Cycle 1
Health 2024-08-29 · Fire 2024-08-29
1 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Valhalla, NY
The Steven And Alexandra Cohen Ped L T C Pavilion
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
95 Bradhurst Ave, Valhalla, NY
(914) 831-2582
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
24
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-09-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
5.34
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
3.07
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
8.41
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
5.34
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
7.52
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
4.71
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
2.33
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
3.14
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 41% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 2.34% |
8.2%
5.9 pts worse
|
Numerator 3 · Denominator 128 |
| Staff flu vaccination coverage | 74.59% |
42%
32.6 pts better
|
Numerator 91 · Denominator 122 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 0.0% |
3.0%
3 pts better
|
3.3%
3.3 pts better
|
Long 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 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 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
6.1%
5 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.8% |
13.5%
26.3 pts worse
|
19.6%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 33.3% · Q3 50.0% · Q4 45.5% · 4Q avg 39.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
14.8%
6.2 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.1% |
0.2%
0.9 pts worse
|
0.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.1% |
20.8%
16.7 pts better
|
19.8%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 5.5% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
6.9%
6.1 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-08 · Fire 2022-09-08
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2019-07-17 · Fire 2019-07-17
1 health deficiencies
Top issue: Infection Control (1 deficiency)
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
2024-08-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-04
E · Potential for more than minimal harm
2022-09-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-09-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-01
E · Potential for more than minimal harm
2022-09-08
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-24
D · Potential for more than minimal harm
2022-09-08
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-09-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-11-09
C · Minimal harm
2022-09-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-11-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-10
D · Potential for more than minimal harm
2019-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-30
Penalties and ownership
What sits behind the stars
Ownership
Adler, Howard
Corporate Director · Individual
Canning, John
Corporate Officer · Individual
Coppolino, Lisa-Marie
Operational/Managerial Control · Individual
Evnin, Timothy
Corporate Director · Individual
Gerstein, Alan
Corporate Director · Individual
Gutfreund, Owen
Corporate Director · Individual
Levine, Larry
Operational/Managerial Control · Individual
Levine, Larry
Corporate Officer · Individual
Levy, Scott
Corporate Director · Individual
Pedowitz, David
Corporate Director · Individual
Popper, Abby
Corporate Director · Individual
Rittmaster, Peter
Corporate Director · Individual
Schmolka, Lucille
Corporate Director · Individual
Starker, Farrel
Corporate Director · Individual
Wachenheim, Lance
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Grove At Valhalla Rehab And Nursing Center
Valhalla, NY
2-star overall rating with 1-star inspections with $76,339 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
The Knolls
Valhalla, NY
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
Kendal On Hudson
Sleepy Hollow, NY
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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