Jamesville, NY

Iroquois Nursing Home Inc

5-star overall rating with 4-star inspections with $3,174 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

4600 Southwood Heights Drive, Jamesville, NY

(315) 469-1300

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

160

Certified beds

Average residents

150

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1992-11-04

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.40

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.94

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.42

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

2.96

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.24

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.15

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.44

CMS adjusted RN staffing hours

Adjusted total hours

3.73

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

27%

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

516

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

68.41

Composite VBP score used to determine payment impact.

Payment multiplier

1.0215

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

8.59

Baseline 19.03% · Performance 17.45% · Measure score 8.59 · Achievement 8.59 · Improvement 7.39

Healthcare-associated infections

10

Baseline 4.70% · Performance 4.67% · Measure score 10 · Achievement 10 · Improvement 9

Total nurse turnover

6.05

Performance 38.97% · Measure score 6.05 · Achievement 6.05 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

2.73

Baseline 3.46 hours · Performance 3.85 hours · Measure score 2.73 · Achievement 2.73 · Improvement 1.19

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.51%	10.72% 2.8 pts worse	Worse than the National Rate · Eligible stays 430 · Observed rate 13.72% · Lower 95% interval 11.12%
Discharge to community	58.46%	50.57% 7.9 pts better	Better than the National Rate · Eligible stays 504 · Observed rate 49.01% · Lower 95% interval 53.59%
Medicare spending per beneficiary	0.87	1.02 0.2 pts better
Drug regimen review with follow-up	99.67%	95.27% 4.4 pts better	Numerator 305 · Denominator 306
Falls with major injury	1.31%	0.77% 0.5 pts worse	Numerator 4 · Denominator 306
Discharge self-care score	64.44%	53.69% 10.8 pts better	Numerator 174 · Denominator 270
Discharge mobility score	71.11%	50.94% 20.2 pts better	Numerator 192 · Denominator 270
Pressure ulcers or injuries, new or worsened	1.31%	2.29% 1 pts better	Numerator 4 · Denominator 306 · Adjusted rate 1.34%
Healthcare-associated infections requiring hospitalization	4.67%	7.12% 2.5 pts better	Better than the National Rate · Eligible stays 287 · Observed rate 3.14% · Lower 95% interval 3.2%
Staff COVID-19 vaccination coverage	12.15%	8.2% 4 pts better	Numerator 22 · Denominator 181
Staff flu vaccination coverage	65.17%	42% 23.2 pts better	Numerator 131 · Denominator 201
Discharge function score	70.37%	56.45% 13.9 pts better	Numerator 190 · Denominator 270
Transfer of health information to provider	92.11%	95.95% 3.8 pts worse	Numerator 35 · Denominator 38
Transfer of health information to patient	99.53%	96.28% 3.2 pts better	Numerator 212 · Denominator 213
Resident COVID-19 vaccinations up to date	38.89%	25.2% 13.7 pts better	Numerator 56 · Denominator 144

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.3	1.7 1.4 pts better	1.9 1.6 pts better	Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.3	1.3 1 pts better	1.8 1.5 pts better	Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.5%	91.2% 4.3 pts better	93.4% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.1% · Q3 96.8% · Q4 88.3% · 4Q avg 95.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.1%	95.3% 3.8 pts better	95.5% 3.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1%
Percentage of long-stay residents experiencing one or more falls with major injury	2.5%	3.0% 0.5 pts better	3.3% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.9% · Q3 1.1% · Q4 1.0% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.8%	18.5% 16.7 pts better	11.4% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8%
Percentage of long-stay residents who lose too much weight	13.6%	6.1% 7.5 pts worse	5.4% 8.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 16.2% · Q3 15.7% · Q4 6.2% · 4Q avg 13.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.1%	13.5% 2.4 pts better	19.6% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 10.5% · Q3 10.9% · Q4 13.6% · 4Q avg 11.1%
Percentage of long-stay residents who received an antipsychotic medication	13.7%	14.8% 1.1 pts better	16.7% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.2% · Q3 14.7% · Q4 10.3% · 4Q avg 13.7% · 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	22.3%	15.1% 7.2 pts worse	16.3% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 27.1% · Q3 11.7% · Q4 15.4% · 4Q avg 22.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.1%	15.5% 3.6 pts worse	14.9% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 21.8% · Q3 12.4% · Q4 18.8% · 4Q avg 19.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.0%	0.6% 1.4 pts worse	1.0% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.5% · Q3 1.6% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	1.4% 0.9 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.8%	20.8% 7 pts worse	19.8% 8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 26.3% · Q3 28.9% · Q4 25.8% · 4Q avg 27.8%
Percentage of long-stay residents with pressure ulcers	7.4%	6.9% 0.5 pts worse	5.1% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.4% · Q3 8.3% · Q4 4.7% · 4Q avg 7.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.9%	76.7% 1.2 pts better	81.7% 3.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 83.9% · Q3 64.7% · Q4 69.2% · 4Q avg 77.9%
Percentage of short-stay residents who had an outpatient emergency department visit	5.9%	9.7% 3.8 pts better	12.0% 6.1 pts better	Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 5.5% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.2% 0.9 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.4% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	87.6%	78.8% 8.8 pts better	79.7% 7.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 87.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	17.3%	20.6% 3.3 pts better	23.9% 6.6 pts better	Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 15.9% · Expected 21.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-20 · Fire 2024-08-20

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2022-07-15 · Fire 2022-07-15

3 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2020-02-06 · Fire 2020-02-06

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-08-20

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-20

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-06

D · Potential for more than minimal harm 2022-07-15

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2022-09-07

D · Potential for more than minimal harm 2022-07-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-09-07

D · Potential for more than minimal harm 2022-07-15

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2022-09-07

D · Potential for more than minimal harm 2022-07-15

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2022-09-07

E · Potential for more than minimal harm 2020-02-06

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2020-03-23

D · Potential for more than minimal harm 2020-02-06

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2020-02-19

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-30

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2026-03-13

E · Potential for more than minimal harm 2024-08-20

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 2024-10-02

D · Potential for more than minimal harm 2024-08-20

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-20

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 2024-10-02

D · Potential for more than minimal harm 2024-08-20

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 2024-10-02

D · Potential for more than minimal harm 2024-08-20

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-10-02

B · Minimal harm 2024-08-20

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-10-02

D · Potential for more than minimal harm 2023-12-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-01-24

D · Potential for more than minimal harm 2022-07-15

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 2022-09-07

D · Potential for more than minimal harm 2022-07-15

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-09-07

D · Potential for more than minimal harm 2022-07-15

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 2022-09-07

D · Potential for more than minimal harm 2020-02-06

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2020-03-23

D · Potential for more than minimal harm 2020-02-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-03-23

Penalties and ownership

What sits behind the stars

$3,174 2023-05-02

Fine

Fine · fine $3,174

Fine