Cycle 1
Health 2024-10-29 · Fire 2024-10-29
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Warwick, NY
Schervier Pavilion
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
22 Van Duzer Place, Warwick, NY
(845) 987-5717
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-05-17
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
1.12
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,607
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9923
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.87
Baseline 16.56% · Performance 20.10% · Measure score 2.87 · Achievement 2.87 · Improvement 0
Healthcare-associated infections
0.64
Baseline 5.81% · Performance 7.64% · Measure score 0.64 · Achievement 0.64 · Improvement 0
Total nurse turnover
6.74
Baseline 49.41% · Performance 36.14% · Measure score 6.74 · Achievement 6.74 · Improvement 4.90
Adjusted total nurse staffing
5.47
Baseline 4.26 hours · Performance 4.63 hours · Measure score 5.47 · Achievement 5.47 · Improvement 1.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 9.38% · Lower 95% interval 7.12% |
| Discharge to community | 53% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 47.86% · Lower 95% interval 43.7% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 146 · Denominator 146 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 146 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 27 · Denominator 108 |
| Discharge mobility score | 24.07% |
50.94%
26.9 pts worse
|
Numerator 26 · Denominator 108 |
| Pressure ulcers or injuries, new or worsened | 3.42% |
2.29%
1.1 pts worse
|
Numerator 5 · Denominator 146 · Adjusted rate 2.59% |
| Healthcare-associated infections requiring hospitalization | 7.64% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 8.24% · Lower 95% interval 4.86% |
| Staff COVID-19 vaccination coverage | 7.37% |
8.2%
0.8 pts worse
|
Numerator 7 · Denominator 95 |
| Staff flu vaccination coverage | 60% |
42%
18 pts better
|
Numerator 75 · Denominator 125 |
| Discharge function score | 38.89% |
56.45%
17.6 pts worse
|
Numerator 42 · Denominator 108 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 93.42% |
96.28%
2.9 pts worse
|
Numerator 71 · Denominator 76 |
| Resident COVID-19 vaccinations up to date | 17.86% |
25.2%
7.3 pts worse
|
Numerator 15 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.7
1.8 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.4 · Expected 1.3 · 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 1.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
91.2%
3.1 pts better
|
93.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.8% · Q4 81.2% · 4Q avg 94.3% |
| 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 | 3.6% |
3.0%
0.6 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.2% · Q3 4.2% · Q4 2.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 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 who lose too much weight | 6.6% |
6.1%
0.5 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.0% · Q3 13.0% · Q4 2.3% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
13.5%
3.6 pts worse
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.7% · Q3 16.7% · Q4 14.9% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
14.8%
1.7 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 17.9% · Q3 12.5% · Q4 17.9% · 4Q avg 16.5% · 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 | 36.3% |
15.1%
21.2 pts worse
|
16.3%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
15.5%
0.7 pts worse
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.5% · Q3 20.0% · Q4 24.4% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
0.6%
2 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.1% · Q3 3.2% · Q4 1.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.4%
0.3 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
20.8%
6.8 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 23.3% · Q3 27.9% · Q4 28.0% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
6.9%
1 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 11.4% · Q3 9.0% · Q4 7.8% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
76.7%
9.4 pts better
|
81.7%
4.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 90.1% · Q3 86.5% · Q4 77.8% · 4Q avg 86.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
9.7%
10.1 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 18.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
78.8%
8.7 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
20.6%
2.8 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 24.2% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-31 · Fire 2022-10-31
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-05-21 · Fire 2019-05-21
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-29
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-29
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-10-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-12-03
E · Potential for more than minimal harm
2022-10-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-10-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-16
C · Minimal harm
2022-10-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-16
C · Minimal harm
2022-10-31
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-12-16
E · Potential for more than minimal harm
2019-05-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-24
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 2025-06-18
F · Potential for more than minimal harm
2024-10-29
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 2024-12-20
E · Potential for more than minimal harm
2024-10-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-29
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 2024-12-20
D · Potential for more than minimal harm
2024-10-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-29
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 2024-12-20
D · Potential for more than minimal harm
2024-10-29
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2024-12-20
D · Potential for more than minimal harm
2022-10-31
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 2022-11-23
D · Potential for more than minimal harm
2022-10-31
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 2022-11-23
D · Potential for more than minimal harm
2022-10-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-31
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 2022-11-23
D · Potential for more than minimal harm
2019-05-21
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 2019-07-19
D · Potential for more than minimal harm
2019-05-21
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 2019-07-19
D · Potential for more than minimal harm
2019-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-19
D · Potential for more than minimal harm
2019-05-21
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 2019-07-19
B · Minimal harm
2019-05-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-07-19
Penalties and ownership
What sits behind the stars
Ownership
Bon Secours Charity Health System, Inc.
5% Or Greater Direct Ownership Interest · Organization
Baker, Patrick
Corporate Director · Individual
Bon Secours Charity Health System, Inc.
Operational/Managerial Control · Organization
Bon Secours Mercy Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Costello, Anthony
Corporate Director · Individual
Difiglia, Mario
Corporate Director · Individual
El-Rayess, Tamer
Corporate Director · Individual
Gevertz, Susan
Corporate Director · Individual
Grannum, Sandra
Corporate Director · Individual
Kelly, Carl
Operational/Managerial Control · Individual
Lubarsky, David
Corporate Director · Individual
Lubarsky, David
Corporate Officer · Individual
Pickens, Andrew
Corporate Director · Individual
Ratner, Joshua
Corporate Director · Individual
Rogowsky, Martin
Corporate Director · Individual
Rosenblut, Michael
Corporate Director · Individual
Scharfenberger, Dennis
Corporate Director · Individual
Westchester Medical Center Health Network
5% Or Greater Indirect Ownership Interest · Organization
Yezzo, Marie
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Valley View Center For Nursing Care And Rehab
Goshen, NY
2-star overall rating with 1-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Glen Arden Inc
Goshen, NY
2-star overall rating with 1-star inspections with $108,046 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Sapphire Nursing And Rehab At Goshen
Goshen, NY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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