25 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Brewster, NY
1-star overall rating with 1-star inspections with 25 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
46 Mt Ebo Road North, Brewster, NY
(845) 278-3636
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
160
Certified beds
Average residents
146
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-08-29
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
RN hours / resident day
0.59
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.33
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
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
6,921
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.55
Baseline 24.52% · Performance 21.49% · Measure score 3.55 · Achievement 0 · Improvement 3.55
Healthcare-associated infections
2.04
Baseline 6.89% · Performance 7.22% · Measure score 2.04 · Achievement 2.04 · Improvement 0
Total nurse turnover
4.74
Baseline 45.63% · Performance 44.29% · Measure score 4.74 · Achievement 4.74 · Improvement 0.15
Adjusted total nurse staffing
2.19
Baseline 3.10 hours · Performance 3.70 hours · Measure score 2.19 · Achievement 2.19 · Improvement 1.75
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 362 · Observed rate 10.22% · Lower 95% interval 7.85% |
| Discharge to community | 57.32% |
50.57%
6.8 pts better
|
Better than the National Rate · Eligible stays 375 · Observed rate 49.87% · Lower 95% interval 52.22% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.46% |
95.27%
3.2 pts better
|
Numerator 256 · Denominator 260 |
| Falls with major injury | 0.38% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 260 |
| Discharge self-care score | 58.72% |
53.69%
5 pts better
|
Numerator 101 · Denominator 172 |
| Discharge mobility score | 48.26% |
50.94%
2.7 pts worse
|
Numerator 83 · Denominator 172 |
| Pressure ulcers or injuries, new or worsened | 5.38% |
2.29%
3.1 pts worse
|
Numerator 14 · Denominator 260 · Adjusted rate 4.77% |
| Healthcare-associated infections requiring hospitalization | 7.23% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 230 · Observed rate 7.39% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 12.23% |
8.2%
4 pts better
|
Numerator 23 · Denominator 188 |
| Staff flu vaccination coverage | 29.88% |
42%
12.1 pts worse
|
Numerator 75 · Denominator 251 |
| Discharge function score | 56.98% |
56.45%
0.5 pts better
|
Numerator 98 · Denominator 172 |
| Transfer of health information to provider | 98.75% |
95.95%
2.8 pts better
|
Numerator 79 · Denominator 80 |
| Transfer of health information to patient | 99.21% |
96.28%
2.9 pts better
|
Numerator 125 · Denominator 126 |
| Resident COVID-19 vaccinations up to date | 35.1% |
25.2%
9.9 pts better
|
Numerator 53 · Denominator 151 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.7
1 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
91.2%
4.5 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 96.2% · Q3 96.0% · Q4 95.2% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
95.3%
0.4 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.0%
2.5 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.4% · Q3 6.4% · Q4 8.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
18.5%
8.3 pts better
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.4% · Q3 13.6% · Q4 14.9% · 4Q avg 10.2% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
6.1%
1 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 8.3% · Q3 9.0% · Q4 5.9% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
13.5%
0.9 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 11.7% · Q3 11.5% · Q4 11.6% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.1% |
14.8%
5.3 pts worse
|
16.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 19.8% · Q3 18.8% · Q4 18.9% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.2% |
0.2%
1 pts worse
|
0.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.6% · Q4 1.6% · 4Q avg 1.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.3% |
15.1%
6.8 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 3.2% · Q3 9.1% · Q4 10.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
15.5%
1.2 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 13.9% · Q3 22.0% · Q4 15.8% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.6%
0.3 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.0% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.4%
1.7 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 0.0% · Q3 1.8% · Q4 6.5% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.2% |
20.8%
10.6 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 12.3% · Q3 5.9% · Q4 14.6% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
6.9%
2.5 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.8% · Q3 8.0% · Q4 6.4% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
76.7%
5.1 pts better
|
81.7%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 85.7% · Q3 77.3% · Q4 79.0% · 4Q avg 81.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
9.7%
6.9 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 16.8% · Expected 11.3% · 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 1.9% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
78.8%
3.3 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
20.6%
1.7 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 24.1% · Expected 25.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-27
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2023-11-24
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-24
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-21
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 2020-11-21
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-11-21
Fire Safety
Implement emergency and standby power systems.
Corrected 2020-11-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-09-24
Fire Safety
Install proper backup exit lighting.
Corrected 2018-09-24
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 2018-09-24
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-09-24
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 2018-09-24
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-09-24
Fire Safety
Implement emergency and standby power systems.
Corrected 2018-09-24
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-21
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-11-21
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-21
Health
Provide activities to meet all resident's needs.
Corrected 2025-11-21
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-11-21
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 2025-08-29
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 2025-07-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-07
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-07
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-07
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2025-07-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-29
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 2025-01-29
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-29
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 2025-01-29
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 2025-01-29
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-12-22
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-22
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 2023-12-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-22
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-22
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-22
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-22
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-12
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-11-16
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-24
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2018-09-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-09-24
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 2018-09-24
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2018-09-24
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 2018-09-24
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 2018-09-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-09-24
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
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