Cycle 1
Health 2023-11-17 · Fire 2023-11-17
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Suffern, NY
The Willows At Ramapo Rehab And Nursing Center
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
30 Cragmere Road, Suffern, NY
(845) 357-1230
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
203
Certified beds
Average residents
189
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.39
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,509
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9872
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.05
Baseline 15.54% · Performance 20.02% · Measure score 3.05 · Achievement 3.05 · Improvement 0
Healthcare-associated infections
0
Baseline 9.10% · Performance 9.26% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 18.06% · Performance 19.01% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.94 hours · Performance 2.79 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 367 · Observed rate 9.26% · Lower 95% interval 8.04% |
| Discharge to community | 56.35% |
50.57%
5.8 pts better
|
No Different than the National Rate · Eligible stays 454 · Observed rate 48.24% · Lower 95% interval 50.33% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.72% |
95.27%
4.5 pts better
|
Numerator 360 · Denominator 361 |
| Falls with major injury | 0.55% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 361 |
| Discharge self-care score | 58.17% |
53.69%
4.5 pts better
|
Numerator 146 · Denominator 251 |
| Discharge mobility score | 60.16% |
50.94%
9.2 pts better
|
Numerator 151 · Denominator 251 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 8 · Denominator 361 · Adjusted rate 2.12% |
| Healthcare-associated infections requiring hospitalization | 9.26% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 286 · Observed rate 10.14% · Lower 95% interval 6.65% |
| Staff COVID-19 vaccination coverage | 1.24% |
8.2%
7 pts worse
|
Numerator 3 · Denominator 242 |
| Staff flu vaccination coverage | 23.66% |
42%
18.3 pts worse
|
Numerator 62 · Denominator 262 |
| Discharge function score | 60.56% |
56.45%
4.1 pts better
|
Numerator 152 · Denominator 251 |
| Transfer of health information to provider | 95.1% |
95.95%
0.9 pts worse
|
Numerator 97 · Denominator 102 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 175 · Denominator 175 |
| Resident COVID-19 vaccinations up to date | 5.58% |
25.2%
19.6 pts worse
|
Numerator 11 · Denominator 197 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.7% |
91.2%
10.5 pts worse
|
93.4%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.5% · Q2 79.6% · Q3 79.9% · Q4 87.8% · 4Q avg 80.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.5% |
95.3%
11.8 pts worse
|
95.5%
12 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.0%
1.3 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.9% · Q3 4.9% · Q4 4.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
18.5%
11.7 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.0% · Q3 6.7% · Q4 4.6% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
6.1%
2.4 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 12.4% · Q3 7.4% · Q4 6.3% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
13.5%
7.9 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 17.1% · Q3 22.4% · Q4 22.1% · 4Q avg 21.4% |
| 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 16.5% · Q2 14.0% · Q3 6.5% · Q4 6.8% · 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 | 16.1% |
15.1%
1 pts worse
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 25.0% · Q3 7.9% · Q4 13.5% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
15.5%
2.6 pts worse
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 23.6% · Q3 14.3% · Q4 10.7% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.6%
0.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.4%
0.7 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 2.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
20.8%
6.2 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 35.0% · Q3 21.6% · Q4 24.2% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.9%
1.1 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.4% · Q3 8.2% · Q4 5.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.7% |
76.7%
22 pts worse
|
81.7%
27 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 44.4% · Q3 68.4% · Q4 84.7% · 4Q avg 54.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
9.7%
2.6 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.6% · Expected 11.9% · 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 0.0% · Q2 0.0% · Q3 0.8% · Q4 1.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.6% |
78.8%
28.2 pts worse
|
79.7%
29.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.9% |
20.6%
3.7 pts better
|
23.9%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 20.9% · Expected 29.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-18 · Fire 2019-04-18
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2017-07-07 · Fire 2017-07-07
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-11-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-28
E · Potential for more than minimal harm
2023-11-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-28
E · Potential for more than minimal harm
2023-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-17
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 2023-12-28
D · Potential for more than minimal harm
2023-11-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-28
E · Potential for more than minimal harm
2019-04-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-18
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 2019-05-31
D · Potential for more than minimal harm
2019-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-05-31
C · Minimal harm
2019-04-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-05-31
C · Minimal harm
2019-04-18
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-05-31
E · Potential for more than minimal harm
2017-07-07
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 2017-08-11
E · Potential for more than minimal harm
2017-07-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2017-08-11
D · Potential for more than minimal harm
2017-07-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2017-08-11
D · Potential for more than minimal harm
2017-07-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2017-08-11
D · Potential for more than minimal harm
2017-07-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2017-08-11
Inspection history
Recent health citations
G · Actual harm
2025-10-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-10-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-04
D · Potential for more than minimal harm
2025-03-04
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 2025-04-08
E · Potential for more than minimal harm
2023-11-17
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 2023-12-30
D · Potential for more than minimal harm
2023-11-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-30
D · Potential for more than minimal harm
2019-04-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-04-18
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 2019-06-14
D · Potential for more than minimal harm
2019-04-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-04-18
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 2019-06-14
D · Potential for more than minimal harm
2019-04-18
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 2019-06-14
D · Potential for more than minimal harm
2019-04-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-14
C · Minimal harm
2019-04-18
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-06-14
C · Minimal harm
2019-04-18
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 2019-06-14
C · Minimal harm
2019-04-18
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-06-14
B · Minimal harm
2019-04-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-06-14
B · Minimal harm
2019-04-18
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 2019-06-14
D · Potential for more than minimal harm
2017-07-07
F279 · Resident Assessment and Care Planning Deficiencies
Health
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2017-08-11
D · Potential for more than minimal harm
2017-07-07
F314 · Quality of Life and Care Deficiencies
Health
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Corrected 2017-08-11
Penalties and ownership
What sits behind the stars
Ownership
Ahuja, Sanjay
5% Or Greater Direct Ownership Interest · Individual
Mohan, Namita
5% Or Greater Direct Ownership Interest · Individual
Mudgil, Vanita
5% Or Greater Direct Ownership Interest · Individual
Zimiles, Joseph
5% Or Greater Direct Ownership Interest · Individual
Einhorn, Neal
5% Or Greater Direct Ownership Interest · Individual
Einhorn, Sharon
5% Or Greater Direct Ownership Interest · Individual
Friedman, Devorah
5% Or Greater Direct Ownership Interest · Individual
Friedman, Mark
5% Or Greater Direct Ownership Interest · Individual
Ahuja, Sanjay
Corporate Officer · Individual
Einhorn, Neal
Corporate Officer · Individual
Friedman, Mark
Corporate Director · Individual
Green-Rivers, Kelly
Operational/Managerial Control · Individual
Halon, Jonathan
Operational/Managerial Control · Individual
Shah, Parag
Operational/Managerial Control · Individual
Zimiles, Joseph
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Northern Metropolitan Res Health Care Facility Inc
Monsey, NY
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#2
Allendale Rehabilitation And Healthcare Center
Allendale, NJ
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Woodcliff Lake Health & Rehabilitation Center
Woodcliff Lake, NJ
5-star overall rating with 4-star inspections with $9,750 in total fines with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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