Cycle 1
Health 2025-12-22 · Fire 2025-12-22
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Spring Valley, NY
Pine Valley Center For Rehabilitation And Nursing
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
661 N Main St, Spring Valley, NY
(845) 356-0567
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
160
Certified beds
Average residents
156
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1969-05-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.66
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.34
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
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,953
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9949
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.65
Baseline 19.82% · Performance 20.67% · Measure score 1.65 · Achievement 1.65 · Improvement 0
Healthcare-associated infections
2.18
Baseline 7.60% · Performance 7.18% · Measure score 2.18 · Achievement 2.18 · Improvement 1.08
Total nurse turnover
9.24
Baseline 38.57% · Performance 25.90% · Measure score 9.24 · Achievement 9.24 · Improvement 8.74
Adjusted total nurse staffing
3.72
Baseline 3.45 hours · Performance 4.14 hours · Measure score 3.72 · Achievement 3.72 · Improvement 2.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 269 · Observed rate 10.04% · Lower 95% interval 7.8% |
| Discharge to community | 41.17% |
50.57%
9.4 pts worse
|
Worse than the National Rate · Eligible stays 255 · Observed rate 35.29% · Lower 95% interval 35.39% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.43% |
95.27%
3.2 pts better
|
Numerator 125 · Denominator 127 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 127 |
| Discharge self-care score | 37.5% |
53.69%
16.2 pts worse
|
Numerator 36 · Denominator 96 |
| Discharge mobility score | 21.88% |
50.94%
29.1 pts worse
|
Numerator 21 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 127 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 7.1% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 13.36% |
8.2%
5.2 pts better
|
Numerator 33 · Denominator 247 |
| Staff flu vaccination coverage | 66.67% |
42%
24.7 pts better
|
Numerator 172 · Denominator 258 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 32 · Denominator 96 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 55 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 28.38% |
25.2%
3.2 pts better
|
Numerator 21 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
91.2%
6.2 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 96.5% · Q3 99.3% · Q4 99.3% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.3%
3.4 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.0%
2.5 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 1.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
18.5%
18.1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.1%
0.9 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.9% · Q3 8.7% · Q4 4.6% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
13.5%
2.2 pts worse
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 16.3% · Q3 14.3% · Q4 14.2% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
14.8%
1.5 pts worse
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 18.6% · Q3 15.2% · Q4 12.9% · 4Q avg 16.3% · 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 | 19.3% |
15.1%
4.2 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 24.7% · Q3 16.1% · Q4 6.5% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
15.5%
3.8 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 20.5% · Q3 22.0% · Q4 7.8% · 4Q avg 19.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.4%
1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
20.8%
8 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 33.7% · Q3 29.6% · Q4 28.9% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
6.9%
1.7 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 7.5% · Q3 9.4% · Q4 8.9% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.3% |
76.7%
14.4 pts worse
|
81.7%
19.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.2% · Q2 64.7% · Q3 71.3% · Q4 73.9% · 4Q avg 62.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
9.7%
0.9 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.6% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.9% |
78.8%
10.9 pts worse
|
79.7%
11.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
20.6%
3.2 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 26.3% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-14 · Fire 2023-07-14
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-11-25 · Fire 2019-11-25
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-22
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-02-13
E · Potential for more than minimal harm
2023-07-14
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 2023-08-24
E · Potential for more than minimal harm
2023-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-07-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-07-14
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-07-14
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-08
D · Potential for more than minimal harm
2019-11-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-11-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-02-05
C · Minimal harm
2019-11-25
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2020-02-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-22
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 2026-02-03
E · Potential for more than minimal harm
2025-12-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-03
E · Potential for more than minimal harm
2025-12-22
F688 · Quality of Life and Care Deficiencies
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 2026-02-03
D · Potential for more than minimal harm
2025-12-22
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-12-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-12-22
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 2026-02-03
D · Potential for more than minimal harm
2025-12-22
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 2026-02-03
D · Potential for more than minimal harm
2025-12-22
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 2026-02-03
D · Potential for more than minimal harm
2025-10-06
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.
Not marked corrected
D · Potential for more than minimal harm
2024-12-02
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 2025-01-31
D · Potential for more than minimal harm
2024-12-02
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 2025-01-31
D · Potential for more than minimal harm
2024-12-02
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
D · Potential for more than minimal harm
2023-07-14
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 2023-10-06
D · Potential for more than minimal harm
2023-07-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-07-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-07-14
F688 · Quality of Life and Care Deficiencies
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 2023-10-06
D · Potential for more than minimal harm
2023-07-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-07-14
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 2023-10-06
D · Potential for more than minimal harm
2023-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-07-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-10-06
D · Potential for more than minimal harm
2019-11-25
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 2020-01-20
D · Potential for more than minimal harm
2019-11-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-20
Penalties and ownership
What sits behind the stars
Ownership
Steif, Efraim
5% Or Greater Direct Ownership Interest · Individual
Koenig, Uri
5% Or Greater Direct Ownership Interest · Individual
Koenig, Lawrence
5% Or Greater Direct Ownership Interest · Individual
Augenstein, Jack
Corporate Director · Individual
Augenstein, Jack
Corporate Officer · Individual
Steif, Efraim
Operational/Managerial Control · Individual
Wuertzer, Amy
Corporate Officer · Individual
Nearby options
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#2
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#3
Northern Manor Geriatric Center Inc
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1-star overall rating with 1-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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