Cycle 1
Health 2025-03-12 · Fire 2025-03-12
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Highland, NY
Taconic Rehabilitation And Nursing At Ulster
2-star overall rating with 2-star inspections with $12,948 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
One Wingate Way, Highland, NY
(845) 691-6800
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-04-09
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
0.67
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,391
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.45
Baseline 22.47% · Performance 20.32% · Measure score 3.45 · Achievement 2.40 · Improvement 3.45
Healthcare-associated infections
4.39
Baseline 9.20% · Performance 7.15% · Measure score 4.39 · Achievement 2.30 · Improvement 4.39
Total nurse turnover
5.28
Performance 42.10% · Measure score 5.28 · Achievement 5.28 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.43
Baseline 3.07 hours · Performance 3.48 hours · Measure score 1.43 · Achievement 1.43 · Improvement 1.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 11.17% · Lower 95% interval 8.34% |
| Discharge to community | 54.56% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 48.09% · Lower 95% interval 47.1% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.12% |
95.27%
0.1 pts worse
|
Numerator 156 · Denominator 164 |
| Falls with major injury | 0.61% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 164 |
| Discharge self-care score | 51.22% |
53.69%
2.5 pts worse
|
Numerator 63 · Denominator 123 |
| Discharge mobility score | 60.98% |
50.94%
10 pts better
|
Numerator 75 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 3.66% |
2.29%
1.4 pts worse
|
Numerator 6 · Denominator 164 · Adjusted rate 4.46% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 109 · Observed rate 7.34% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | 6.13% |
8.2%
2.1 pts worse
|
Numerator 10 · Denominator 163 |
| Staff flu vaccination coverage | 38.1% |
42%
3.9 pts worse
|
Numerator 96 · Denominator 252 |
| Discharge function score | 54.47% |
56.45%
2 pts worse
|
Numerator 67 · Denominator 123 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 86 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 45.24% |
25.2%
20 pts better
|
Numerator 38 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.4 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 76.8% |
91.2%
14.4 pts worse
|
93.4%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 77.9% · Q3 93.0% · Q4 93.1% · 4Q avg 76.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
95.3%
0.9 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.0%
2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.0% · Q3 7.0% · Q4 2.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
18.5%
17.4 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.1%
2.8 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.8% · Q3 5.3% · Q4 1.4% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
13.5%
0.4 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 9.9% · Q3 15.6% · Q4 15.6% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.0% |
14.8%
0.8 pts better
|
16.7%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 14.9% · Q3 11.5% · Q4 12.1% · 4Q avg 14.0% · 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 | 8.1% |
15.1%
7 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 11.4% · Q3 5.7% · Q4 11.1% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
15.5%
2.1 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 20.0% · Q3 12.3% · Q4 13.1% · 4Q avg 17.6% · 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 | 0.9% |
1.4%
0.5 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.4% |
20.8%
14.4 pts better
|
19.8%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.7% · Q3 12.9% · Q4 0.0% · 4Q avg 6.4% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.9%
1.1 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.3% · Q3 8.3% · Q4 9.9% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.8% |
76.7%
2.9 pts worse
|
81.7%
7.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.7% · Q2 70.7% · Q3 86.0% · Q4 93.9% · 4Q avg 73.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
9.7%
1.7 pts worse
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.2% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.2%
2.1 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.2% · Q3 4.9% · Q4 5.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.1% |
78.8%
2.3 pts better
|
79.7%
1.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
20.6%
6.5 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 27.2% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-07 · Fire 2022-02-07
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-01-25 · Fire 2019-01-25
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-12
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-04-18
C · Minimal harm
2025-03-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-18
E · Potential for more than minimal harm
2022-02-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-04-01
D · Potential for more than minimal harm
2022-02-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-01
D · Potential for more than minimal harm
2022-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-01
D · Potential for more than minimal harm
2019-01-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-03-15
Inspection history
Recent health citations
G · Actual harm
2025-03-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-12
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 2025-04-18
D · Potential for more than minimal harm
2025-03-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-12
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 2025-04-18
D · Potential for more than minimal harm
2025-03-12
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 2025-04-18
D · Potential for more than minimal harm
2025-03-12
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 2025-04-18
D · Potential for more than minimal harm
2025-03-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-12
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 2025-04-18
D · Potential for more than minimal harm
2025-03-12
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 2025-04-18
D · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-04-18
E · Potential for more than minimal harm
2019-01-25
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 2019-03-15
D · Potential for more than minimal harm
2019-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-15
Penalties and ownership
What sits behind the stars
$12,948
2025-03-12
Fine
Fine · fine $12,948
Fine
Ownership
Eaton Mercurio, Stephen
5% Or Greater Direct Ownership Interest · Individual
Farbenblum, Michael
5% Or Greater Direct Ownership Interest · Individual
Eaton Mercurio, Stephen
Operational/Managerial Control · Individual
Farbenblum, Michael
Operational/Managerial Control · Individual
Mazur, Michael
Corporate Director · Individual
Mazur, Michael
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Hudson Valley Rehabilitation & Extended Care Ctr
Highland, NY
1-star overall rating with 1-star inspections with abuse icon flag with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
The Grand Rehabilitation And Nrsg At River Valley
Poughkeepsie, NY
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Woodland Pond At New Paltz
New Paltz, NY
4-star overall rating with 3-star inspections with $13,099 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out