Home / New York / Valley Cottage
100 Lake Road, Valley Cottage, NY 10989 · Rockland County · (845) 268-6813
96 certified beds, about 58 residents a day · Non profit - Corporation · Medicare and Medicaid since 1970
CMS Care Compare ratings, data as of September 1, 2026 · CCN 335311 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on September 2, 2025, inspectors cited 14 health deficiencies (the New York average is 8.1, the national average 9.2).
Of 45 health citations since June 2021, 2 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 1 fine totaling $126,926 in the last three years; the largest was $126,926, and the latest is dated September 2, 2025.
35.5% of nursing staff left within the year CMS measured (New York average 40.3%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 45 health citations on file.
Inspectors wroteBased on interview, observation and record review during the recertification and extended survey from 08/21/2025 - 09/02/2025, the facility failed to establish consistent mechanisms for documenting and communicating a resident's choice regarding advance directives to the staff responsible for the resident's care, resulting in staff not being able to appropriately identify Do Not Resuscitate orders for (6) six of 26 residents with Advance Directives. Specifically, Residents #64 and #67 were admitted to the facility with Do Not Resuscitate directives signed at the hospital that were not transcribed to the physician orders in the electronic medical record at the time of admission. Additionally, there was not a consistent process for identifying or communicating the resident's wishes regarding Do Not Resuscitate orders for Residents #9, #16, #28 and #36. [...]
Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility failed to ensure that properly trained personnel (and certified in CPR for Healthcare Providers) were available immediately (24 hours per day) to provide basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident's advance directives, and physician orders between [DATE] and [DATE]. Specifically, eight (8) out of 14 licensed nurses reviewed did not have current or acceptable completed standardized training and certification. This included six (6) Licensed Practical Nurses (Licensed Practical Nurse #1, #12, #11, #5, #17, #27), and one (1) Registered Nurse (Registered Nurse #3). [...]
Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification and extended survey from 08/21/2025 to 09/02/2025, the facility did not ensure sufficient staff was consistently provided to meet the needs of residents on all shifts. Specifically, residents and family members reported during confidential interviews and group meetings that there were frequent delays in responses to call bells. An analysis of the facility assessment and the daily staffing levels documented on multiple occasions between 07/21/2025 and 08/21/2025 the facility did not meet their staffing requirements set forth in their Facility assessment dated [DATE].
Inspectors wroteBased on interview and record review during the recertification and extended survey on [DATE] - [DATE] the facility administration did not use its resources effectively and efficiently to attain, or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) the facility administration failed to ensure policies and procedures for residents' advance directives were properly identified, communicated, and consistently implemented (See F578). 2) The facility failed to ensure a the policy for cardiopulmonary resuscitation (CPR) was implemented and there were certified staff on every shift (See F678).
Inspectors wroteBased on interview conducted during the recertification and extended survey on 08/21/2025 - 09/02/2025 the facility did not have a process and frequency by which the administrator reported to the governing body, the method of communication was not recorded, and the governing body did not establish and implement procedures for a clear line of communication regarding the management and operation of the facility. Specifically, the governing body did not receive minutes of the facility Quality Assurance Performance Improvement. The facility did not provide documented evidence that minutes of Quality Assurance Performance Improvement were provided to the governing body. During an interview on 8/28/2025 at 10:38 AM, the Chairman of the Board of Directors stated that the Board of Directors was the governing body of the facility. The management was led by the Interim Administrator. [...]
Inspectors wroteBased on observation, record review and interview during a recertification survey it was determined the facility did not make information on how to file a grievance or complaint available to residents. Specifically, during an 08/22/2025 resident council meeting Residents # 8, 11, 32, 34, 35, 36, 40, 41, 50, 53, 54, 59 and 65 stated they were unaware of the process of filing a formal grievance with the facility and were unaware of who the facility grievance official was.
Inspectors wroteBased on interviews and record review during the recertification and extended survey from 8/27/2025-9/3/2025, the facility did not ensure that the resident, resident's representative(s), or ombudsman was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for three (3) of 3 residents (Resident #61, #63 and Resident #66) reviewed for hospitalization or discharge home. Specifically, 1) the facility did not complete a discharge notice or notification of bed hold or notify the ombudsman for Residents #61 and #66 when they were hospitalized . 2) The facility did not notify the ombudsman for Resident #63 when they were discharged to the home.
Inspectors wroteBased on observation, record review and interviews conducted during the recertification and extended survey from 8/21/2025 through 9/2/2025, the facility did not ensure residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Specifically, 1) the light above the residents' doors on the second floor were not functioning in five (5) of the 26 rooms (Rooms #202 A, 202B, 205B, 207B, 212B, and 217B). The call lights lit up above the residents' rooms but had no audible sound. Additionally, tap bells were not provided or readily available for three bathrooms (Rooms #202, 207, and 212). [...]
Inspectors wroteBased on record review and interview during the recertification survey the facility did not ensure residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for one (1) of three (3) residents (Resident #71) reviewed for Beneficiary Protection Notification. Specifically, Resident #71 who received Medicare Part A services did not receive two (2) day notification of the termination of services with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123.
Inspectors wroteBased on observation, record review, and interview conducted during the recertification and extended survey from 08/21/2025 through 09/02/2025, the facility did not ensure that residents who had pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote wound healing for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers. Specifically, Resident #1 was readmitted to the facility on [DATE] with a hospital acquired sacral pressure ulcer and there was no documented evidence of treatment or assessment from 08/01/2025 to 08/13/2025.
Inspectors wroteBased on observation, interview, and record review during a recertification and extended survey from [DATE] to [DATE], the facility did not ensure that pharmaceutical services including procedures that assure the accurate acquiring of medications, met the needs of each resident for (1) one of three (3) residents (Resident #47) reviewed during the medication administration task; and the facility did not ensure a system of disposition and reconciliation for all controlled drugs. Specifically, 1) Resident #47's oral hypoglycemic medication was not available for administration as ordered; and 2) Resident #68 was discharged [DATE] and two boxes of Lorazepam concentration, prescribed for the resident, were not counted by two licensed staff members.
Inspectors wroteBased on record review and staff interviews during the Recertification and Extended surveys from 08/21/2025-09/02/2025, the facility did not ensure residents were free of significant medication errors for (1) one of (5) five residents (Resident # 3) reviewed for Unnecessary Medications. Specifically, Resident #3 had blood pressure parameters for Metoprolol (decreases blood pressure and heart rate) and Midodrine (increases blood pressure), and on 25 occasions the medications were given outside of the blood pressure parameters specified in the physician orders.
Inspectors wroteBased on observations, record review and interviews conducted during the recertification and extended survey from 08/21/2025 to 09/02/2025, the facility did not ensure the labeling of medications in accordance with currently accepted principles and the facility did not ensure all drugs and biologicals were stored in a locked compartment. Specifically, 1) an open Insulin pen was found in a medication cart without an open date. The manufacturer recommendation is to date the insulin pen when opened. After opening the medication is considered viable for 28 days. 2) a medication cart was observed unattended and un-locked.
Inspectors wroteBased on observation, interview, and record review during a recertification survey the facility did not ensure they maintained an infection prevention and control program designed to provide a sanitary environment and to help prevent development and transmission of infection for two (2) of seven (7) residents reviewed for infection control. Specifically, (1) Certified Nurse Aide #26 was observed touching dresser drawers in Resident #65's room who was on contact precautions. [...]
Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00374955/724315, NY00364233/724313), the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, Resident #4, Resident #5) reviewed for care planning. Specifically, (1) Resident #1 was identified as a high risk for fall on admission and there was no documented evidence of a fall risk care plan being initiated. Resident #1 sustained a fall on 3/5/2025 when they attempted to self-transfer from the bed to a chair and slid down to the floor; (2) on 12/10/2024 Resident #4 reported that their roommate Resident #5 had hit them after they engaged in a verbal disagreement. [...]
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00364233/724313), the facility did not ensure the resident right to be free from abuse for 1 of 3 residents (Resident #4) reviewed for abuse. Specifically, on 12/10/2024 Resident #4 reported that their roommate Resident #5 hit them during a verbal altercation. Resident #4 stated Resident #5 propelled their wheelchair over to their side of the room and struck them two times on their left chest/neck area.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00347972) the facility did not ensure that the resident is free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for 1 out of 3 residents (Resident #3) reviewed for restraints. Specifically, on 7/10/2024 Resident #3 who was moderately cognitively impaired and needed moderate assistance for bed mobility was found in bed with their floor mats propped up against their bed and held in place with two wooden night tables preventing the resident moving out the bed. The investigation revealed Certified Nurse Aide #1 was responsible and that Certified Nurse Aide #1 believed that placing the mats that way will prevent Resident #3 from rolling out of bed. There was no documented physician need/order for restraints.
Inspectors wroteBased on record review and interview during an abbreviated survey (NY00347972/724229, NY00364233/724313), the facility did not ensure an allegation involving abuse was reported immediately, but no later than two hours after the allegation is made if the events that cause the allegation involve abuse and to report the results of all investigations to the New York State Department of Health within 5 working days of the incident for 2 out of 3 residents (Resident #3, Resident #4) reviewed for abuse. Specifically, (1) on 7/10/2024 Resident #3 was found in bed with their floor mats propped up against their bed and held in place with two wooden night tables preventing the resident from exiting. The investigation revealed Certified Nurse Aide #1 who was responsible. [...]
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00374955/724315), the facility did not ensure a thorough investigation was completed for 1 out of 3 residents (Resident #1) reviewed for falls. Specifically, on 3/5/2025 Resident #1 had a fall while attempting to transfer themself from the bed to a chair. The accident/incident report submitted by the facility was incomplete with no investigative summary and no staff statements were obtained.
Inspectors wroteBased on record review and interview during an abbreviated survey (NY00370834/724309) the facility did not ensure the comprehensive care plan was reviewed, updated, and revised for 1 out of 3 residents reviewed (Resident #2) for care planning. Specifically, Resident #2 had a Stage 2 pressure ulcer to their sacrum and bilateral buttocks. The pressure ulcer worsened to a Stage 4 pressure ulcer. The actual skin impairment care plan had no documentation of the sacral pressure ulcer, measurements, treatments ordered and there were no updates of wound progression and physician findings when physician finding reports were submitted to the facility.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00374955), the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 out 3 residents (Resident #1) reviewed for pressure ulcers. Specifically, Resident #1 admitted to the facility on [DATE] was noted to have a Stage 2 pressure ulcer to their intergluteal medial cleft on their admission skin check. There was no documented evidence that the Physician was informed of Resident #1's Stage 2 pressure ulcer or of any treatments being ordered for the pressure ulcer.
Inspectors wroteBased on record review and interview during an abbreviated survey (NY00346485), the facility did not ensure residents were free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, on 6/26/2024 a visitor to the facility reported that while walking down the hallway they witnessed Certified Nurse Assistant #1 punching Resident #1 in their head, in the resident's room.
Inspectors wroteBased on record review and interview during an abbreviated survey (NY00346485) , the facility did not ensure allegations of abuse were thoroughly investigated for 1 out of 3 (Resident #1) residents reviewed for abuse. Specifically, a visitor in the facility reported they witnessed Certified Nurse Assistant #1 punching Resident #1 in the head on 6/26/2024, there was no written statement obtained from Certified Nurse Assistant #1. There was also no documented evidence of Resident #1 being assessed by a Medical Physician, a Nurse Practitioner, or Registered Nursing staff. In addition, the residents Certified Nurse Assistant #1 cared for were not interviewed or assessed to rule out abuse.
Inspectors wroteBased on record reviews and interviews during the recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months. Specifically, performance appraisals were not documented every 12 months for 5 of 5 certified nurse aides (Staff #2, #4, #8, #10, #11) records reviewed.
Inspectors wroteBased on observation, interview, and record review during the recertification survey from 5/28/24-6/4/24, the facility did not properly establish and/or maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, 1) The facility did not ensure cleans linens were transported throughout facility in a clean manor, or that hand hygiene was practice after handling dirty linens. 2) The facility did not have a current Water Management Plan in place; 3) Contact Precautions were not implemented for a resident with Clostridium Difficile infection (Resident#280) and staff were observed breaching infection control precautions.
Inspectors wroteBased on interview and record review during the recertification survey conducted 05/28/24-6/04/24, the facility did not ensure each staff was screened, offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 3 of 10 staff reviewed for COVID-19 vaccines. Specifically, there was no documented evidence of immunization records for Staff #13, #14, and #15.
Inspectors wroteBased on observation, interview, and record review during a recertification survey from 5/28/24 through 6/4/24, the facility did not ensure residents had the right to a dignified experience for 2 of 9 residents (Residents #328, and #46) reviewed for dining. Specifically, certified nurse aides were observed standing over Residents #328 and #36 while assisting the residents with their meals.
Inspectors wroteBased on record review and interview conducted during the recertification survey from [DATE] through [DATE], it was determined for 1 of 3 residents reviewed for advance directives, the facility did not ensure residents had the right to formulate advance directives. Specifically, there was no documented evidence that Resident #334 had a physician's order for advanced directives.
Inspectors wroteBased on record review and interviews during the recertification and abbreviated surveys (#NY00341484) from 5/28/24 to 6/4/24, the facility did not ensure an allegation of abuse was reported to the New York State Department of Health within 2 hours of becoming aware of the allegation for 1 (Resident #70) of 2 residents reviewed for abuse. Specifically, the facility did not ensure an allegation of sexual abuse involving Resident #70 was reported within 2 hours of becoming aware of the allegation on 5/6/24 and was not reported until 5/7/24.
Inspectors wroteBased on record review and interviews conducted during the recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood, and the facility did not notify the Ombudsman for 2 of 3 residents (Residents #18 and #24) reviewed for hospitalization. Specifically, Resident #18 and Resident #24 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the resident representatives and that notification was sent to the Ombudsman.
Inspectors wroteBased on record review and interviews during the recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that residents or resident's representatives were notified in writing of the facility policy for bed hold for 2 of 3 residents (Residents #18 and #24) reviewed for hospitalization. Specifically, the residents were transferred to the hospital and the facility was unable to provide evidence that written notice of the facility policy for bed hold was given to the residents or their representatives.
Inspectors wroteBased on record review and interviews conducted during the recertification survey from 5/28/24 through 6/4/24, the facility did not ensure the Minimum Data Set 3.0 comprehensive assessment was completed in a timely manner. Specifically, for 1 of 1 resident (Resident #30), the Minimum Data Set admission assessment was not completed within 14 calendar days from admission and/or by the required Assessment Reference Date.
Inspectors wroteBased on record review and interviews conducted during the recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that each resident's screen for a mental disorder or intellectual disability was signed and included the required digital ID. This was evident for 3 of 25 residents reviewed. Specially, Residents #18, #35 and #46 did not have the required signatures and digital IDs documented on their pre-admission screening and resident review assessment prior to their admission to the facility.
Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 5/28/24 to 6/4/24, it was determined for 1 of 6 residents (Resident #280) reviewed for Pressure Ulcers, the facility did not ensure a Baseline Care Plan was developed and implemented for a newly admitted resident that included the instructions needed to provide effective care within 48 hours of a resident's admission and that a summary of the Baseline Care Plan was provided to the resident. Specifically, Resident #280's baseline care plan was not developed.
Inspectors wroteBased on record review and interviews during a recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that the Infection Preventionist (IP) completed specialized training in infection prevention and control prior to assuming the role. Specifically, the facility's designated IP was the Assistant Director of Nursing and did not have documented evidence of completed specialized training in infection prevention and control until 05/29/24.
Inspectors wroteBased on record reviews and interviews conducted during a recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that the certified nurse aides were provided the required 12 hours of training and annual in-services on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 2 of 5 certified nurse aides (Staff # 8 and #11), reviewed for Nurse Aide training, were provided 12 hours of mandatory training.
Inspectors wroteBased on record reviews and interviews during the recertification and abbreviated surveys(NY00308566) from 5/28/24 to 6/4/24, the facility did not ensure that a resident's representative was immediately notified of the presence of an unstageable sacral pressure ulcer. This was evident for 1 of 6 residents (Resident #229) reviewed for pressure ulcers. Specifically, Resident #229's representative was not made aware the resident developed a pressure ulcer in the facility.
Inspectors wrote3. Resident #70 was admitted to the facility with diagnoses which included amyotrophic lateral sclerosis (nervous system disease), cerebrovascular accident, and dementia. The resident's Minimum Data Set (an assessment tool) dated 3/18/24 documented the resident has intact cognition and is dependent on staff for Activities of Daily Living, ambulates with supervision and is incontinent of bowel and bladder. An Incident and Accident (I&A) report dated 5/7/24 documented the facility Administrator visited the resident on 5/6/24 to encourage them to take a shower. The resident informed the Administrator that They were not taking any more showers because the last time three women pulled off my clothes and dragged me down the hallway naked to take a shower. One of the women squeezed my genitals in the shower 12 times. [...]
Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that the residents' call bell system was functioning to enable residents to call for assistance if needed, or for anyone to use in case of an emergency. Specifically, during environmental rounds, 4 of 4 residents (Residents #31, #34, #48, and #78) occupied rooms and bathrooms call bells were observed in non-functioning status. Additionally, one emergency bathroom call bell was partially detached from the wall.
Inspectors wroteF582 Based on the interview and record review conducted during the Recertification and Abbreviated Survey, the facility did not ensure that the beneficiary protection notice was reviewed with all residents and/or resident representatives. Specifically, there was no documented evidence that a beneficiary protection notice had been reviewed with 1 of 3 resident/representative reviewed for Advance Directives (Resident # 33). Resident #33 was admitted to facility 3/02/2021 with diagnoses including but not limited to Dementia and Depression. Resident # 33 was discharged [DATE], The resident had a (Brief Interview of Mental Status) BIMS score of 07/10 (severe cognitive impairment) Review of the resident record revealed the facility did not have a signed beneficiary protection notice to indicate it had been given to and/or reviewed with the resident and/or representative. [...]
Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that an injury of unknown origin was investigated. Specifically, Resident #30 was observed with ecchymosis to the left cheek. Record review revealed that Nursing was aware of the ecchymosis, and the ecchymosis was not investigated to ascertain the cause of the injury and/or prevent potential abuse.
Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that person-centered care plans with measurable goals and interventions were developed for a resident who is dependant on oxygen therapy and for a resident with skin bruising issues. Specifically; (1) One resident (Resident #31) reviewed for respiratory care, Actual Impaired Oxygen Care Plan was initiated for conditions such Shortness of Breath (SOB), and Chronic Obstructive Pulmonary Disease (COPD). The care plan had no measurable goals and interventions to address the resident's respiratory needs; and (2) One of 3 Residents (Resident #48) reviewed for skin conditions had no skin care plan in place to address the resident's skin bruising issues.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that each resident's person-centered Comprehensive Care Plan (CCP) was reviewed and revised to reflect the resident's current health status. This was evident for 1 of 5 residents (#30) reviewed for Accidents. Specifically, Resident #30 was identified with ecchymoses to the left cheek and the Incident/Accident care plan was not reviewed and revised to address this change in skin status and new interventions to protect from further ecchymoses.
Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that medications and biologicals were stored and labeled according to current acceptable professional standard of practice regarding storage of multi-dose insulin injection, and the recommended refrigerator temperature range. Specifically, (1) An unopened multi-dose Aspart Flex Pen Insulin (Novolog Flex Pen Insulin) assigned to Resident #26 was observed in a medication cart without a pharmacy dispensed date or instructions; (2) The above multi-dose Aspart Flex Pen Insulin for Resident #26 and a multi-dose Lantus Solostar Insulin Pen for Resident #36 were stored together in a plastic bag in the same medication cart; (3) The medication refrigerator temperature was not maintained at the proper recommended temperature range between 36 to 46 degrees Fahrenheit (F); [...]
Inspectors wroteBased on observation, interview, and record review, conducted during a recertification survey, the facility did not ensure that facility staff followed proper hand hygiene and gloving technique to prevent cross contamination and the spread of infection. Specifically, (1) Hand hygiene was not observed for 4 of 4 residents (Residents #26, #9, #54, and #47) randomly observed during a lunch meal observation; (2) Cross contamination of wounds and wound supplies, was observed; and (3) Removal of soiled gloves and hand hygiene were not observed during wound care procedures for 3 of 4 residents (Residents #31, #34 and #38) reviewed for pressure ulcer. This was evident on one of two units (Lower Level).
43 fire safety citations on file: 13 on September 2, 2025, 13 on June 4, 2024, 17 on June 15, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| September 2, 2025 | Fine | $126,926 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | New York | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 3.63 | 3.86 |
| Registered nurses | not reported | 0.71 | 0.69 |
| All nursing staff on weekends | not reported | 3.18 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | 35.5% | 40.3% | 45.8% |
| Registered nurse turnover | 62.5% | 39.8% | 42.9% |
| Administrators who left | 1 |
CMS note on this home's staffing data: The accuracy of the staffing data for this measure could not be validated by CMS.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.02 on weekdays and 3.37 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.73 in April to June 2025 to 3.83 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.83 | 0.48 | 4.02 | 3.37 | 1.9% | 0 of 90 | 58 |
| Oct to Dec 2025 | 4.76 | 0.51 | 5.01 | 4.13 | 0.1% | 0 of 92 | 53 |
| Jul to Sep 2025 | 3.73 | 0.51 | 3.89 | 3.31 | 0.0% | 0 of 92 | 57 |
| Apr to Jun 2025 | 4.73 | 0.19 | 5.15 | 3.70 | 0.0% | 4 of 91 | 64 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| New York, Jan to Mar 2026 | 3.55 | 0.68 | 3.72 | 3.13 | 9.8% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| New York, all employers | |||
| CNAs (nursing assistants) | $23.36 | $21.04 to $24.99 | 87,990 |
| LPNs and LVNs | $32.30 | $29.52 to $37.00 | 39,400 |
| Registered nurses | $52.62 | $45.60 to $62.34 | 205,810 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | New York | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 22.5 | 14.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.8 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 1.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.9 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 5.2 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 25.5 | 12.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 12.9 | 6.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.9 | 13.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 22.1 | 20.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.2 | 9.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.0 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 1.4 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Tolstoy Foundation Rehabilitation and Nrsg Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (59.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
59.1% this home
Better than the national rate
US median of homes 51.5% · New York: 101 better, 157 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 274 eligible stays.
11.2% this home
No different from the national rate
US median of homes 10.7% · New York: 12 better, 5 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 258 eligible stays.
8.3% this home
No different from the national rate
US median of homes 7.1% · New York: 7 better, 21 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 176 eligible stays.
58.3% this home
Median of homes: New York60.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 84 residents counted.
2.6% this home
Median of homes: New York0.6% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 116 residents counted.
3.4% this home
Median of homes: New York2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 116 residents counted.
96.4% this home
Median of homes: New York98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 55 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: TOLSTOY FOUNDATION NURSING HOME COMPANY INC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Corbett, Dorothy | W-2 managing employee | Individual | 02/20/2007 | |
| Corbett, Dorothy | Corporate director | Individual | 02/20/2007 | |
| Kostura, Gregory | Corporate director | Individual | 05/26/2015 | |
| Kotchoubey, Andrew | Corporate director | Individual | 05/26/2015 | |
| Lundquist, Don | Corporate director | Individual | 05/26/2015 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its New York inspection record.
These are the official offices in New York. NursingHomeClear cannot take or act on complaints.