2 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Bronx, NY
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
707 Throggs Neck Expressway, Bronx, NY
(718) 430-0003
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
205
Certified beds
Average residents
198
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
1993-12-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 2 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
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
5,529
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.74
Baseline 16.31% · Performance 18.31% · Measure score 6.74 · Achievement 6.74 · Improvement 0
Healthcare-associated infections
0
Baseline 7.44% · Performance 9.54% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.61
Baseline 40.52% · Performance 32.56% · Measure score 7.61 · Achievement 7.61 · Improvement 4.58
Adjusted total nurse staffing
0
Baseline 2.59 hours · Performance 2.48 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 179 · Observed rate 7.26% · Lower 95% interval 6.59% |
| Discharge to community | 45.66% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 202 · Observed rate 40.1% · Lower 95% interval 38.15% |
| Medicare spending per beneficiary | 1.69 |
1.02
0.7 pts worse
|
|
| Drug regimen review with follow-up | 4.88% |
95.27%
90.4 pts worse
|
Numerator 12 · Denominator 246 |
| Falls with major injury | 4.88% |
0.77%
4.1 pts worse
|
Numerator 12 · Denominator 246 |
| Discharge self-care score | 65.94% |
53.69%
12.2 pts better
|
Numerator 91 · Denominator 138 |
| Discharge mobility score | 62.32% |
50.94%
11.4 pts better
|
Numerator 86 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 6 · Denominator 246 · Adjusted rate 2.42% |
| Healthcare-associated infections requiring hospitalization | 9.54% |
7.12%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 12.98% · Lower 95% interval 7.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 273 |
| Staff flu vaccination coverage | 46.64% |
42%
4.6 pts better
|
Numerator 125 · Denominator 268 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 92 · Denominator 138 |
| Transfer of health information to provider | 98.09% |
95.95%
2.1 pts better
|
Numerator 154 · Denominator 157 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.77% |
25.2%
18.4 pts worse
|
Numerator 9 · Denominator 133 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.7
1.2 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.3
1.3 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.8% |
91.2%
15.4 pts worse
|
93.4%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.0% · Q2 66.0% · Q3 79.0% · Q4 87.0% · 4Q avg 75.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
95.3%
2.4 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.0%
0.7 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.5% · Q3 2.5% · Q4 2.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
18.5%
17.2 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.7% · Q3 0.0% · Q4 0.7% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.1%
1.4 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.2% · Q3 8.6% · Q4 4.4% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.1% |
13.5%
7.4 pts better
|
19.6%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 7.5% · Q3 5.6% · Q4 4.3% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.6% |
14.8%
1.8 pts worse
|
16.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 15.2% · Q3 18.0% · Q4 16.7% · 4Q avg 16.6% · 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 | 3.7% |
15.1%
11.4 pts better
|
16.3%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.2% · Q3 6.2% · Q4 4.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.7% |
15.5%
10.8 pts better
|
14.9%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.4% · Q3 6.0% · Q4 6.6% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.6%
0.5 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.0% · 4Q avg 0.1% · 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 | 29.4% |
20.8%
8.6 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 31.7% · Q3 27.3% · Q4 30.7% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
6.9%
4.3 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.2% · Q3 1.5% · Q4 2.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.2% |
76.7%
35.5 pts worse
|
81.7%
40.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 38.3% · Q3 50.0% · Q4 48.6% · 4Q avg 41.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.8% |
9.7%
4.9 pts better
|
12.0%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 4.4% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.8% · Q4 0.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.1% |
78.8%
26.7 pts worse
|
79.7%
27.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
20.6%
3.1 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 16.8% · Expected 22.9% · Used in QM five-star |
Survey summary
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
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 2024-01-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-31
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-11-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-03
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-03-08
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-03-08
Fire Safety
Develop a communication plan.
Corrected 2019-03-08
Inspection history
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2026-01-13
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-16
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-11-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-11-01
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-11-01
Health
Provide activities to meet all resident's needs.
Corrected 2021-11-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-11-01
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 2021-11-01
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2021-11-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-11-01
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-01
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2019-03-11
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-07
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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