13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Rome, NY
1-star overall rating with 1-star inspections with $58,988 in total fines with 13 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
950 Floyd Avenue, Rome, NY
(315) 336-5400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1967-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
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
0.46
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.65
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
13,300
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.65% · Performance 22.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.58% · Performance 8.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.72
Baseline 54.80% · Performance 52.56% · Measure score 2.72 · Achievement 2.72 · Improvement 0.25
Adjusted total nurse staffing
0
Baseline 3 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.12% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 21.43% · Lower 95% interval 8.72% |
| Discharge to community | 37.77% |
50.57%
12.8 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 24.24% · Lower 95% interval 27.82% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.08% |
95.27%
3.8 pts better
|
Numerator 108 · Denominator 109 |
| Falls with major injury | 0.92% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 109 |
| Discharge self-care score | 50.85% |
53.69%
2.8 pts worse
|
Numerator 30 · Denominator 59 |
| Discharge mobility score | 47.46% |
50.94%
3.5 pts worse
|
Numerator 28 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 5.5% |
2.29%
3.2 pts worse
|
Numerator 6 · Denominator 109 · Adjusted rate 5.1% |
| Healthcare-associated infections requiring hospitalization | 8.12% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 12.28% · Lower 95% interval 4.76% |
| Staff COVID-19 vaccination coverage | 1.74% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 115 |
| Staff flu vaccination coverage | 69.28% |
42%
27.3 pts better
|
Numerator 106 · Denominator 153 |
| Discharge function score | 50.85% |
56.45%
5.6 pts worse
|
Numerator 30 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | 81.25% |
96.28%
15 pts worse
|
Numerator 26 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 9 · Denominator 63 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.8 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.3
1.2 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.4% |
91.2%
16.8 pts worse
|
93.4%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 76.1% · Q3 76.5% · Q4 71.4% · 4Q avg 74.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
95.3%
3.3 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.0%
3.6 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.5% · Q3 5.9% · Q4 7.1% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
18.5%
10.7 pts better
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 10.8% · Q3 3.2% · Q4 0.0% · 4Q avg 7.8% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
6.1%
4.5 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 9.7% · Q3 9.8% · Q4 7.5% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
13.5%
3.4 pts worse
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 13.4% · Q3 19.4% · Q4 17.1% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.1% |
14.8%
10.3 pts worse
|
16.7%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 25.5% · Q3 25.0% · Q4 19.6% · 4Q avg 25.1% · 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 | 17.1% |
15.1%
2 pts worse
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 9.9% · Q3 23.4% · Q4 16.5% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
15.5%
0.3 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 12.7% · Q3 17.5% · Q4 15.2% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.6%
1.8 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.8% · Q3 3.1% · Q4 1.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.4%
0.6 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
20.8%
5.5 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 12.1% · Q3 30.1% · Q4 31.7% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 12.6% |
6.9%
5.7 pts worse
|
5.1%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 13.6% · Q3 16.4% · Q4 10.2% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.2% |
76.7%
35.5 pts worse
|
81.7%
40.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.6% · Q2 42.6% · Q3 36.9% · Q4 40.7% · 4Q avg 41.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
9.7%
6.1 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 17.6% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.8% |
78.8%
31 pts worse
|
79.7%
31.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
20.6%
4 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 30.6% · Expected 29.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-11-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-04
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-17
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-29
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-29
Fire Safety
Install proper backup exit lighting.
Corrected 2024-11-29
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-29
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 2024-12-04
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-29
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-29
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-10-05
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2024-11-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-05
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-29
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-05
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 2024-10-05
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-05
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-11-29
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-25
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-07-25
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 2022-07-25
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 2022-07-25
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-07-25
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-29
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-07-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-07-25
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 2019-08-30
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-08-30
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-26
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2026-01-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
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 2024-09-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-16
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 2024-09-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-16
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-16
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-16
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-16
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-16
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-30
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-30
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 2022-07-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-07-25
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-25
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-07-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-25
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 2022-07-25
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-07-25
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-07-25
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-10-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-10-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-10-21
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2019-10-21
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 2019-10-21
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 2019-10-21
Penalties and ownership
Payment Denial · denial start 2024-11-06 · 41 days
41 day denial
Fine · fine $58,988
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
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4-star overall rating with 4-star inspections with 4 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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