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
Chain footprint
22 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
0.33
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9949
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.98
Performance 35.13% · Measure score 6.98 · Achievement 6.98 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.42
Baseline 3.18 hours · Performance 3.48 hours · Measure score 1.42 · Achievement 1.42 · Improvement 0.65
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 5.89% |
| Discharge to community | 50.64% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 48.15% · Lower 95% interval 35.28% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 20 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 87.91% |
42%
45.9 pts better
|
Numerator 80 · Denominator 91 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
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 · Adjusted 3.2 · Observed 3.0 · Expected 1.8 · Used in QM five-star |
| 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 · Adjusted 2.0 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 97.2% · Q2 48.5% · Q3 52.8% · Q4 50.0% · 4Q avg 62.6% |
| 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 · 4Q avg 97.4% |
| 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 · Q1 5.6% · Q2 6.1% · Q3 8.3% · Q4 5.9% · 4Q avg 6.5% · Used in QM five-star |
| 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 · Q1 57.6% · Q2 55.2% · Q3 37.5% · Q4 9.7% · 4Q avg 40.0% |
| 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 · Q1 3.1% · Q2 17.2% · Q3 21.9% · Q4 13.0% · 4Q avg 13.8% |
| 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 · Q1 29.4% · Q2 20.0% · Q3 18.2% · Q4 21.4% · 4Q avg 22.4% |
| 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 · Q1 12.9% · Q2 12.5% · Q3 11.1% · 4Q avg 10.1% · 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 | 20.4% |
15.1%
5.3 pts worse
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · 4Q avg 20.4% · Used in QM five-star |
| 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 · Q1 22.6% · Q2 25.9% · Q3 17.2% · Q4 24.0% · 4Q avg 22.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 6.2% · Q3 2.9% · Q4 6.9% · 4Q avg 3.8% · Used in QM five-star |
| 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 · Q1 16.6% · Q2 32.7% · Q3 22.2% · Q4 18.8% · 4Q avg 22.5% |
| 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 · Q1 0.0% · Q2 12.0% · Q3 9.6% · Q4 11.6% · 4Q avg 8.1% · Used in QM five-star |
| 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 · 4Q avg 46.5% |
| 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 · Adjusted 15.0% · Observed 16.7% · Expected 12.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · Adjusted 22.3% · Observed 29.2% · Expected 31.2% · Used in QM five-star |
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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