Cycle 1
Health 2025-11-18 · Fire 2025-11-18
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Moravia, NY
Northwoods Rehab And Nursing Center At Moravia
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
7 Keeler Avenue, Moravia, NY
(315) 497-0440
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stern Consultants
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing
LPN hours / resident day
1.00
Licensed practical nurse staffing
Aide hours / resident day
2.10
Nurse aide staffing
Weekend hours
3.09
Weekend nurse staffing
RN turnover
80%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
1.7
1.5 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.6% |
91.2%
28.6 pts worse
|
93.4%
30.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.3%
2.1 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.0%
3.5 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 40.0% |
18.5%
21.5 pts worse
|
11.4%
28.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
13.5%
8.9 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
14.8%
4.7 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.4% |
15.1%
5.3 pts worse
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
15.5%
6.8 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.6%
About the same
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
1.4%
2.4 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
20.8%
1.7 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
6.9%
1.2 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.5% |
76.7%
30.2 pts worse
|
81.7%
35.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
9.7%
5.3 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
20.6%
1.7 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-05-25 · Fire 2022-05-25
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2026-02-06
F · Potential for more than minimal harm
2025-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
F · Potential for more than minimal harm
2025-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-11-18
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-11-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-11-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-11-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
E · Potential for more than minimal harm
2024-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-13
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 2024-07-19
D · Potential for more than minimal harm
2024-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-19
C · Minimal harm
2024-06-13
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-07-19
E · Potential for more than minimal harm
2022-05-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-05-25
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 2022-06-22
D · Potential for more than minimal harm
2022-05-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-05-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-05-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-05-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-18
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-11-18
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 2025-12-15
D · Potential for more than minimal harm
2025-11-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-11-18
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-11-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-11-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-15
D · Potential for more than minimal harm
2024-06-13
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 2024-07-31
D · Potential for more than minimal harm
2024-06-13
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 2024-07-26
D · Potential for more than minimal harm
2024-06-13
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 2024-07-26
D · Potential for more than minimal harm
2024-06-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
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 2024-08-09
C · Minimal harm
2024-06-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-26
E · Potential for more than minimal harm
2022-05-25
F700 · Quality of Life and Care Deficiencies
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 2022-07-01
D · Potential for more than minimal harm
2022-05-25
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 2022-07-01
D · Potential for more than minimal harm
2022-05-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-05-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-05-25
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 2022-07-01
D · Potential for more than minimal harm
2022-05-25
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 2022-07-01
B · Minimal harm
2022-05-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-06-24
Penalties and ownership
What sits behind the stars
Ownership
Sheps, Boruch
5% Or Greater Direct Ownership Interest · Individual
Sheps, Boruch
Operational/Managerial Control · Individual
Strom, Rochel
Operational/Managerial Control · Individual
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#3
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