Cycle 1
Health 2025-07-28 · Fire 2025-07-28
4 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mount Vernon, NY
The Wartburg Home
5-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1 Wartburg Place, Mount Vernon, NY
(914) 699-0800
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
210
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-06-07
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
1.07
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.50
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.39
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.72
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
15%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,033
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9997
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.75
Baseline 18.39% · Performance 19.23% · Measure score 4.75 · Achievement 4.75 · Improvement 0
Healthcare-associated infections
4.64
Baseline 6.66% · Performance 6.45% · Measure score 4.64 · Achievement 4.64 · Improvement 0.77
Total nurse turnover
6.23
Baseline 11.67% · Performance 38.23% · Measure score 6.23 · Achievement 6.23 · Improvement 0
Adjusted total nurse staffing
2.92
Baseline 3 hours · Performance 3.91 hours · Measure score 2.92 · Achievement 2.92 · Improvement 2.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 568 · Observed rate 8.98% · Lower 95% interval 8.2% |
| Discharge to community | 65.06% |
50.57%
14.5 pts better
|
Better than the National Rate · Eligible stays 608 · Observed rate 58.72% · Lower 95% interval 60.81% |
| 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 301 · Denominator 301 |
| Falls with major injury | 0.66% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 301 |
| Discharge self-care score | 83.76% |
53.69%
30.1 pts better
|
Numerator 196 · Denominator 234 |
| Discharge mobility score | 83.33% |
50.94%
32.4 pts better
|
Numerator 195 · Denominator 234 |
| Pressure ulcers or injuries, new or worsened | 2.66% |
2.29%
0.4 pts worse
|
Numerator 8 · Denominator 301 · Adjusted rate 1.95% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 293 · Observed rate 5.46% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 0.51% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 196 |
| Staff flu vaccination coverage | 45.93% |
42%
3.9 pts better
|
Numerator 113 · Denominator 246 |
| Discharge function score | 81.62% |
56.45%
25.2 pts better
|
Numerator 191 · Denominator 234 |
| Transfer of health information to provider | 26.47% |
95.95%
69.5 pts worse
|
Numerator 18 · Denominator 68 |
| Transfer of health information to patient | 92.82% |
96.28%
3.5 pts worse
|
Numerator 194 · Denominator 209 |
| Resident COVID-19 vaccinations up to date | 55.28% |
25.2%
30.1 pts better
|
Numerator 89 · Denominator 161 |
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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
18.5%
14.7 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
6.1%
4.8 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
13.5%
0.7 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
14.8%
2.3 pts better
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 40.7% |
15.5%
25.2 pts worse
|
14.9%
25.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.7% · 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 | 39.4% |
20.8%
18.6 pts worse
|
19.8%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.4% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.9%
0.3 pts better
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.5% |
76.7%
0.8 pts better
|
81.7%
4.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.1% · Q2 76.4% · Q3 78.2% · Q4 77.4% · 4Q avg 77.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
9.7%
4.3 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 4.7% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.9% |
78.8%
8.9 pts worse
|
79.7%
9.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
20.6%
1.8 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 16.4% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-20 · Fire 2023-06-20
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
12 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2021-05-17 · Fire 2021-05-17
6 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-28
F · Potential for more than minimal harm
2025-07-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-28
E · Potential for more than minimal harm
2025-07-28
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 2025-09-28
E · Potential for more than minimal harm
2025-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-07-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-28
E · Potential for more than minimal harm
2023-06-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-06-20
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 2023-07-25
E · Potential for more than minimal harm
2023-06-20
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-06-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-20
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-20
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-06-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-19
C · Minimal harm
2023-06-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-16
E · Potential for more than minimal harm
2021-05-17
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 2021-07-19
E · Potential for more than minimal harm
2021-05-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-07-19
E · Potential for more than minimal harm
2021-05-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-19
E · Potential for more than minimal harm
2021-05-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-19
E · Potential for more than minimal harm
2021-05-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-07-19
E · Potential for more than minimal harm
2021-05-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-19
E · Potential for more than minimal harm
2021-05-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-19
D · Potential for more than minimal harm
2021-05-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-19
D · Potential for more than minimal harm
2021-05-17
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-07-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-28
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 2025-09-26
F · Potential for more than minimal harm
2025-07-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-07-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-07-28
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 2025-09-26
D · Potential for more than minimal harm
2024-01-16
F585 · Resident Rights Deficiencies
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 2024-03-15
E · Potential for more than minimal harm
2023-06-20
F625 · Resident Rights Deficiencies
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 2023-08-17
E · Potential for more than minimal harm
2023-06-20
F947 · Nursing and Physician Services Deficiencies
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 2023-08-17
D · Potential for more than minimal harm
2023-06-20
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 2023-08-17
D · Potential for more than minimal harm
2023-06-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-17
E · Potential for more than minimal harm
2021-05-17
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 2021-07-16
D · Potential for more than minimal harm
2021-05-17
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 2021-07-16
D · Potential for more than minimal harm
2021-05-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-16
D · Potential for more than minimal harm
2021-05-17
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 2021-07-16
D · Potential for more than minimal harm
2021-05-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-16
Penalties and ownership
What sits behind the stars
Ownership
Benson, Thomas
Corporate Director · Individual
Carlson, Jeanette
Corporate Director · Individual
Carpenter, Mae
Corporate Director · Individual
Delaney, Carol
Corporate Director · Individual
Derr, Amandus
Corporate Director · Individual
Gentner, David
Corporate Officer · Individual
Gentner, David
W-2 Managing Employee · Individual
Hammond, Mark
Corporate Officer · Individual
Holden, Michael
Corporate Director · Individual
Mitchell, Clesont
Corporate Director · Individual
Myers, Floyd
Corporate Director · Individual
Ocker, Kevin
Corporate Director · Individual
Olsen, Eric
Corporate Director · Individual
Ranieri, Robert
Corporate Director · Individual
Roth, Thomas
Corporate Director · Individual
Wagner, Carol
Corporate Director · Individual
Wartburg Home Of The Evangelical Lutheran Church
Operational/Managerial Control · Organization
Williams, Judy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Westchester Center For Rehabilitation & Nursing
Mount Vernon, NY
2-star overall rating with 1-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Schaffer Extended Care Center
New Rochelle, NY
1-star overall rating with 1-star inspections with $10,358 in total fines with 12 recent health deficiencies
#3
Sutton Park Center For Nursing And Rehabilitation
New Rochelle, NY
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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