Cycle 1
Health 2025-04-22 · Fire 2025-04-22
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Brooklyn, NY
Saints Joachim & Anne Nursing And Rehab Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2720 Surf Avenue, Brooklyn, NY
(718) 714-4800
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
190
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-02-04
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
0.78
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.07
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
1.12
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
2.86
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,398
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.15% · Performance 23.05% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.43
Baseline 8.00% · Performance 6.82% · Measure score 3.43 · Achievement 3.40 · Improvement 3.43
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0.32
Baseline 2.84 hours · Performance 3.09 hours · Measure score 0.32 · Achievement 0 · Improvement 0.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.31% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 10.08% · Lower 95% interval 6.43% |
| Discharge to community | 49.62% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 40.48% · Lower 95% interval 40.75% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 124 · Denominator 124 |
| Falls with major injury | 1.61% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 124 |
| Discharge self-care score | 66.27% |
53.69%
12.6 pts better
|
Numerator 55 · Denominator 83 |
| Discharge mobility score | 68.67% |
50.94%
17.7 pts better
|
Numerator 57 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 1.61% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 124 · Adjusted rate 1.23% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 7.14% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 6.38% |
8.2%
1.8 pts worse
|
Numerator 12 · Denominator 188 |
| Staff flu vaccination coverage | 79.73% |
42%
37.7 pts better
|
Numerator 177 · Denominator 222 |
| Discharge function score | 67.47% |
56.45%
11 pts better
|
Numerator 56 · Denominator 83 |
| Transfer of health information to provider | 85.71% |
95.95%
10.2 pts worse
|
Numerator 30 · Denominator 35 |
| Transfer of health information to patient | 90.63% |
96.28%
5.7 pts worse
|
Numerator 29 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 25.37% |
25.2%
0.2 pts better
|
Numerator 17 · Denominator 67 |
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 2.1 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| 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 · Q1 99.4% · Q2 100.0% · Q3 98.7% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
95.3%
1.2 pts better
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.0%
2.2 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.7% · Q3 6.6% · Q4 6.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 51.4% |
18.5%
32.9 pts worse
|
11.4%
40 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 42.0% · Q3 66.7% · Q4 74.5% · 4Q avg 51.4% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.1%
1.5 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 10.3% · Q3 12.2% · Q4 2.5% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.1% |
13.5%
9.4 pts better
|
19.6%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.4% · Q3 3.3% · Q4 4.3% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
14.8%
1.3 pts worse
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 17.6% · Q3 12.6% · Q4 12.7% · 4Q avg 16.1% · 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 | 4.9% |
15.1%
10.2 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.9% · Q3 5.7% · Q4 2.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
15.5%
8.2 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.2% · Q3 8.5% · Q4 7.4% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.6%
0.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.4%
1.2 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
20.8%
3.3 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 21.3% · Q3 19.7% · Q4 6.7% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
6.9%
0.2 pts better
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.1% · Q3 4.3% · Q4 4.6% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
76.7%
20.7 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 98.4% · Q3 100.0% · Q4 99.4% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
9.7%
5.1 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.6% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.2%
1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.9% · Q3 2.3% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
78.8%
17.3 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.7% |
20.6%
3.9 pts better
|
23.9%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 18.3% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-24 · Fire 2023-04-24
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2020-09-15 · Fire 2020-09-15
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-22
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 2025-04-27
F · Potential for more than minimal harm
2023-04-24
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-04-24
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-04-24
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-04-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-06-24
F · Potential for more than minimal harm
2023-04-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-04-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-04-24
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-04-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-04-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-04-24
K255 · Egress Deficiencies
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-04-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-04-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-04-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-03
C · Minimal harm
2023-04-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-05
C · Minimal harm
2023-04-24
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-07-05
E · Potential for more than minimal harm
2020-09-15
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-10-28
E · Potential for more than minimal harm
2020-09-15
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 2020-10-28
E · Potential for more than minimal harm
2020-09-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-10-28
E · Potential for more than minimal harm
2020-09-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-10-28
D · Potential for more than minimal harm
2020-09-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-10-28
D · Potential for more than minimal harm
2020-09-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2020-10-28
D · Potential for more than minimal harm
2020-09-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-10-28
B · Minimal harm
2020-09-15
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-22
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-04-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-17
B · Minimal harm
2025-04-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-17
F · Potential for more than minimal harm
2023-04-24
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 2023-06-15
D · Potential for more than minimal harm
2023-04-24
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 2023-06-28
D · Potential for more than minimal harm
2023-04-24
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 2023-06-16
D · Potential for more than minimal harm
2023-04-24
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 2023-06-16
D · Potential for more than minimal harm
2023-04-24
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-24
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-06-15
D · Potential for more than minimal harm
2020-09-15
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 2020-09-23
Penalties and ownership
What sits behind the stars
Ownership
Caccavale, Charles
Corporate Director · Individual
D'ottavio, Christine
Corporate Officer · Individual
Glynn Ryan, Mary
Corporate Director · Individual
Gorey, Broughan
Corporate Director · Individual
Keating, Patrick
Corporate Director · Individual
Lopinto, Alfred
Corporate Director · Individual
Monaco, Salvatore
Corporate Director · Individual
Russo, Louis
Corporate Director · Individual
Smyth, Steven
W-2 Managing Employee · Individual
Sossi, Anthony
Corporate Director · Individual
Stumbo, Anthony
Corporate Director · Individual
Wolinetz, Alan
Corporate Director · Individual
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