Cycle 1
Health 2025-03-28 · Fire 2025-03-28
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Waverly, NY
Elderwood At Waverly
1-star overall rating with 2-star inspections with $10,364 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
37 North Chemung Street, Waverly, NY
(607) 565-2861
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
180
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elderwood
Operator or chain grouping
Approved since
1971-12-10
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
0.43
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.43
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.41
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
0.98
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.03
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.26
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
2.64
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,215
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.93% · Performance 21.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.32
Baseline 6.19% · Performance 5.95% · Measure score 6.32 · Achievement 6.32 · Improvement 1.57
Total nurse turnover
5.22
Baseline 50.00% · Performance 42.36% · Measure score 5.22 · Achievement 5.22 · Improvement 2.54
Adjusted total nurse staffing
0.62
Baseline 3.29 hours · Performance 3.25 hours · Measure score 0.62 · Achievement 0.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.42% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 319 · Observed rate 8.46% · Lower 95% interval 6.89% |
| Discharge to community | 61.76% |
50.57%
11.2 pts better
|
Better than the National Rate · Eligible stays 304 · Observed rate 54.93% · Lower 95% interval 57.02% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 227 · Denominator 227 |
| Falls with major injury | 0.44% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 227 |
| Discharge self-care score | 58.9% |
53.69%
5.2 pts better
|
Numerator 96 · Denominator 163 |
| Discharge mobility score | 61.35% |
50.94%
10.4 pts better
|
Numerator 100 · Denominator 163 |
| Pressure ulcers or injuries, new or worsened | 3.52% |
2.29%
1.2 pts worse
|
Numerator 8 · Denominator 227 · Adjusted rate 3.61% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 4.92% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 8.4% |
8.2%
0.2 pts better
|
Numerator 21 · Denominator 250 |
| Staff flu vaccination coverage | 66.24% |
42%
24.2 pts better
|
Numerator 157 · Denominator 237 |
| Discharge function score | 64.42% |
56.45%
8 pts better
|
Numerator 105 · Denominator 163 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 110 · Denominator 110 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 34.13% |
25.2%
8.9 pts better
|
Numerator 43 · Denominator 126 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
91.2%
5.4 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 98.7% · Q3 97.5% · Q4 96.2% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
95.3%
0.7 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| 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 3.9% · Q2 8.3% · Q3 10.7% · Q4 7.6% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
18.5%
9.7 pts better
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 10.1% · Q3 10.7% · Q4 10.9% · 4Q avg 8.8% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
6.1%
3.1 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.3% · Q3 10.3% · Q4 13.6% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
13.5%
0.7 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 14.2% · Q3 12.8% · Q4 12.2% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
14.8%
9.8 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 27.1% · Q3 21.8% · Q4 24.8% · 4Q avg 24.6% · 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 | 22.7% |
15.1%
7.6 pts worse
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 28.2% · Q3 24.3% · Q4 17.0% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
15.5%
9.6 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 27.7% · Q3 23.5% · Q4 23.8% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.6%
0.7 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 3.6% · Q3 0.6% · Q4 0.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.4%
1.6 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.1% · Q3 3.3% · Q4 3.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.3% |
20.8%
9.5 pts worse
|
19.8%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 30.9% · Q3 26.8% · Q4 35.7% · 4Q avg 30.3% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
6.9%
0.4 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 7.4% · Q3 9.2% · Q4 4.2% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
76.7%
8.7 pts better
|
81.7%
3.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 91.3% · Q3 81.9% · Q4 73.2% · 4Q avg 85.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
9.7%
1.7 pts worse
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.4% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.5% |
78.8%
4.3 pts worse
|
79.7%
5.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
20.6%
4.9 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 24.3% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-27 · Fire 2023-04-27
15 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2020-10-16 · Fire 2020-10-16
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-28
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-03-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-03-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-28
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 2025-05-16
D · Potential for more than minimal harm
2025-03-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-16
F · Potential for more than minimal harm
2023-04-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-02
F · Potential for more than minimal harm
2023-04-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-04-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-04-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-04-27
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 2023-05-03
D · Potential for more than minimal harm
2023-04-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-27
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 2023-05-18
D · Potential for more than minimal harm
2023-04-27
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-04-27
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-05-01
F · Potential for more than minimal harm
2020-10-16
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2020-11-11
F · Potential for more than minimal harm
2020-10-16
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2020-10-21
F · Potential for more than minimal harm
2020-10-16
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2020-10-21
E · Potential for more than minimal harm
2020-10-16
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 2020-10-28
D · Potential for more than minimal harm
2020-10-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-10-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-28
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-28
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 2025-05-09
D · Potential for more than minimal harm
2025-03-28
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 2025-05-09
D · Potential for more than minimal harm
2025-03-28
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-28
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 2025-05-09
D · Potential for more than minimal harm
2025-03-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-28
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 2025-05-09
D · Potential for more than minimal harm
2025-03-28
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 2025-05-09
J · Immediate jeopardy
2025-01-30
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 2025-01-30
D · Potential for more than minimal harm
2025-01-30
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 2025-03-25
E · Potential for more than minimal harm
2023-12-29
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 2024-02-28
E · Potential for more than minimal harm
2023-04-27
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 2023-06-15
E · Potential for more than minimal harm
2023-04-27
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 2023-06-26
D · Potential for more than minimal harm
2023-04-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-27
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 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
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 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-27
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-27
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-23
C · Minimal harm
2023-04-27
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-04-27
Penalties and ownership
What sits behind the stars
$10,364
2025-01-30
Fine
Fine · fine $10,364
Fine
Ownership
Cole, Warren
5% Or Greater Direct Ownership Interest · Individual
Rubin, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Cole, Warren
Operational/Managerial Control · Individual
Landy, Maria
W-2 Managing Employee · Individual
Rubin, Jeffrey
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sayre Health Care Center
Sayre, PA
1-star overall rating with 2-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Athens Nursing And Rehabilitation Center
Athens, PA
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 6 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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