5 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
New Paltz, NY
4-star overall rating with 3-star inspections with $13,099 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
100 Woodland Pond Circle, New Paltz, NY
(845) 256-5910
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
40
Certified beds
Average residents
39
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-03-25
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
1.15
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.70
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.18
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.85
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.56
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
5.45
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
1,729
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0093
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.13
Baseline 18.03% · Performance 19.05% · Measure score 5.13 · Achievement 5.13 · Improvement 0
Healthcare-associated infections
2.59
Baseline 5.44% · Performance 7.06% · Measure score 2.59 · Achievement 2.59 · Improvement 0
Total nurse turnover
4.85
Baseline 59.68% · Performance 43.86% · Measure score 4.85 · Achievement 4.85 · Improvement 4.04
Adjusted total nurse staffing
9.20
Baseline 5.68 hours · Performance 5.69 hours · Measure score 9.20 · Achievement 9.20 · Improvement 1.18
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 6.19% · Lower 95% interval 6.96% |
| Discharge to community | 34.73% |
50.57%
15.8 pts worse
|
Worse than the National Rate · Eligible stays 92 · Observed rate 30.43% · Lower 95% interval 25.88% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.08% |
95.27%
0.2 pts worse
|
Numerator 58 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 68.09% |
53.69%
14.4 pts better
|
Numerator 32 · Denominator 47 |
| Discharge mobility score | 78.72% |
50.94%
27.8 pts better
|
Numerator 37 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 6.56% |
2.29%
4.3 pts worse
|
Numerator 4 · Denominator 61 · Adjusted rate 5.95% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 5.26% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 4.62% |
8.2%
3.6 pts worse
|
Numerator 9 · Denominator 195 |
| Staff flu vaccination coverage | 25.15% |
42%
16.9 pts worse
|
Numerator 85 · Denominator 338 |
| Discharge function score | 76.6% |
56.45%
20.1 pts better
|
Numerator 36 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 73.08% |
25.2%
47.9 pts better
|
Numerator 19 · Denominator 26 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.4 · Expected 1.3 · 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 1.0 · Expected 1.2 · Used in QM five-star |
| 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 | 6.8% |
3.0%
3.8 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.5% · Q3 8.8% · Q4 8.6% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
18.5%
16.7 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 3.2% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 9.9% |
6.1%
3.8 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 13.0% · Q3 4.2% · Q4 3.6% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
13.5%
5.2 pts worse
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.8% · Q3 15.4% · Q4 16.7% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
14.8%
8 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q3 5.0% · Q4 3.8% · 4Q avg 6.8% · 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 | 15.4% |
15.1%
0.3 pts worse
|
16.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
15.5%
0.6 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q4 19.2% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.6%
0.4 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
1.4%
2.5 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.3% · Q3 3.1% · Q4 6.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
20.8%
3 pts worse
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 25.9% · Q3 28.7% · Q4 32.5% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 10.7% |
6.9%
3.8 pts worse
|
5.1%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.9% · Q3 13.7% · Q4 5.5% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
76.7%
23.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.7%
3.7 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.3% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.2%
1.5 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.8%
21.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
20.6%
0.3 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 17.5% · Expected 20.6% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-12-19
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-12-19
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-12-19
Inspection history
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 2025-06-24
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 2025-06-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-24
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-24
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 2020-04-26
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-04-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-04-26
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 2020-04-26
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-26
Penalties and ownership
Fine · fine $3,011
Fine
Fine · fine $6,836
Fine
Fine · fine $3,252
Fine
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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