Cycle 1
Health 2025-05-30 · Fire 2025-05-30
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cortland, NY
Cortland Park Rehabilitation And Nursing Center
3-star overall rating with 3-star inspections with $76,339 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
193 Clinton Avenue, Cortland, NY
(607) 756-9921
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1967-01-01
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
Hours and turnover
RN hours / resident day
0.29
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
1.99
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,544
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.68% · Performance 21.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.88% · Performance 10.91% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.24
Baseline 65.66% · Performance 62.62% · Measure score 0.24 · Achievement 0 · Improvement 0.24
Adjusted total nurse staffing
1.30
Baseline 3.56 hours · Performance 3.45 hours · Measure score 1.30 · Achievement 1.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 10.31% · Lower 95% interval 7.68% |
| Discharge to community | 38.82% |
50.57%
11.8 pts worse
|
Worse than the National Rate · Eligible stays 111 · Observed rate 31.53% · Lower 95% interval 29.31% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 90.74% |
95.27%
4.5 pts worse
|
Numerator 49 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 67.65% |
53.69%
14 pts better
|
Numerator 23 · Denominator 34 |
| Discharge mobility score | 55.88% |
50.94%
4.9 pts better
|
Numerator 19 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 3 · Denominator 54 · Adjusted rate 7.3% |
| Healthcare-associated infections requiring hospitalization | 10.91% |
7.12%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 16.9% · Lower 95% interval 6.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 106 |
| Staff flu vaccination coverage | 70.75% |
42%
28.8 pts better
|
Numerator 75 · Denominator 106 |
| Discharge function score | 76.47% |
56.45%
20 pts better
|
Numerator 26 · Denominator 34 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 7 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 60.0% |
91.2%
31.2 pts worse
|
93.4%
33.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.6% · Q2 62.9% · Q3 64.4% · Q4 60.7% · 4Q avg 60.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.1% |
95.3%
7.2 pts worse
|
95.5%
7.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.0%
0.1 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.4% · Q3 3.4% · Q4 1.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
18.5%
17 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
6.1%
1.7 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 9.1% · Q3 9.6% · Q4 7.2% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
13.5%
9.7 pts worse
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 22.7% · Q3 23.3% · Q4 21.3% · 4Q avg 23.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.3% |
14.8%
8.5 pts worse
|
16.7%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 26.9% · Q3 20.0% · Q4 19.4% · 4Q avg 23.3% · 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 | 14.0% |
15.1%
1.1 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 13.6% · Q3 15.2% · Q4 8.4% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
15.5%
2.6 pts worse
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 12.9% · Q3 21.4% · Q4 13.4% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.6%
0.2 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.4%
0.3 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
20.8%
2.1 pts worse
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 13.2% · Q3 29.3% · Q4 17.2% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.9%
2.8 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.0% · Q3 3.2% · Q4 2.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.9% |
76.7%
40.8 pts worse
|
81.7%
45.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 35.9% · Q3 43.8% · Q4 35.7% · 4Q avg 35.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
9.7%
10.1 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 19.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.7% · Q3 1.4% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.7% |
78.8%
31.1 pts worse
|
79.7%
32 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.4% |
20.6%
9.8 pts worse
|
23.9%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 33.3% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-20 · Fire 2023-10-20
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-05-06 · Fire 2021-05-06
10 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-30
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 2025-08-06
E · Potential for more than minimal harm
2025-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-06
E · Potential for more than minimal harm
2025-05-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-06
E · Potential for more than minimal harm
2025-05-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-05-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-05-30
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 2025-08-06
D · Potential for more than minimal harm
2025-05-30
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-05-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-06
D · Potential for more than minimal harm
2023-10-20
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 2023-12-06
D · Potential for more than minimal harm
2023-10-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-06
C · Minimal harm
2023-10-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-12-06
F · Potential for more than minimal harm
2021-05-06
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-07-09
E · Potential for more than minimal harm
2021-05-06
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 2021-06-08
D · Potential for more than minimal harm
2021-05-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-06
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-06-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-30
F761 · Pharmacy Service Deficiencies
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 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-30
D · Potential for more than minimal harm
2023-12-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-10-20
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 2023-11-30
D · Potential for more than minimal harm
2023-10-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-20
F761 · Pharmacy Service Deficiencies
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 2023-11-30
D · Potential for more than minimal harm
2023-10-20
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 2023-11-30
D · Potential for more than minimal harm
2023-10-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-11-30
G · Actual harm
2023-05-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-28
E · Potential for more than minimal harm
2023-05-11
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 2023-06-28
D · Potential for more than minimal harm
2023-05-11
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 2023-06-28
D · Potential for more than minimal harm
2023-05-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-28
E · Potential for more than minimal harm
2021-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-23
D · Potential for more than minimal harm
2021-05-06
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 2021-06-23
Penalties and ownership
What sits behind the stars
$76,339
2023-05-11
Fine
Fine · fine $76,339
Fine
Ownership
Koenig, Uri
5% Or Greater Direct Ownership Interest · Individual
Steif, Efraim
5% Or Greater Direct Ownership Interest · Individual
Gaska, Christina
W-2 Managing Employee · Individual
Richardson, William
Contracted Managing Employee · Individual
Steif, Efraim
Operational/Managerial Control · Individual
Wuertzer, Amy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Crown Park Rehabilitation And Nursing Center
Cortland, NY
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Guthrie Cortland Medical Center
Cortland, NY
4-star overall rating with 3-star inspections with $70,434 in total fines with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Groton Community Health Care Ctr Res Care Fac
Groton, NY
1-star overall rating with 1-star inspections with Special Focus status with $132,948 in total fines with 16 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
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