Cycle 1
Health 2024-09-10 · Fire 2024-09-10
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Bronx, NY
Split Rock Rehabilition And Health Care Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3525 Baychester Ave, Bronx, NY
(718) 798-8900
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
240
Certified beds
Average residents
224
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-03-05
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
0.97
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.25
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
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
2.75
CMS adjusted total nurse staffing hours
Case-mix index
1.86
Higher values indicate more complex resident acuity
RN turnover
49%
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
3,243
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.3
Composite VBP score used to determine payment impact.
Payment multiplier
0.9985
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.79
Baseline 20.60% · Performance 19.68% · Measure score 3.79 · Achievement 3.79 · Improvement 2.08
Healthcare-associated infections
6.87
Baseline 8.28% · Performance 5.86% · Measure score 6.87 · Achievement 6.61 · Improvement 6.87
Total nurse turnover
7.46
Baseline 28.43% · Performance 33.20% · Measure score 7.46 · Achievement 7.46 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.86 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.49% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 8.2% · Lower 95% interval 6.7% |
| Discharge to community | 51.94% |
50.57%
1.4 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 27.91% · Lower 95% interval 35.49% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 119 · Denominator 119 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 57.41% |
53.69%
3.7 pts better
|
Numerator 31 · Denominator 54 |
| Discharge mobility score | 59.26% |
50.94%
8.3 pts better
|
Numerator 32 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0.84% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 119 · Adjusted rate 0.53% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 90.45% |
8.2%
82.2 pts better
|
Numerator 180 · Denominator 199 |
| Staff flu vaccination coverage | 78.57% |
42%
36.6 pts better
|
Numerator 275 · Denominator 350 |
| Discharge function score | 62.96% |
56.45%
6.5 pts better
|
Numerator 34 · Denominator 54 |
| Transfer of health information to provider | 98.04% |
95.95%
2.1 pts better
|
Numerator 50 · Denominator 51 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.59% |
25.2%
23.6 pts worse
|
Numerator 1 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
91.2%
2.5 pts worse
|
93.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 92.2% · Q3 89.4% · Q4 80.6% · 4Q avg 88.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
95.3%
0.2 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| 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 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
18.5%
15.5 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.6% · Q3 0.5% · Q4 4.8% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.1%
1.3 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.7% · Q3 7.1% · Q4 3.9% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
13.5%
5.1 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 8.9% · Q3 7.7% · Q4 7.8% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.9% |
14.8%
9.9 pts better
|
16.7%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.7% · Q3 4.6% · Q4 4.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.1% |
15.1%
4 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 15.2% · Q3 11.5% · Q4 9.2% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
15.5%
2.9 pts better
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 8.7% · Q3 13.6% · Q4 15.7% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.6%
0.5 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.3% · 4Q avg 0.1% · 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 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.6% |
20.8%
10.2 pts better
|
19.8%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 11.4% · Q3 13.1% · Q4 8.8% · 4Q avg 10.6% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
6.9%
2.9 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 10.7% · Q3 8.8% · Q4 9.4% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 48.6% |
76.7%
28.1 pts worse
|
81.7%
33.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.2% · Q2 51.8% · Q3 46.6% · Q4 41.5% · 4Q avg 48.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.4% |
9.7%
6.3 pts better
|
12.0%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.4% · Observed 3.7% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.2% · Q3 1.5% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.1% |
78.8%
20.7 pts worse
|
79.7%
21.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
20.6%
4.9 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 22.4% · Expected 34.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-08 · Fire 2022-06-08
1 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-08-20 · Fire 2019-08-20
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-08
F · Potential for more than minimal harm
2022-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-08
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 2022-08-12
D · Potential for more than minimal harm
2022-06-08
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 2022-08-12
C · Minimal harm
2022-06-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-08-12
E · Potential for more than minimal harm
2019-08-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-10-09
E · Potential for more than minimal harm
2019-08-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-20
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 2025-07-20
E · Potential for more than minimal harm
2024-09-10
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 2024-11-07
E · Potential for more than minimal harm
2024-09-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-07
D · Potential for more than minimal harm
2022-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-21
E · Potential for more than minimal harm
2019-08-20
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 2019-10-06
E · Potential for more than minimal harm
2019-08-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-06
E · Potential for more than minimal harm
2019-08-20
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 2019-10-06
E · Potential for more than minimal harm
2019-08-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-06
D · Potential for more than minimal harm
2019-08-20
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 2019-10-06
D · Potential for more than minimal harm
2019-08-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-10-06
D · Potential for more than minimal harm
2019-08-20
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 2019-10-06
Penalties and ownership
What sits behind the stars
Ownership
Webster, Helen
5% Or Greater Direct Ownership Interest · Individual
Webster, Moshe
5% Or Greater Direct Ownership Interest · Individual
Webster, Yecheskel
5% Or Greater Direct Ownership Interest · Individual
Webster, Boruch
5% Or Greater Direct Ownership Interest · Individual
Fasten, Naftali
Corporate Officer · Individual
Reiter, Marilyn
W-2 Managing Employee · Individual
Webster, Helen
Corporate Director · Individual
Weiss, Aharon
Corporate Officer · Individual
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#3
Pinnacle Multicare Nursing And Rehab Center
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3-star overall rating with 3-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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