Cycle 1
Health 2023-09-20 · Fire 2023-09-20
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Lake Katrine, NY
Ten Broeck Commons
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
One Commons Drive, Lake Katrine, NY
(845) 336-6666
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
258
Certified beds
Average residents
244
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-03-26
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
0.52
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.20
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
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.67
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,062
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9944
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.61
Baseline 19.31% · Performance 17.91% · Measure score 7.61 · Achievement 7.61 · Improvement 5.65
Healthcare-associated infections
0
Baseline 7.15% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.38
Baseline 40.93% · Performance 29.44% · Measure score 8.38 · Achievement 8.38 · Improvement 6.64
Adjusted total nurse staffing
0.61
Baseline 2.57 hours · Performance 2.93 hours · Measure score 0.61 · Achievement 0 · Improvement 0.61
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.49% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 559 · Observed rate 6.26% · Lower 95% interval 6.56% |
| Discharge to community | 56.76% |
50.57%
6.2 pts better
|
Better than the National Rate · Eligible stays 588 · Observed rate 54.08% · Lower 95% interval 52.1% |
| Medicare spending per beneficiary | 1.36 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 62.36% |
95.27%
32.9 pts worse
|
Numerator 270 · Denominator 433 |
| Falls with major injury | 0.46% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 433 |
| Discharge self-care score | 56.96% |
53.69%
3.3 pts better
|
Numerator 180 · Denominator 316 |
| Discharge mobility score | 66.46% |
50.94%
15.5 pts better
|
Numerator 210 · Denominator 316 |
| Pressure ulcers or injuries, new or worsened | 0.46% |
2.29%
1.8 pts better
|
Numerator 2 · Denominator 433 · Adjusted rate 0.43% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 370 · Observed rate 6.49% · Lower 95% interval 5.52% |
| Staff COVID-19 vaccination coverage | 1.63% |
8.2%
6.6 pts worse
|
Numerator 6 · Denominator 368 |
| Staff flu vaccination coverage | 72.87% |
42%
30.9 pts better
|
Numerator 282 · Denominator 387 |
| Discharge function score | 67.41% |
56.45%
11 pts better
|
Numerator 213 · Denominator 316 |
| Transfer of health information to provider | 97.22% |
95.95%
1.3 pts better
|
Numerator 105 · Denominator 108 |
| Transfer of health information to patient | 99.09% |
96.28%
2.8 pts better
|
Numerator 218 · Denominator 220 |
| Resident COVID-19 vaccinations up to date | 33.47% |
25.2%
8.3 pts better
|
Numerator 81 · Denominator 242 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · 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 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
91.2%
6.2 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 98.1% · Q3 95.8% · Q4 97.9% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
95.3%
0.6 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.0%
About the same
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.3% · Q3 3.7% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.5% |
18.5%
8 pts worse
|
11.4%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 23.0% · Q3 24.7% · Q4 30.4% · 4Q avg 26.5% |
| 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 8.5% · Q2 5.4% · Q3 1.7% · Q4 2.9% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
13.5%
2.2 pts worse
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 18.2% · Q3 11.6% · Q4 13.3% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
14.8%
5 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 11.8% · Q3 9.9% · Q4 9.7% · 4Q avg 9.8% · 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 | 9.4% |
15.1%
5.7 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 8.8% · Q3 12.7% · Q4 5.0% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
15.5%
2.3 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 16.4% · Q3 13.8% · Q4 9.1% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.6%
0.2 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.4% · 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 0.0% · Q2 0.5% · Q3 1.6% · Q4 2.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
20.8%
7.2 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 28.6% · Q3 26.3% · Q4 25.9% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
6.9%
3.9 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.5% · Q3 2.4% · Q4 3.5% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
76.7%
13 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 92.9% · Q3 88.5% · Q4 87.2% · 4Q avg 89.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
9.7%
1.2 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 6.7% · Expected 8.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.4% |
78.8%
8.6 pts better
|
79.7%
7.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
20.6%
3.8 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 21.8% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-08 · Fire 2020-01-08
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-02-13 · Fire 2018-02-13
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-09-20
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-11-15
E · Potential for more than minimal harm
2023-09-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-09-20
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 2023-11-15
E · Potential for more than minimal harm
2023-09-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-10-19
E · Potential for more than minimal harm
2020-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-07-17
E · Potential for more than minimal harm
2020-01-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-07-17
E · Potential for more than minimal harm
2020-01-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-07-17
D · Potential for more than minimal harm
2020-01-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-07-17
D · Potential for more than minimal harm
2020-01-08
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 2020-07-17
D · Potential for more than minimal harm
2020-01-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-07-17
D · Potential for more than minimal harm
2018-02-13
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-03-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-10
D · Potential for more than minimal harm
2023-09-20
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-06-12
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 2023-07-10
D · Potential for more than minimal harm
2020-01-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2020-10-14
D · Potential for more than minimal harm
2020-01-08
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 2020-10-14
D · Potential for more than minimal harm
2020-01-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-10-14
D · Potential for more than minimal harm
2020-01-08
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 2020-10-14
D · Potential for more than minimal harm
2020-01-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-10-14
D · Potential for more than minimal harm
2018-02-13
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 2018-03-31
D · Potential for more than minimal harm
2018-02-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
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 2018-03-31
D · Potential for more than minimal harm
2018-02-13
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2018-03-31
D · Potential for more than minimal harm
2018-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-03-31
Penalties and ownership
What sits behind the stars
Ownership
Kingston Nh Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Schlesinger, Ernest
5% Or Greater Indirect Ownership Interest · Individual
Klein, Esther
5% Or Greater Indirect Ownership Interest · Individual
Klein, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Getz, Mordechai
5% Or Greater Indirect Ownership Interest · Individual
Gold, Avrom
5% Or Greater Indirect Ownership Interest · Individual
Mendlowits, Eugene
5% Or Greater Indirect Ownership Interest · Individual
Perez, Kathryn
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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1-star overall rating with 1-star inspections with $25,435 in total fines with 14 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Ferncliff Nursing Home Co Inc
Rhinebeck, NY
2-star overall rating with 1-star inspections with abuse icon flag with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Golden Hill Nursing And Rehabilitation Center
Kingston, NY
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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