Cycle 1
Health 2024-08-20 · Fire 2024-08-20
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Poughkeepsie, NY
The Pines At Poughkeepsie Ctr For Nursing & Rehab
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
100 Franklin Street, Poughkeepsie, NY
(845) 454-4100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
181
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
National Health Care Associates
Operator or chain grouping
Approved since
1976-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,925
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.22% · Performance 23.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.61% · Performance 9.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.03
Baseline 25.17% · Performance 26.79% · Measure score 9.03 · Achievement 9.03 · Improvement 0
Adjusted total nurse staffing
1.08
Baseline 3.43 hours · Performance 3.38 hours · Measure score 1.08 · Achievement 1.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 513 · Observed rate 8.97% · Lower 95% interval 7.58% |
| Discharge to community | 57.94% |
50.57%
7.4 pts better
|
Better than the National Rate · Eligible stays 520 · Observed rate 52.69% · Lower 95% interval 53% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.7% |
95.27%
4.4 pts better
|
Numerator 329 · Denominator 330 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 330 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 84 · Denominator 180 |
| Discharge mobility score | 48.33% |
50.94%
2.6 pts worse
|
Numerator 87 · Denominator 180 |
| Pressure ulcers or injuries, new or worsened | 0.61% |
2.29%
1.7 pts better
|
Numerator 2 · Denominator 330 · Adjusted rate 0.73% |
| Healthcare-associated infections requiring hospitalization | 9.09% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 273 · Observed rate 9.52% · Lower 95% interval 6.45% |
| Staff COVID-19 vaccination coverage | 0.29% |
8.2%
7.9 pts worse
|
Numerator 1 · Denominator 340 |
| Staff flu vaccination coverage | 28.46% |
42%
13.5 pts worse
|
Numerator 113 · Denominator 397 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 90 · Denominator 180 |
| Transfer of health information to provider | 95.58% |
95.95%
0.4 pts worse
|
Numerator 216 · Denominator 226 |
| Transfer of health information to patient | 93.55% |
96.28%
2.7 pts worse
|
Numerator 29 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 16% |
25.2%
9.2 pts worse
|
Numerator 24 · Denominator 150 |
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 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.7% |
91.2%
9.5 pts worse
|
93.4%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.1% · Q2 82.8% · Q3 79.7% · Q4 78.4% · 4Q avg 81.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
95.3%
0.2 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.0%
0.1 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.6% · Q3 3.4% · Q4 2.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.7% |
18.5%
1.2 pts worse
|
11.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 23.8% · Q3 18.9% · Q4 11.5% · 4Q avg 19.7% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.1%
2.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.5% · Q3 3.3% · Q4 1.6% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
13.5%
6.1 pts worse
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 18.6% · Q3 18.9% · Q4 17.8% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
14.8%
4 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 10.5% · Q3 7.8% · Q4 7.4% · 4Q avg 10.8% · 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 | 12.5% |
15.1%
2.6 pts better
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 22.4% · Q3 9.7% · Q4 5.2% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
15.5%
3.6 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 14.6% · Q3 12.2% · Q4 5.7% · 4Q avg 11.9% · 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 0.7% · Q2 0.7% · Q3 0.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.4%
1.1 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.2% |
20.8%
13.4 pts worse
|
19.8%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.1% · Q2 31.3% · Q3 28.6% · Q4 36.7% · 4Q avg 34.2% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
6.9%
4.7 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.3% · Q3 1.9% · Q4 0.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.7% |
76.7%
12 pts worse
|
81.7%
17 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 57.2% · Q2 61.9% · Q3 70.7% · Q4 71.1% · 4Q avg 64.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
9.7%
3.1 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 0.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.5% |
78.8%
14.3 pts worse
|
79.7%
15.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
20.6%
3.1 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 21.7% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-12 · Fire 2021-10-12
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2018-12-06 · Fire 2018-12-06
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-08-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-15
C · Minimal harm
2024-08-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-04
F · Potential for more than minimal harm
2021-10-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-10-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-10-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-10-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-12-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-20
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 2024-10-08
D · Potential for more than minimal harm
2024-08-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-20
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 2024-10-08
D · Potential for more than minimal harm
2024-08-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-20
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 2024-10-08
D · Potential for more than minimal harm
2024-03-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-10
D · Potential for more than minimal harm
2021-10-12
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 2021-12-24
D · Potential for more than minimal harm
2021-10-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-24
E · Potential for more than minimal harm
2018-12-06
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 2019-02-07
E · Potential for more than minimal harm
2018-12-06
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 2019-02-07
D · Potential for more than minimal harm
2018-12-06
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 2019-02-07
D · Potential for more than minimal harm
2018-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-02-07
D · Potential for more than minimal harm
2018-12-06
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 2019-02-07
D · Potential for more than minimal harm
2018-12-06
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 2019-02-07
D · Potential for more than minimal harm
2018-12-06
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 2019-02-07
D · Potential for more than minimal harm
2018-12-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-02-07
D · Potential for more than minimal harm
2018-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-02-07
Penalties and ownership
What sits behind the stars
Ownership
Ostreicher, Susan
5% Or Greater Direct Ownership Interest · Individual
Fuchs, Morris
5% Or Greater Direct Ownership Interest · Individual
Biderman, Nechama
5% Or Greater Direct Ownership Interest · Individual
Cohen, David
5% Or Greater Direct Ownership Interest · Individual
Roberts, Laurence
5% Or Greater Direct Ownership Interest · Individual
Goldenberg, Chaim
5% Or Greater Direct Ownership Interest · Individual
Lipman, Michael
5% Or Greater Direct Ownership Interest · Individual
Manela, Magda
5% Or Greater Direct Ownership Interest · Individual
Ostreicher, Marc
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Lutheran Center At Poughkeepsie Inc
Poughkeepsie, NY
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
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
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