18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Syracuse, NY
1-star overall rating with 1-star inspections with $121,573 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4101 E Genesee St, Syracuse, NY
(315) 446-9111
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
132
Certified beds
Average residents
113
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
RN hours / resident day
0.43
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.23
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
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
12,150
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.07% · Performance 22.22% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.54% · Performance 10.10% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.26
Performance 58.54% · Measure score 1.26 · Achievement 1.26 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.21
Baseline 2.12 hours · Performance 3.84 hours · Measure score 4.21 · Achievement 2.69 · Improvement 4.21
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.09% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 174 · Observed rate 12.07% · Lower 95% interval 8.4% |
| Discharge to community | 49.59% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 207 · Observed rate 43.48% · Lower 95% interval 41.7% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.17% |
95.27%
0.1 pts worse
|
Numerator 138 · Denominator 145 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 145 |
| Discharge self-care score | 39.6% |
53.69%
14.1 pts worse
|
Numerator 40 · Denominator 101 |
| Discharge mobility score | 48.51% |
50.94%
2.4 pts worse
|
Numerator 49 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 4.83% |
2.29%
2.5 pts worse
|
Numerator 7 · Denominator 145 · Adjusted rate 4.12% |
| Healthcare-associated infections requiring hospitalization | 10.1% |
7.12%
3 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 11.41% · Lower 95% interval 6.51% |
| Staff COVID-19 vaccination coverage | 10.19% |
8.2%
2 pts better
|
Numerator 22 · Denominator 216 |
| Staff flu vaccination coverage | 54.23% |
42%
12.2 pts better
|
Numerator 173 · Denominator 319 |
| Discharge function score | 56.44% |
56.45%
About the same
|
Numerator 57 · Denominator 101 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 81 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 20.73% |
25.2%
4.5 pts worse
|
Numerator 17 · Denominator 82 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.3
0.9 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
91.2%
14 pts worse
|
93.4%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.7% · Q2 81.9% · Q3 82.4% · Q4 82.4% · 4Q avg 77.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.3% |
95.3%
1 pts worse
|
95.5%
1.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.0%
1.5 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.1% · Q3 4.4% · Q4 7.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
18.5%
16 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.2% · Q3 2.2% · Q4 1.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
6.1%
2.1 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.7% · Q3 9.1% · Q4 9.3% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.7% |
13.5%
3.8 pts better
|
19.6%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 7.5% · Q3 9.0% · Q4 11.4% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
14.8%
0.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 13.8% · Q3 15.2% · Q4 13.5% · 4Q avg 15.0% · 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 | 14.6% |
15.1%
0.5 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 18.3% · Q3 13.6% · Q4 12.7% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
15.5%
5 pts worse
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 20.5% · Q3 20.5% · Q4 22.4% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.4%
1.5 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.2% · Q3 2.2% · Q4 1.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.9% |
20.8%
13.1 pts worse
|
19.8%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 46.8% · Q3 19.5% · Q4 40.8% · 4Q avg 33.9% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
6.9%
3.4 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.0% · Q3 2.9% · Q4 2.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.6% |
76.7%
22.1 pts worse
|
81.7%
27.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 41.5% · Q3 67.2% · Q4 71.0% · 4Q avg 54.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
9.7%
4.7 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 12.4% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.9% · Q3 0.8% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.7% |
78.8%
36.1 pts worse
|
79.7%
37 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
20.6%
0.8 pts worse
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 19.3% · Expected 21.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-10
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-07-10
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-07-10
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-17
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-10
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2022-04-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-22
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-04-22
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-04-22
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-22
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-11-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-14
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-11-06
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2019-11-06
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-06
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-10-16
Inspection history
Health
Provide appropriate foot care.
Corrected 2025-12-30
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 2024-07-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-19
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-19
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-07-19
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 2024-07-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-19
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-19
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-19
Health
Post nurse staffing information every day.
Corrected 2024-07-19
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-07-19
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-19
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-07-19
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-01
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-01
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-04-22
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 2022-04-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-22
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-04-22
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-04-22
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 2022-04-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-22
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-22
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-04-22
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 2019-11-07
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-11-06
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-06
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-11-06
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-11-06
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-11-06
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2019-11-06
Health
Respond appropriately to all alleged violations.
Corrected 2019-11-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-06
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 2019-11-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-11-06
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-11-06
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 2019-11-06
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2019-11-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-06
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 2019-11-06
Penalties and ownership
Fine · fine $121,573
Fine
Corporate Director · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
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