Valley Cottage, NY
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $191,580 in total fines with 21 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
100 Lake Road, Valley Cottage, NY
(845) 268-6813
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
96
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-10-05
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
RN hours / resident day
0.51
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
13,717
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 22.23% · Performance 23.98% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.19
Baseline 8.59% · Performance 8.34% · Measure score 0.19 · Achievement 0 · Improvement 0.19
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.58 hours · Performance 2.55 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.16% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 258 · Observed rate 11.24% · Lower 95% interval 8.71% |
| Discharge to community | 59.08% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 274 · Observed rate 50% · Lower 95% interval 52.29% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 78.34% |
95.27%
16.9 pts worse
|
Numerator 123 · Denominator 157 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 157 |
| Discharge self-care score | 57.27% |
53.69%
3.6 pts better
|
Numerator 63 · Denominator 110 |
| Discharge mobility score | 55.45% |
50.94%
4.5 pts better
|
Numerator 61 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 3.18% |
2.29%
0.9 pts worse
|
Numerator 5 · Denominator 157 · Adjusted rate 2.97% |
| Healthcare-associated infections requiring hospitalization | 8.34% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 176 · Observed rate 9.66% · Lower 95% interval 5.99% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 149 · Denominator 149 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 70 · Denominator 110 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| Transfer of health information to patient | 97.44% |
96.28%
1.2 pts better
|
Numerator 76 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 22.08% |
25.2%
3.1 pts worse
|
Numerator 17 · Denominator 77 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.8 · 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 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
91.2%
3.3 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 90.6% · Q3 96.4% · Q4 90.7% · 4Q avg 94.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.9% |
95.3%
14.4 pts worse
|
95.5%
14.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.0%
3.4 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 7.8% · Q3 7.3% · Q4 3.7% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.6% |
18.5%
9.1 pts worse
|
11.4%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 20.7% · Q3 21.6% · Q4 48.1% · 4Q avg 27.6% |
| Percentage of long-stay residents who lose too much weight | 12.4% |
6.1%
6.3 pts worse
|
5.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 13.0% · Q3 11.8% · Q4 17.6% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
13.5%
11.9 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 26.7% · Q3 29.6% · Q4 26.9% · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
14.8%
4.4 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 22.2% · Q3 20.5% · Q4 19.0% · 4Q avg 19.2% · 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 | 24.8% |
15.1%
9.7 pts worse
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 26.3% · Q3 21.0% · Q4 32.7% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.3% |
15.5%
10.8 pts worse
|
14.9%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 28.0% · Q3 28.6% · Q4 23.9% · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.6%
1.1 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 1.0% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.4%
0.9 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.9% |
20.8%
6.9 pts better
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 14.6% · Q3 6.5% · Q4 8.4% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 12.3% |
6.9%
5.4 pts worse
|
5.1%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.1% · Q3 14.2% · Q4 11.1% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.0% |
76.7%
4.7 pts worse
|
81.7%
9.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 68.8% · Q3 60.7% · Q4 75.5% · 4Q avg 72.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
9.7%
5.7 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 17.6% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.2%
2.5 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.3% · Q3 2.6% · Q4 5.7% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.4% |
78.8%
4.4 pts worse
|
79.7%
5.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
20.6%
About the same
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 24.4% · Expected 28.2% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Resident Rights (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-24
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 2025-10-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-24
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-12-18
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-10-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-22
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-24
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-24
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-10-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-07
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-11-21
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-10-24
Fire Safety
Establish methods for sharing information.
Corrected 2025-10-24
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2024-07-08
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 2024-07-08
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-08
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-08
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-07-08
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-18
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-08
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-08
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-07-08
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-07-08
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-08-10
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-08-10
Fire Safety
Provide family notifications of emergency plan.
Corrected 2021-08-10
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-08-10
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-08-10
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-09-10
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 2021-08-10
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-08-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-10
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2021-09-14
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-08-10
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-08-10
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-10
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-08-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-10
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2021-08-10
Inspection history
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 2025-10-23
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-10-23
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-10-23
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-23
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2025-10-23
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 2025-10-23
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-23
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-10-23
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-10-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-10-23
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-23
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 2025-10-23
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-03
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-12-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-03
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-03
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 2025-12-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-27
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-27
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-07-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-19
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-07-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-19
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 2024-07-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-19
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-19
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 2024-07-19
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-07-19
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-19
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-19
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-07-19
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 2024-07-19
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-09-08
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-09-08
Health
Respond appropriately to all alleged violations.
Corrected 2021-09-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-09-08
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 2021-09-08
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 2021-09-08
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-08
Penalties and ownership
Fine · fine $191,580
Fine
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
Valley Cottage, NY
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Tarrytown, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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