Cycle 1
Health 2022-11-17 · Fire 2022-11-17
3 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Albany, NY
St Peters Nursing And Rehabilitation Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
301 Hackett Blvd, Albany, NY
(518) 525-7600
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
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
0.80
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.29
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
1.95
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.99% · Performance 24.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.42
Baseline 5.89% · Performance 6.22% · Measure score 5.42 · Achievement 5.42 · Improvement 0
Total nurse turnover
0
Baseline 48.99% · Performance 64.56% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.90
Baseline 4.55 hours · Performance 4.76 hours · Measure score 5.90 · Achievement 5.90 · Improvement 1.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.98% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 194 · Observed rate 14.95% · Lower 95% interval 9.45% |
| Discharge to community | 47.9% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 207 · Observed rate 43.48% · Lower 95% interval 42.76% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 132 · Denominator 132 |
| Falls with major injury | 1.52% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 132 |
| Discharge self-care score | 51.04% |
53.69%
2.6 pts worse
|
Numerator 49 · Denominator 96 |
| Discharge mobility score | 45.83% |
50.94%
5.1 pts worse
|
Numerator 44 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 6.87% |
2.29%
4.6 pts worse
|
Numerator 9 · Denominator 131 · Adjusted rate 7.81% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 4.65% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 7.14% |
8.2%
1.1 pts worse
|
Numerator 15 · Denominator 210 |
| Staff flu vaccination coverage | 47.96% |
42%
6 pts better
|
Numerator 188 · Denominator 392 |
| Discharge function score | 55.21% |
56.45%
1.2 pts worse
|
Numerator 53 · Denominator 96 |
| Transfer of health information to provider | 97.89% |
95.95%
1.9 pts better
|
Numerator 93 · Denominator 95 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.84% |
25.2%
11.6 pts better
|
Numerator 21 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
91.2%
5.4 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 95.2% · Q3 96.2% · Q4 100.0% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.8% |
95.3%
8.5 pts worse
|
95.5%
8.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.0%
1.3 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.8% · Q3 3.8% · Q4 3.8% · 4Q avg 4.3% · 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 | 2.6% |
6.1%
3.5 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.1% · Q3 0.0% · Q4 1.9% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
13.5%
5.5 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.5% · Q3 5.3% · Q4 10.7% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
14.8%
5.4 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 7.6% · Q3 11.3% · Q4 6.5% · 4Q avg 9.4% · 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 | 33.7% |
15.1%
18.6 pts worse
|
16.3%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.2% · Q2 52.6% · Q3 13.0% · 4Q avg 33.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
15.5%
2.2 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 28.9% · Q3 12.9% · Q4 5.6% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.6%
0.5 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.9% · Q3 0.0% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.4%
0.2 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
20.8%
1 pts better
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 17.1% · Q3 16.9% · Q4 18.4% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
6.9%
0.7 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 10.0% · Q3 4.4% · Q4 8.6% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.5% |
76.7%
0.2 pts worse
|
81.7%
5.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.6% · Q2 75.9% · Q3 87.1% · Q4 71.6% · 4Q avg 76.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
9.7%
1.8 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.8% |
78.8%
11 pts worse
|
79.7%
11.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.9% |
20.6%
13.3 pts worse
|
23.9%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.9% · Observed 34.8% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-10-07 · Fire 2020-10-07
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2019-02-15 · Fire 2019-02-15
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-11-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-13
E · Potential for more than minimal harm
2020-10-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2020-12-04
E · Potential for more than minimal harm
2019-02-15
K162 · Construction Deficiencies
Fire Safety
Have a combustible roofing system that meets safety standards.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-02-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-02-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-02-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-02-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-04-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-11-17
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 2023-01-13
D · Potential for more than minimal harm
2022-11-17
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 2023-01-13
D · Potential for more than minimal harm
2022-11-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-01-13
E · Potential for more than minimal harm
2020-10-07
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 2020-12-04
D · Potential for more than minimal harm
2020-10-07
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 2020-12-04
D · Potential for more than minimal harm
2020-10-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-10-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2020-12-04
E · Potential for more than minimal harm
2019-02-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-04-12
E · Potential for more than minimal harm
2019-02-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-04-12
E · Potential for more than minimal harm
2019-02-15
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-04-12
E · Potential for more than minimal harm
2019-02-15
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2019-04-12
E · Potential for more than minimal harm
2019-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-12
D · Potential for more than minimal harm
2019-02-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-04-12
D · Potential for more than minimal harm
2019-02-15
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 2019-04-12
D · Potential for more than minimal harm
2019-02-15
F693 · Quality of Life and Care Deficiencies
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 2019-04-12
D · Potential for more than minimal harm
2019-02-15
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 2019-04-12
Penalties and ownership
What sits behind the stars
Ownership
St Peters Health Partners
5% Or Greater Direct Ownership Interest · Organization
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Bala, Guha
Corporate Director · Individual
Burke, Michael
Operational/Managerial Control · Individual
Farrell, Eric
Corporate Officer · Individual
Hanks, Steven
Corporate Director · Individual
Isacksen, Daniel
Corporate Director · Individual
Jimino, Kathleen
Corporate Officer · Individual
Lapczynski, Patricia
Corporate Director · Individual
Manganaro, Helen
Operational/Managerial Control · Individual
Marshall, John
Corporate Officer · Individual
Mazzacco, Michelle
Operational/Managerial Control · Individual
Mccormick, Robert
Corporate Director · Individual
Meath, Michael
Corporate Director · Individual
Myers, Gina
Corporate Director · Individual
Pollard, Merriette
Corporate Director · Individual
Signor, Kristin
Operational/Managerial Control · Individual
Signor, Kristin
Corporate Officer · Individual
St Peters Health Partners
Operational/Managerial Control · Organization
Sullivan, Marguerite
Corporate Director · Individual
Sweet Zavaglia, Kerri
Corporate Director · Individual
Tofade, Oluwatoyin
Corporate Director · Individual
Trinity Health Corporation
Operational/Managerial Control · Organization
Wildridge, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
St Margarets Center
Albany, NY
3-star overall rating with 2-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Eddy Village Green At Beverwyck
Slingerlands, NY
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Delmar Center For Rehabilitation And Nursing
Delmar, NY
1-star overall rating with 1-star inspections with Special Focus status with 32 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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