Cycle 1
Health 2024-11-08 · Fire 2024-11-08
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Albany, NY
Teresian House Nursing Home Co Inc
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
200 Washington Ave Ext, Albany, NY
(518) 456-2000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
302
Certified beds
Average residents
290
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-06-20
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
0.36
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.80
Composite VBP score used to determine payment impact.
Payment multiplier
1.0074
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.17
Baseline 16.30% · Performance 17.64% · Measure score 8.17 · Achievement 8.17 · Improvement 0
Healthcare-associated infections
6.70
Baseline 6.10% · Performance 5.83% · Measure score 6.70 · Achievement 6.70 · Improvement 1.91
Total nurse turnover
4.60
Baseline 39.36% · Performance 44.88% · Measure score 4.60 · Achievement 4.60 · Improvement 0
Adjusted total nurse staffing
1.65
Baseline 3.86 hours · Performance 3.55 hours · Measure score 1.65 · Achievement 1.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.69% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 3.76% · Lower 95% interval 5.88% |
| Discharge to community | 40.98% |
50.57%
9.6 pts worse
|
Worse than the National Rate · Eligible stays 121 · Observed rate 35.54% · Lower 95% interval 31.26% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 52.73% |
53.69%
1 pts worse
|
Numerator 29 · Denominator 55 |
| Discharge mobility score | 56.36% |
50.94%
5.4 pts better
|
Numerator 31 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 70 · Adjusted rate 1.19% |
| Healthcare-associated infections requiring hospitalization | 5.83% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 1.43% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 4.38% |
8.2%
3.8 pts worse
|
Numerator 24 · Denominator 548 |
| Staff flu vaccination coverage | 77.73% |
42%
35.7 pts better
|
Numerator 499 · Denominator 642 |
| Discharge function score | 58.18% |
56.45%
1.7 pts better
|
Numerator 32 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 14 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.2 · 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 | 6.6% |
3.0%
3.6 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.5% · Q3 8.5% · Q4 5.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
18.5%
15.6 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.0% · Q3 3.1% · Q4 3.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
6.1%
3.3 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.8% · Q3 3.8% · Q4 2.1% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
13.5%
2.3 pts worse
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.2% · Q3 16.2% · Q4 14.3% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
14.8%
1.4 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 13.5% · Q3 13.8% · Q4 13.3% · 4Q avg 13.4% · 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 | 9.1% |
15.1%
6 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 8.0% · Q3 9.0% · Q4 6.7% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
15.5%
5.5 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.5% · Q3 7.6% · Q4 7.8% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.4%
1.2 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.7% |
20.8%
8.1 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 13.1% · Q3 10.2% · Q4 11.3% · 4Q avg 12.7% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
6.9%
4.3 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.6% · Q3 0.8% · Q4 2.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
76.7%
22.6 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
9.7%
3.4 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.1% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 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 | 12.1% |
20.6%
8.5 pts better
|
23.9%
11.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 10.3% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-23 · Fire 2021-12-23
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-11-08
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-11-25
E · Potential for more than minimal harm
2021-12-23
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2022-01-23
D · Potential for more than minimal harm
2021-12-23
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 2022-01-23
E · Potential for more than minimal harm
2019-10-10
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-12-02
E · Potential for more than minimal harm
2019-10-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-12-02
D · Potential for more than minimal harm
2019-10-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-12-02
D · Potential for more than minimal harm
2019-10-10
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-12-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-11-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-08
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 2024-11-08
D · Potential for more than minimal harm
2024-11-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-08
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 2024-11-14
D · Potential for more than minimal harm
2024-11-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-11-08
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 2024-11-18
D · Potential for more than minimal harm
2024-11-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-11-08
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 2024-11-20
D · Potential for more than minimal harm
2024-01-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-20
D · Potential for more than minimal harm
2023-05-04
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 2023-05-19
J · Immediate jeopardy
2021-12-23
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 2021-12-15
E · Potential for more than minimal harm
2021-12-23
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 2022-01-23
D · Potential for more than minimal harm
2021-12-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-01-30
D · Potential for more than minimal harm
2021-12-23
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 2022-01-30
D · Potential for more than minimal harm
2021-12-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-01-23
E · Potential for more than minimal harm
2019-10-10
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 2019-12-09
E · Potential for more than minimal harm
2019-10-10
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 2019-12-09
D · Potential for more than minimal harm
2019-10-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-10-10
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 2019-12-09
D · Potential for more than minimal harm
2019-10-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-10-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-10-10
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 2019-12-09
D · Potential for more than minimal harm
2019-10-10
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 2019-12-09
D · Potential for more than minimal harm
2019-10-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-10-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-12-09
C · Minimal harm
2019-10-10
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 2019-12-09
Penalties and ownership
What sits behind the stars
Ownership
Bowks, Harvey
Corporate Director · Individual
Butler, Karen
Corporate Director · Individual
Delbrocco, Michael
Corporate Director · Individual
Delbrocco, Michael
W-2 Managing Employee · Individual
Napierski, Eugene
Corporate Director · Individual
Odabashian, Harry
Corporate Director · Individual
Yeboah, Frank
Operational/Managerial Control · Individual
Yeboah, Frank
Corporate Officer · Individual
Yeboah, Frank
W-2 Managing Employee · Individual
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#3
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