Cycle 1
Health 2023-10-16 · Fire 2023-10-16
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Valhalla, NY
The Knolls
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
55 Grassland Road, Valhalla, NY
(914) 989-7800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
17
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-04-15
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
1.97
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
2.87
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.84
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.35
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
1.54
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
2.17
CMS adjusted RN staffing hours
Adjusted total hours
5.33
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,072
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9995
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.65
Baseline 19.66% · Performance 19.28% · Measure score 4.65 · Achievement 4.65 · Improvement 0.97
Healthcare-associated infections
1.77
Baseline 5.36% · Performance 7.31% · Measure score 1.77 · Achievement 1.77 · Improvement 0
Total nurse turnover
7.42
Baseline 34.78% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 0.96
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 6.59% · Lower 95% interval 6.96% |
| Discharge to community | 62.68% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 96 · Observed rate 59.38% · Lower 95% interval 53.33% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.39% |
95.27%
3.1 pts better
|
Numerator 61 · Denominator 62 |
| Falls with major injury | 3.23% |
0.77%
2.5 pts worse
|
Numerator 2 · Denominator 62 |
| Discharge self-care score | 82.14% |
53.69%
28.5 pts better
|
Numerator 46 · Denominator 56 |
| Discharge mobility score | 85.71% |
50.94%
34.8 pts better
|
Numerator 48 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 62 · Adjusted rate 3.12% |
| Healthcare-associated infections requiring hospitalization | 7.31% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 7.14% |
8.2%
1.1 pts worse
|
Numerator 3 · Denominator 42 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 89.29% |
56.45%
32.8 pts better
|
Numerator 50 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 24.24% |
25.2%
1 pts worse
|
Numerator 8 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
91.2%
4.5 pts worse
|
93.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 86.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
3.0%
3.7 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
6.1%
1 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
13.5%
3.2 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.8% |
14.8%
20 pts worse
|
16.7%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.8% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
15.5%
8.6 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
20.8%
5.4 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.9%
6.9 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.6% |
76.7%
41.1 pts worse
|
81.7%
46.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 34.9% · Q3 42.0% · Q4 32.1% · 4Q avg 35.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
9.7%
2.6 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 10.9% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.7% |
78.8%
12.1 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
20.6%
5.5 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 14.5% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-06 · Fire 2021-07-06
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2019-09-12 · Fire 2019-09-12
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-10-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-10-16
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-11-27
E · Potential for more than minimal harm
2021-07-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-09-06
C · Minimal harm
2021-07-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-09-06
E · Potential for more than minimal harm
2019-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-07-06
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 2021-09-06
D · Potential for more than minimal harm
2021-07-06
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 2021-09-06
D · Potential for more than minimal harm
2021-07-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-09-06
D · Potential for more than minimal harm
2021-07-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-09-06
D · Potential for more than minimal harm
2021-07-06
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 2021-09-06
D · Potential for more than minimal harm
2021-07-06
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 2021-09-06
D · Potential for more than minimal harm
2021-07-06
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 2021-09-06
D · Potential for more than minimal harm
2021-07-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-06
Penalties and ownership
What sits behind the stars
Ownership
Alexander, Jennifer
W-2 Managing Employee · Individual
Goldstein, Beth
Corporate Officer · Individual
Markopoulos, Anastasios
Corporate Officer · Individual
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