46.83% |
50.94%
4.1 pts worse
|
Numerator 96 · Denominator 205 |
| Pressure ulcers or injuries, new or worsened | 3.67% |
2.29%
1.4 pts worse
|
Numerator 15 · Denominator 409 · Adjusted rate 2.41% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 392 · Observed rate 7.65% · Lower 95% interval 5.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 417 |
| Staff flu vaccination coverage | 46.28% |
42%
4.3 pts better
|
Numerator 255 · Denominator 551 |
| Discharge function score | 45.37% |
56.45%
11.1 pts worse
|
Numerator 93 · Denominator 205 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 287 · Denominator 287 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 8.76% |
25.2%
16.4 pts worse
|
Numerator 19 · Denominator 217 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.8% |
91.2%
16.4 pts worse
|
93.4%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.8% · Q2 75.6% · Q3 82.3% · Q4 76.6% · 4Q avg 74.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
95.3%
1.1 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.0%
About the same
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.5% · Q3 3.9% · Q4 3.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.9% |
18.5%
8.6 pts better
|
11.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 10.5% · Q3 10.1% · Q4 8.9% · 4Q avg 9.9% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
6.1%
2.8 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 11.0% · Q3 8.9% · Q4 6.7% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
13.5%
4 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.4% · Q3 9.7% · Q4 9.8% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
14.8%
6.9 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.7% · Q3 9.0% · Q4 8.3% · 4Q avg 7.9% · 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 | 23.0% |
15.1%
7.9 pts worse
|
16.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 17.6% · Q3 25.8% · Q4 13.9% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
15.5%
1.5 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 17.2% · Q3 18.1% · Q4 13.4% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.8% · Q3 0.0% · Q4 0.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
1.4%
2.5 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.9% · Q3 4.9% · Q4 2.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
20.8%
4.3 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 22.7% · Q3 27.7% · Q4 21.3% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
6.9%
3.4 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.0% · Q3 3.2% · Q4 2.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.6% |
76.7%
31.1 pts worse
|
81.7%
36.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 44.3% · Q3 53.4% · Q4 53.6% · 4Q avg 45.6% |
| 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 6.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.3% · Q3 1.0% · Q4 0.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.0% |
78.8%
11.8 pts worse
|
79.7%
12.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.0% |
| 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 · Adjusted 20.4% · Observed 20.5% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-19 · Fire 2022-07-19
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-10-21 · Fire 2019-10-21
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-10-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-27
C · Minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-27
F · Potential for more than minimal harm
2022-07-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-07-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-07-19
K222 · Egress Deficiencies
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 2022-09-18
D · Potential for more than minimal harm
2022-07-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-07-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-07-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-07-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-09-18
E · Potential for more than minimal harm
2019-10-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-18
C · Minimal harm
2019-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-16
C · Minimal harm
2019-10-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-03
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 2024-11-27
D · Potential for more than minimal harm
2024-10-03
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-03
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 2024-11-27
D · Potential for more than minimal harm
2024-10-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-03
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-27
E · Potential for more than minimal harm
2022-07-19
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 2022-08-31
D · Potential for more than minimal harm
2022-07-19
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 2022-08-31
D · Potential for more than minimal harm
2022-07-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-31
D · Potential for more than minimal harm
2019-10-21
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 2019-12-15
D · Potential for more than minimal harm
2019-10-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-15
D · Potential for more than minimal harm
2019-10-21
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 2019-12-15
D · Potential for more than minimal harm
2019-10-21
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 2019-12-11
C · Minimal harm
2019-10-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-11-29
Penalties and ownership
What sits behind the stars
Ownership
Carmelite Sisters For The Aged And Infirm, Inc.
5% Or Greater Direct Ownership Interest · Organization
Roman Catholic Disocese Of Brooklyn
5% Or Greater Direct Ownership Interest · Organization
Bowden, Mary
Operational/Managerial Control · Individual
Bowden, Mary
Corporate Director · Individual
Bowden, Mary
Contracted Managing Employee · Individual
Devlin, Leslee
Corporate Director · Individual
Fonti, Joseph
Corporate Officer · Individual
Gathers, Patricia
Corporate Officer · Individual
Gelfant, Michael
Corporate Director · Individual
Heery, Mary
Corporate Officer · Individual
Kasper, Rose Marie
Corporate Director · Individual
Keating, Patrick
Corporate Director · Individual
Lynch, Patricia
Corporate Director · Individual
Mcaleer, Marty
Corporate Director · Individual
Pfeffer, Theresa
Corporate Director · Individual
Powers, Keith
Corporate Director · Individual
Reilly, Patrica
Corporate Director · Individual
Tullis, Neola
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Marys Hospital For Children
Bayside, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Elmhurst Care Center Inc
East Elmhurst, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Bridge View Nursing Home
Whitestone, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out