Cycle 1
Health 2025-03-21 · Fire 2025-03-21
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Horseheads, NY
Bethany Nursing Home & Health Related Facility Inc
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
3005 Watkins Road, Horseheads, NY
(607) 378-6547
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
100
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-06-08
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
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,314
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.87
Baseline 18.21% · Performance 21.03% · Measure score 0.87 · Achievement 0.87 · Improvement 0
Healthcare-associated infections
3.05
Baseline 6.01% · Performance 6.92% · Measure score 3.05 · Achievement 3.05 · Improvement 0
Total nurse turnover
4.21
Baseline 33.78% · Performance 46.47% · Measure score 4.21 · Achievement 4.21 · Improvement 0
Adjusted total nurse staffing
2.73
Baseline 3.78 hours · Performance 3.86 hours · Measure score 2.73 · Achievement 2.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 156 · Observed rate 7.69% · Lower 95% interval 7.24% |
| Discharge to community | 38.59% |
50.57%
12 pts worse
|
Worse than the National Rate · Eligible stays 161 · Observed rate 34.78% · Lower 95% interval 31.67% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 55.84% |
53.69%
2.2 pts better
|
Numerator 43 · Denominator 77 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 42 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 3.06% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 98 · Adjusted rate 3.43% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 4.9% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 2.91% |
8.2%
5.3 pts worse
|
Numerator 5 · Denominator 172 |
| Staff flu vaccination coverage | 61.48% |
42%
19.5 pts better
|
Numerator 166 · Denominator 270 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 49 · Denominator 77 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 48 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 43.75% |
25.2%
18.6 pts better
|
Numerator 21 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · 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 | 94.4% |
91.2%
3.2 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 91.9% · Q3 93.1% · Q4 94.3% · 4Q avg 94.4% |
| 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 | 5.9% |
3.0%
2.9 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.0% · Q3 5.7% · Q4 6.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
18.5%
12.7 pts better
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 11.2% · Q3 1.2% · Q4 3.7% · 4Q avg 5.8% |
| Percentage of long-stay residents who lose too much weight | 12.5% |
6.1%
6.4 pts worse
|
5.4%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 12.0% · Q3 11.8% · Q4 15.5% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
13.5%
13.9 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 29.4% · Q3 26.7% · Q4 27.6% · 4Q avg 27.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
14.8%
3.9 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.3% · Q3 9.3% · Q4 11.5% · 4Q avg 10.9% · 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 | 27.3% |
15.1%
12.2 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 33.9% · Q3 32.4% · Q4 14.2% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.2% |
15.5%
11.7 pts worse
|
14.9%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 31.6% · Q3 30.9% · Q4 24.7% · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.4%
1.3 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 1.2% · Q3 0.0% · Q4 1.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.2% |
20.8%
10.4 pts worse
|
19.8%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 30.6% · Q3 38.2% · Q4 24.4% · 4Q avg 31.2% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
6.9%
4.1 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 15.7% · Q3 8.5% · Q4 11.8% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
76.7%
18.6 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 94.4% · Q3 94.0% · Q4 94.7% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
9.7%
4.9 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 12.9% · 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 1.6% · Q3 4.8% · Q4 4.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.8% |
78.8%
10 pts better
|
79.7%
9.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
20.6%
4.6 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 22.6% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-24 · Fire 2023-03-24
3 health deficiencies
Top issue: Administration (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-07-23 · Fire 2021-07-23
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
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 2025-05-20
D · Potential for more than minimal harm
2025-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-20
E · Potential for more than minimal harm
2023-03-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-03-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-03-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-03-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-03-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-03-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-03-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-23
C · Minimal harm
2023-03-24
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-23
C · Minimal harm
2023-03-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-05-23
E · Potential for more than minimal harm
2021-07-23
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 2021-09-21
E · Potential for more than minimal harm
2021-07-23
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 2021-09-21
E · Potential for more than minimal harm
2021-07-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-21
E · Potential for more than minimal harm
2021-07-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-21
E · Potential for more than minimal harm
2021-07-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-09-21
C · Minimal harm
2021-07-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-09-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-21
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 2025-05-20
B · Minimal harm
2025-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-20
B · Minimal harm
2025-03-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-20
E · Potential for more than minimal harm
2023-03-24
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-03-24
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 2023-05-23
D · Potential for more than minimal harm
2023-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
E · Potential for more than minimal harm
2021-07-23
F585 · Resident Rights Deficiencies
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 2021-09-21
Penalties and ownership
What sits behind the stars
Ownership
Balok-Middaugh, Kimberlee
Corporate Director · Individual
Benjamin, John
Corporate Director · Individual
Burlew, Dawn
Corporate Director · Individual
Carr, Richard
Corporate Director · Individual
Helsing, David
Corporate Director · Individual
Herbst, Walter
Corporate Director · Individual
Hewit, Randi
Corporate Director · Individual
Hunt, Alison
Corporate Director · Individual
Kiser, Michael
Corporate Officer · Individual
Kiser, Michael
W-2 Managing Employee · Individual
Lincoln, Carol
Corporate Director · Individual
Mark, James
W-2 Managing Employee · Individual
Owen, Mary Therese
Corporate Director · Individual
Parmenter, Jason
Corporate Director · Individual
Santobianco, Thomas
Corporate Officer · Individual
Santobianco, Thomas
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Elcor Nursing and Rehabilitation Center
Horseheads, NY
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
St. Joseph's Hospital - Skilled Nursing Facility
Elmira, NY
3-star overall rating with 4-star inspections with $4,194 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Chemung County Health Center - Nursing Facility
Elmira, NY
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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