9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Herkimer, NY
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
104 North Washington Street, Herkimer, NY
(315) 866-6964
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
Beds
163
Certified beds
Average residents
137
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wecare Centers
Operator or chain grouping
Approved since
1976-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 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
0.44
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.50
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.76
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.28
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
0.22
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
2.72
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
11,813
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.64% · Performance 24.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.13% · Performance 8.17% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.71
Baseline 100.00% · Performance 53.33% · Measure score 5.71 · Achievement 2.53 · Improvement 5.71
Adjusted total nurse staffing
0.35
Baseline 2.89 hours · Performance 3.14 hours · Measure score 0.35 · Achievement 0 · Improvement 0.35
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.31% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 214 · Observed rate 13.55% · Lower 95% interval 9.67% |
| Discharge to community | 38.35% |
50.57%
12.2 pts worse
|
Worse than the National Rate · Eligible stays 171 · Observed rate 32.75% · Lower 95% interval 31.69% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 85.56% |
95.27%
9.7 pts worse
|
Numerator 154 · Denominator 180 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 180 |
| Discharge self-care score | 45.69% |
53.69%
8 pts worse
|
Numerator 53 · Denominator 116 |
| Discharge mobility score | 41.38% |
50.94%
9.6 pts worse
|
Numerator 48 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 6 · Denominator 180 · Adjusted rate 3% |
| Healthcare-associated infections requiring hospitalization | 8.17% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 9.02% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 4.31% |
8.2%
3.9 pts worse
|
Numerator 9 · Denominator 209 |
| Staff flu vaccination coverage | 64.88% |
42%
22.9 pts better
|
Numerator 133 · Denominator 205 |
| Discharge function score | 47.41% |
56.45%
9 pts worse
|
Numerator 55 · Denominator 116 |
| Transfer of health information to provider | 92.45% |
95.95%
3.5 pts worse
|
Numerator 49 · Denominator 53 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 57 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 18.39% |
25.2%
6.8 pts worse
|
Numerator 16 · Denominator 87 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
91.2%
4.4 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 93.5% · Q3 93.9% · Q4 95.9% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.6% |
95.3%
3.7 pts worse
|
95.5%
3.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.0%
2.1 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.5% · Q3 3.5% · Q4 5.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 47.7% |
18.5%
29.2 pts worse
|
11.4%
36.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 19.0% · Q3 37.1% · Q4 59.8% · 4Q avg 47.7% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
6.1%
1.9 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 14.7% · Q3 6.3% · Q4 4.4% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
13.5%
9 pts worse
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 22.8% · Q3 24.3% · Q4 20.5% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
14.8%
1.7 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 14.3% · Q3 15.9% · Q4 21.2% · 4Q avg 16.5% · 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 | 22.8% |
15.1%
7.7 pts worse
|
16.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 24.1% · Q3 17.4% · Q4 20.3% · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
15.5%
8.7 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 23.2% · Q3 21.1% · Q4 23.5% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.6%
1.3 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 1.3% · Q3 0.6% · Q4 0.8% · 4Q avg 1.9% · 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 1.0% · Q2 1.0% · Q3 1.8% · Q4 0.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.2% |
20.8%
11.4 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 35.3% · Q3 27.4% · Q4 30.6% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.9%
0.9 pts better
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.6% · Q3 4.8% · Q4 7.6% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.4% |
76.7%
6.7 pts better
|
81.7%
1.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.5% · Q2 80.8% · Q3 87.0% · Q4 84.0% · 4Q avg 83.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
9.7%
5.9 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 17.8% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.6% |
78.8%
1.8 pts better
|
79.7%
0.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
20.6%
About the same
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 25.6% · Expected 29.6% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-30
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-30
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-03-30
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-30
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-30
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-30
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-30
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-30
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-30
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-03-30
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 2025-03-30
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 2025-03-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-30
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-20
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-08-20
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-08-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-20
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-20
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-08-20
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-21
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-20
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-06-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-28
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2021-06-28
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2021-06-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-06-28
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-06-28
Inspection history
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 2025-03-19
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-19
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-19
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 2025-03-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-19
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 2025-01-24
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 2023-08-09
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-08-09
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-09
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 2023-08-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-07-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-07-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-07-11
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 2021-07-11
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2021-07-11
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-07-11
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 2021-06-29
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-11
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-07-05
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
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Little Falls, NY
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