Rome, NY

Betsy Ross Rehabilitation Center, Inc

1-star overall rating with 3-star inspections with $32,254 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

1 Elsie Street, Rome, NY

(315) 339-2220

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

106

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1992-01-10

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

0.36

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.85

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.20

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.41

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.21

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.11

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.34

CMS adjusted RN staffing hours

Adjusted total hours

3.22

CMS adjusted total nurse staffing hours

Case-mix index

1.45

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,175

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

13.57

Composite VBP score used to determine payment impact.

Payment multiplier

0.9812

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 19.23% · Performance 25.25% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 7.74% · Performance 7.87% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

5.43

Baseline 58.24% · Performance 41.49% · Measure score 5.43 · Achievement 5.43 · Improvement 4.52

Adjusted total nurse staffing

0

Baseline 3.37 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 12.56%
10.72%
1.8 pts worse
No Different than the National Rate · Eligible stays 95 · Observed rate 17.89% · Lower 95% interval 8.97%
Discharge to community 42.24%
50.57%
8.3 pts worse
No Different than the National Rate · Eligible stays 95 · Observed rate 32.63% · Lower 95% interval 32.79%
Medicare spending per beneficiary 1.21
1.02
0.2 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 144 · Denominator 144
Falls with major injury 1.39%
0.77%
0.6 pts worse
Numerator 2 · Denominator 144
Discharge self-care score 27.78%
53.69%
25.9 pts worse
Numerator 15 · Denominator 54
Discharge mobility score 42.59%
50.94%
8.3 pts worse
Numerator 23 · Denominator 54
Pressure ulcers or injuries, new or worsened 3.47%
2.29%
1.2 pts worse
Numerator 5 · Denominator 144 · Adjusted rate 2.69%
Healthcare-associated infections requiring hospitalization 7.87%
7.12%
0.8 pts worse
No Different than the National Rate · Eligible stays 73 · Observed rate 9.59% · Lower 95% interval 4.69%
Staff COVID-19 vaccination coverage 60.94%
8.2%
52.7 pts better
Numerator 117 · Denominator 192
Staff flu vaccination coverage 87.03%
42%
45 pts better
Numerator 255 · Denominator 293
Discharge function score 40.74%
56.45%
15.7 pts worse
Numerator 22 · Denominator 54
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 70 · Denominator 70
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 40 · Denominator 40
Resident COVID-19 vaccinations up to date 10.39%
25.2%
14.8 pts worse
Numerator 8 · Denominator 77

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.0
1.7
0.3 pts worse
1.9
0.1 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.9
1.3
1.6 pts worse
1.8
1.1 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.1 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 81.6%
91.2%
9.6 pts worse
93.4%
11.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 81.4% · Q3 78.9% · Q4 81.2% · 4Q avg 81.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98.0%
95.3%
2.7 pts better
95.5%
2.5 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0%
Percentage of long-stay residents experiencing one or more falls with major injury 3.5%
3.0%
0.5 pts worse
3.3%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.3% · Q3 4.2% · Q4 3.1% · 4Q avg 3.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 9.9%
18.5%
8.6 pts better
11.4%
1.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 15.9% · Q3 4.5% · Q4 1.1% · 4Q avg 9.9%
Percentage of long-stay residents who lose too much weight 6.9%
6.1%
0.8 pts worse
5.4%
1.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 6.0% · Q3 3.4% · Q4 6.7% · 4Q avg 6.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 13.5%
13.5%
About the same
19.6%
6.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.1% · Q3 12.6% · Q4 16.1% · 4Q avg 13.5%
Percentage of long-stay residents who received an antipsychotic medication 17.0%
14.8%
2.2 pts worse
16.7%
0.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 13.9% · Q3 21.2% · Q4 22.1% · 4Q avg 17.0% · 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 33.1%
15.1%
18 pts worse
16.3%
16.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 43.6% · Q3 21.1% · Q4 33.7% · 4Q avg 33.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 20.1%
15.5%
4.6 pts worse
14.9%
5.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 11.5% · Q3 20.5% · Q4 24.1% · 4Q avg 20.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.9%
0.6%
0.3 pts worse
1.0%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 2.3%
1.4%
0.9 pts worse
1.7%
0.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.6% · Q3 2.2% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 24.9%
20.8%
4.1 pts worse
19.8%
5.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 27.4% · Q3 23.8% · Q4 22.1% · 4Q avg 24.9%
Percentage of long-stay residents with pressure ulcers 3.7%
6.9%
3.2 pts better
5.1%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.1% · Q3 3.2% · Q4 4.3% · 4Q avg 3.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 59.1%
76.7%
17.6 pts worse
81.7%
22.6 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 50.8% · Q2 58.5% · Q3 62.4% · Q4 68.4% · 4Q avg 59.1%
Percentage of short-stay residents who had an outpatient emergency department visit 22.0%
9.7%
12.3 pts worse
12.0%
10 pts worse
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 22.8% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 4.0%
1.2%
2.8 pts worse
1.6%
2.4 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.7% · Q3 4.1% · Q4 0.0% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 62.1%
78.8%
16.7 pts worse
79.7%
17.6 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 27.8%
20.6%
7.2 pts worse
23.9%
3.9 pts worse
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 35.0% · Expected 30.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-30 · Fire 2025-06-30

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-12-01 · Fire 2023-12-01

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 3 Health 2021-10-08 · Fire 2021-10-08

10 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-08-29

F · Potential for more than minimal harm 2025-06-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-29

F · Potential for more than minimal harm 2025-06-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-08-29

E · Potential for more than minimal harm 2025-06-30

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 2025-08-29

E · Potential for more than minimal harm 2025-06-30

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-06-30

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-06-30

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-06-30

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-08-29

E · Potential for more than minimal harm 2023-12-01

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-02-06

E · Potential for more than minimal harm 2023-12-01

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-01-29

E · Potential for more than minimal harm 2023-12-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-02-06

E · Potential for more than minimal harm 2023-12-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-02-20

D · Potential for more than minimal harm 2023-12-01

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-01-29

D · Potential for more than minimal harm 2023-12-01

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-01-29

D · Potential for more than minimal harm 2023-12-01

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2024-01-29

D · Potential for more than minimal harm 2023-12-01

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-01-29

D · Potential for more than minimal harm 2023-12-01

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-01-29

D · Potential for more than minimal harm 2023-12-01

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-02-09

D · Potential for more than minimal harm 2023-12-01

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-02-09

E · Potential for more than minimal harm 2021-10-08

K901 · Electrical Deficiencies

Fire Safety

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

Corrected 2021-12-02

E · Potential for more than minimal harm 2021-10-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-12-02

E · Potential for more than minimal harm 2021-10-08

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

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 2021-12-02

D · Potential for more than minimal harm 2021-10-08

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2021-11-06

D · Potential for more than minimal harm 2021-10-08

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 2021-12-02

D · Potential for more than minimal harm 2021-10-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-12-02

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-30

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-06-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-06-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-06-30

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-06-30

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-06-30

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-08-26

G · Actual harm 2024-02-29

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-04-19

E · Potential for more than minimal harm 2023-12-01

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-01-25

E · Potential for more than minimal harm 2023-12-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-01-25

D · Potential for more than minimal harm 2023-12-01

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 2024-01-25

D · Potential for more than minimal harm 2023-12-01

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-01-25

D · Potential for more than minimal harm 2023-12-01

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2024-01-25

D · Potential for more than minimal harm 2023-12-01

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-01-25

D · Potential for more than minimal harm 2023-12-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-25

D · Potential for more than minimal harm 2023-05-03

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-06-29

D · Potential for more than minimal harm 2023-03-02

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-05-01

E · Potential for more than minimal harm 2021-10-08

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2021-12-02

E · Potential for more than minimal harm 2021-10-08

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-12-02

D · Potential for more than minimal harm 2021-10-08

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2021-12-02

Penalties and ownership

What sits behind the stars

$9,318 2024-02-29

Fine

Fine · fine $9,318

Fine

$4,587 2023-09-18

Fine

Fine · fine $4,587

Fine

$4,587 2023-09-11

Fine

Fine · fine $4,587

Fine

$13,762 2023-08-21

Fine

Fine · fine $13,762

Fine

Ownership

Altman, Donald

5% Or Greater Direct Ownership Interest · Individual

45% 1 facilities 1998-05-21
Chiaraluce, Joanne

5% Or Greater Direct Ownership Interest · Individual

10% 1 facilities 2011-01-01
Altman, Donald

Corporate Director · Individual

0% 1 facilities 1998-05-21
Brodock, Christine

W-2 Managing Employee · Individual

0% 1 facilities 2017-04-20
Chamberlin, Brian

W-2 Managing Employee · Individual

0% 1 facilities 2016-06-17
Chiaraluce, Joanne

Corporate Director · Individual

0% 1 facilities 2011-01-01

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