Cycle 1
Health 2024-02-02 · Fire 2024-02-02
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Hornell, NY
Elderwood at Hornell
5-star overall rating with 5-star inspections with $4,194 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1 Bethesda Drive, Hornell, NY
(607) 324-6916
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elderwood
Operator or chain grouping
Approved since
1988-01-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.53
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.62
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.77
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.38
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,682
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.38% · Performance 21.94% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.28
Baseline 6.55% · Performance 6.85% · Measure score 3.28 · Achievement 3.28 · Improvement 0
Total nurse turnover
3.86
Baseline 51.55% · Performance 47.92% · Measure score 3.86 · Achievement 3.86 · Improvement 0.86
Adjusted total nurse staffing
2.02
Baseline 3.12 hours · Performance 3.65 hours · Measure score 2.02 · Achievement 2.02 · Improvement 1.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.28% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 191 · Observed rate 13.61% · Lower 95% interval 8.69% |
| Discharge to community | 56.61% |
50.57%
6 pts better
|
No Different than the National Rate · Eligible stays 197 · Observed rate 50.76% · Lower 95% interval 49.04% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.99% |
95.27%
2.7 pts better
|
Numerator 146 · Denominator 149 |
| Falls with major injury | 2.68% |
0.77%
1.9 pts worse
|
Numerator 4 · Denominator 149 |
| Discharge self-care score | 65.57% |
53.69%
11.9 pts better
|
Numerator 80 · Denominator 122 |
| Discharge mobility score | 68.85% |
50.94%
17.9 pts better
|
Numerator 84 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 2.72% |
2.29%
0.4 pts worse
|
Numerator 4 · Denominator 147 · Adjusted rate 3.29% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 6.02% · Lower 95% interval 4.02% |
| Staff COVID-19 vaccination coverage | 3.47% |
8.2%
4.7 pts worse
|
Numerator 6 · Denominator 173 |
| Staff flu vaccination coverage | 59.35% |
42%
17.4 pts better
|
Numerator 92 · Denominator 155 |
| Discharge function score | 72.95% |
56.45%
16.5 pts better
|
Numerator 89 · Denominator 122 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 101 · Denominator 101 |
| Resident COVID-19 vaccinations up to date | 26.74% |
25.2%
1.5 pts better
|
Numerator 23 · Denominator 86 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
91.2%
7.6 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.8% · Q3 98.8% · Q4 98.9% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
95.3%
3.6 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.7% |
3.0%
4.7 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 5.9% · Q3 7.1% · Q4 9.2% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
18.5%
12.5 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.3% · Q3 5.1% · Q4 13.0% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 13.8% |
6.1%
7.7 pts worse
|
5.4%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 20.0% · Q3 16.0% · Q4 8.3% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.2% |
13.5%
7.3 pts better
|
19.6%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.7% · Q3 6.0% · Q4 9.2% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
14.8%
6.3 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 24.3% · Q3 21.1% · Q4 18.3% · 4Q avg 21.1% · 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 | 17.8% |
15.1%
2.7 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 14.2% · Q3 10.2% · Q4 23.7% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.6% |
15.5%
4.1 pts worse
|
14.9%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 17.1% · Q3 16.2% · Q4 30.0% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.6%
0.4 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.9% · Q3 0.0% · Q4 0.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.4%
0.2 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 2.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
20.8%
3.1 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 26.1% · Q3 23.0% · Q4 24.8% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.9%
4.4 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 17.2% · Q3 8.4% · Q4 10.9% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
76.7%
8.4 pts better
|
81.7%
3.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 85.4% · Q3 88.6% · Q4 82.5% · 4Q avg 85.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.2% |
9.7%
10.5 pts worse
|
12.0%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 19.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.9% · Q4 0.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.6% |
78.8%
4.2 pts worse
|
79.7%
5.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
20.6%
5.7 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 24.8% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-07 · Fire 2021-10-07
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2019-03-22 · Fire 2019-03-22
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-02-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-29
E · Potential for more than minimal harm
2021-10-07
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2021-11-19
E · Potential for more than minimal harm
2021-10-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-19
C · Minimal harm
2021-10-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-11-19
E · Potential for more than minimal harm
2019-03-22
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2019-05-31
C · Minimal harm
2019-03-22
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-02-02
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 2024-03-29
D · Potential for more than minimal harm
2021-10-07
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 2021-11-20
D · Potential for more than minimal harm
2021-10-07
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 2021-11-20
D · Potential for more than minimal harm
2021-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-20
B · Minimal harm
2021-10-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-11-20
D · Potential for more than minimal harm
2019-03-22
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-03-22
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 2019-05-22
D · Potential for more than minimal harm
2019-03-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-05-22
Penalties and ownership
What sits behind the stars
$4,194
2023-10-02
Fine
Fine · fine $4,194
Fine
Ownership
1 Bethesda Drive Operating Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Cole, Warren
5% Or Greater Indirect Ownership Interest · Individual
Rubin, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Cole, Warren
Operational/Managerial Control · Individual
Cole, Warren
Corporate Officer · Individual
Neal, Sabrina
W-2 Managing Employee · Individual
Quillard, Philip
Operational/Managerial Control · Individual
Rubin, Jeffrey
Operational/Managerial Control · Individual
Rubin, Jeffrey
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Maple City Rehabilitation and Nursing Center
Hornell, NY
1-star overall rating with 1-star inspections with $62,207 in total fines with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Steuben Center for Rehabilitation and Healthcare
Bath, NY
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Ira Davenport Memorial Hospital SNF/HRF
Bath, NY
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
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