Cycle 1
Health 2024-05-14 · Fire 2024-05-14
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Scarsdale, NY
Sprain Brook Manor Rehab
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
77 Jackson Ave, Scarsdale, NY
(914) 472-3200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1973-11-01
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
1.56
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
1.07
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
2.92
CMS adjusted total nurse staffing hours
Case-mix index
1.99
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,641
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Baseline 24.27% · Performance 21.22% · Measure score 3.71 · Achievement 0 · Improvement 3.71
Healthcare-associated infections
0
Baseline 8.84% · Performance 10.58% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.51
Baseline 44.04% · Performance 41.18% · Measure score 5.51 · Achievement 5.51 · Improvement 0.99
Adjusted total nurse staffing
0
Baseline 3.21 hours · Performance 2.39 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.12% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 254 · Observed rate 12.6% · Lower 95% interval 9.47% |
| Discharge to community | 48.69% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 233 · Observed rate 41.63% · Lower 95% interval 42.73% |
| Medicare spending per beneficiary | 1.88 |
1.02
0.9 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 226 · Denominator 226 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 226 |
| Discharge self-care score | 65.47% |
53.69%
11.8 pts better
|
Numerator 91 · Denominator 139 |
| Discharge mobility score | 74.82% |
50.94%
23.9 pts better
|
Numerator 104 · Denominator 139 |
| Pressure ulcers or injuries, new or worsened | 2.21% |
2.29%
0.1 pts better
|
Numerator 5 · Denominator 226 · Adjusted rate 1.37% |
| Healthcare-associated infections requiring hospitalization | 10.58% |
7.12%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 178 · Observed rate 14.61% · Lower 95% interval 7.71% |
| Staff COVID-19 vaccination coverage | 13.33% |
8.2%
5.1 pts better
|
Numerator 20 · Denominator 150 |
| Staff flu vaccination coverage | 97.24% |
42%
55.2 pts better
|
Numerator 141 · Denominator 145 |
| Discharge function score | 76.98% |
56.45%
20.5 pts better
|
Numerator 107 · Denominator 139 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 90 · Denominator 90 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 72 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 42.73% |
25.2%
17.5 pts better
|
Numerator 47 · Denominator 110 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.7
1.6 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.3
1.3 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.1% · Q3 2.3% · Q4 3.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.3% |
18.5%
41.8 pts worse
|
11.4%
48.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 62.6% · Q3 52.3% · Q4 52.9% · 4Q avg 60.3% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.1%
0.6 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.7% · Q3 3.9% · Q4 11.1% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
13.5%
5.4 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.7% · Q3 6.8% · Q4 8.0% · 4Q avg 8.1% |
| 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 24.0% · Q2 15.8% · Q3 12.3% · Q4 12.5% · 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 | 10.6% |
15.1%
4.5 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.9% · Q3 19.7% · Q4 14.2% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
15.5%
2 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.5% · Q3 15.7% · Q4 16.2% · 4Q avg 13.5% · 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 | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 2.0% |
20.8%
18.8 pts better
|
19.8%
17.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
6.9%
4.4 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.8% · Q3 0.8% · Q4 7.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
76.7%
23.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
9.7%
2.2 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.7% · Expected 12.0% · 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 2.2% · Q2 1.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.8%
21.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
20.6%
1.8 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 22.1% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-02 · Fire 2021-06-02
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-02-19 · Fire 2019-02-19
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
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 2024-06-28
D · Potential for more than minimal harm
2024-05-14
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-28
C · Minimal harm
2024-05-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-28
E · Potential for more than minimal harm
2021-06-02
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 2021-07-29
E · Potential for more than minimal harm
2021-06-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-06-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-06-02
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-06-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-06-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-06-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-07-29
C · Minimal harm
2021-06-02
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2021-07-29
D · Potential for more than minimal harm
2019-02-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-04-16
D · Potential for more than minimal harm
2019-02-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-04-16
D · Potential for more than minimal harm
2019-02-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-04-16
D · Potential for more than minimal harm
2019-02-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-16
D · Potential for more than minimal harm
2019-02-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-04-16
D · Potential for more than minimal harm
2019-02-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-04-16
D · Potential for more than minimal harm
2019-02-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-04-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-14
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 2024-06-28
D · Potential for more than minimal harm
2024-05-14
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 2024-06-28
D · Potential for more than minimal harm
2024-05-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
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 2024-06-28
D · Potential for more than minimal harm
2023-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-02
E · Potential for more than minimal harm
2019-02-19
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 2019-04-16
D · Potential for more than minimal harm
2019-02-19
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 2019-04-16
D · Potential for more than minimal harm
2019-02-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-04-16
B · Minimal harm
2019-02-19
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 2019-04-16
Penalties and ownership
What sits behind the stars
Ownership
Strulovitch, Lazer
5% Or Greater Direct Ownership Interest · Individual
Stein, Allen
5% Or Greater Direct Ownership Interest · Individual
Schwimmer, Leopold
5% Or Greater Direct Ownership Interest · Individual
Chopra, Ashok
Operational/Managerial Control · Individual
Kahan, Benjamin
Operational/Managerial Control · Individual
Nachfolger, Israel
Corporate Director · Individual
Stein, Allen
Operational/Managerial Control · Individual
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#3
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