17 health deficiencies
Top issue: Resident Rights (6 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Pawling, NY
1-star overall rating with 1-star inspections with $15,935 in total fines with 17 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
9 Reservoir Road, Pawling, NY
(845) 855-5700
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
122
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Grand Healthcare
Operator or chain grouping
Approved since
1976-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
RN hours / resident day
0.43
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.64
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.65
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
13,057
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.55% · Performance 22.71% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.22% · Performance 9.21% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.47
Baseline 54.17% · Performance 49.48% · Measure score 3.47 · Achievement 3.47 · Improvement 1.10
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 2.84 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 10.05% · Lower 95% interval 7.03% |
| Discharge to community | 35.45% |
50.57%
15.1 pts worse
|
Worse than the National Rate · Eligible stays 254 · Observed rate 25.2% · Lower 95% interval 29.49% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.19% |
95.27%
3.9 pts better
|
Numerator 123 · Denominator 124 |
| Falls with major injury | 0.81% |
0.77%
About the same
|
Numerator 1 · Denominator 124 |
| Discharge self-care score | 60.61% |
53.69%
6.9 pts better
|
Numerator 40 · Denominator 66 |
| Discharge mobility score | 46.97% |
50.94%
4 pts worse
|
Numerator 31 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 4.03% |
2.29%
1.7 pts worse
|
Numerator 5 · Denominator 124 · Adjusted rate 3.55% |
| Healthcare-associated infections requiring hospitalization | 9.21% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 14.63% · Lower 95% interval 6.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 160 |
| Staff flu vaccination coverage | 52.81% |
42%
10.8 pts better
|
Numerator 122 · Denominator 231 |
| Discharge function score | 62.12% |
56.45%
5.7 pts better
|
Numerator 41 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 51.52% |
25.2%
26.3 pts better
|
Numerator 34 · Denominator 66 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
91.2%
5.7 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 93.0% · Q3 97.8% · Q4 100.0% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
95.3%
0.1 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.0%
0.7 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.0% · Q3 5.4% · Q4 3.1% · 4Q avg 3.7% · 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 2.3% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
6.1%
2.6 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 12.8% · Q3 9.3% · Q4 4.3% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
13.5%
0.4 pts worse
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 14.4% · Q3 13.2% · Q4 13.7% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
14.8%
1.3 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 14.5% · Q3 13.2% · Q4 11.1% · 4Q avg 13.5% · 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 | 14.5% |
15.1%
0.6 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 17.3% · Q3 16.5% · Q4 2.3% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
15.5%
1.5 pts better
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 17.9% · Q3 10.0% · Q4 10.7% · 4Q avg 14.0% · 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 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.4%
0.2 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.1% · Q3 1.1% · Q4 1.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
20.8%
3.5 pts better
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 21.0% · Q3 16.7% · Q4 15.0% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.9%
1.9 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.3% · Q3 4.7% · Q4 6.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.3% |
76.7%
18.4 pts worse
|
81.7%
23.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.7% · Q2 58.1% · Q3 67.6% · Q4 59.1% · 4Q avg 58.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
9.7%
0.4 pts worse
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 11.0% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.2% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.4% |
78.8%
21.4 pts worse
|
79.7%
22.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
20.6%
8.8 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 32.0% · Expected 26.0% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (6 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-09
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-21
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-01
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-18
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-04-27
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-06-02
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-05-30
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-17
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-12-26
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-12-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-26
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-12-26
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-03-29
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-03-29
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-03-29
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2018-03-29
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-03-29
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-03-29
Fire Safety
Implement emergency and standby power systems.
Corrected 2018-03-29
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2018-03-29
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2018-04-13
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2018-03-29
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-23
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-10-08
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-08
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-07-23
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-08-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-20
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-05-20
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-20
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 2023-05-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-20
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 2023-05-20
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 2023-05-20
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-20
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-05-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-30
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-03-16
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-03-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-03-16
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2018-03-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-03-16
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-03-16
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-03-16
Penalties and ownership
Fine · fine $15,935
Fine
Payment Denial · denial start 2023-07-13 · 8 days
8 day denial
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
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Brewster, NY
1-star overall rating with 1-star inspections with 25 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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