Cycle 1
Health 2025-08-01 · Fire 2025-08-01
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Norwich, NY
Norwich Rehabilitation & Nursing Center
3-star overall rating with 3-star inspections with $63,215 in total fines with 6 recent health deficiencies
88 Calvary Drive, Norwich, NY
(607) 336-3915
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1992-06-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 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
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,871
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.77
Baseline 16.54% · Performance 17.37% · Measure score 8.77 · Achievement 8.77 · Improvement 0
Healthcare-associated infections
0
Baseline 5.76% · Performance 8.31% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 56.41% · Performance 67.42% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.4
Baseline 2.64 hours · Performance 3.24 hours · Measure score 1.4 · Achievement 0.57 · Improvement 1.4
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.88% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 5.92% · Lower 95% interval 5.53% |
| Discharge to community | 49.52% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 186 · Observed rate 44.62% · Lower 95% interval 42% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.88% |
95.27%
1.4 pts worse
|
Numerator 92 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 54.69% |
53.69%
1 pts better
|
Numerator 35 · Denominator 64 |
| Discharge mobility score | 67.19% |
50.94%
16.2 pts better
|
Numerator 43 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 4.08% |
2.29%
1.8 pts worse
|
Numerator 4 · Denominator 98 · Adjusted rate 4.11% |
| Healthcare-associated infections requiring hospitalization | 8.31% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 8.85% · Lower 95% interval 5.13% |
| Staff COVID-19 vaccination coverage | 43.55% |
8.2%
35.3 pts better
|
Numerator 54 · Denominator 124 |
| Staff flu vaccination coverage | 80% |
42%
38 pts better
|
Numerator 96 · Denominator 120 |
| Discharge function score | 60.94% |
56.45%
4.5 pts better
|
Numerator 39 · Denominator 64 |
| Transfer of health information to provider | 91.67% |
95.95%
4.3 pts worse
|
Numerator 22 · Denominator 24 |
| Transfer of health information to patient | 92% |
96.28%
4.3 pts worse
|
Numerator 46 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 22.81% |
25.2%
2.4 pts worse
|
Numerator 13 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
91.2%
15.8 pts worse
|
93.4%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.5% · Q2 72.4% · Q3 79.7% · Q4 84.6% · 4Q avg 75.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.9% |
95.3%
4.4 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.0%
0.8 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.4% · Q3 1.7% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 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 who lose too much weight | 7.8% |
6.1%
1.7 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.6% · Q3 5.5% · Q4 6.2% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
13.5%
0.9 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 14.8% · Q3 12.3% · Q4 15.4% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
14.8%
4.6 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 7.5% · Q3 10.9% · Q4 10.0% · 4Q avg 10.2% · 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 | 13.3% |
15.1%
1.8 pts better
|
16.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 14.1% · Q3 9.9% · Q4 25.8% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
15.5%
3.5 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 18.4% · Q3 11.3% · Q4 35.6% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.6%
0.6 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.2% · Q3 0.9% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.4%
0.5 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 6.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
20.8%
7.8 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 21.8% · Q3 36.5% · Q4 21.4% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 16.4% |
6.9%
9.5 pts worse
|
5.1%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 15.4% · Q3 18.4% · Q4 16.4% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.7% |
76.7%
14 pts worse
|
81.7%
19 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.9% · Q2 57.6% · Q3 62.0% · Q4 70.8% · 4Q avg 62.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
9.7%
4.2 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 12.9% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.7% |
78.8%
14.1 pts worse
|
79.7%
15 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
20.6%
1.8 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 18.8% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-09 · Fire 2024-01-09
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-07-09 · Fire 2021-07-09
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-07-09
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 2021-08-01
D · Potential for more than minimal harm
2021-07-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-09-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-01
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 2025-09-30
D · Potential for more than minimal harm
2025-08-01
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-01
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 2025-09-30
D · Potential for more than minimal harm
2025-08-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-30
J · Immediate jeopardy
2024-12-03
F578 · Resident Rights Deficiencies
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 2025-01-05
E · Potential for more than minimal harm
2024-01-09
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 2024-02-25
D · Potential for more than minimal harm
2024-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-09
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 2024-02-25
D · Potential for more than minimal harm
2024-01-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-25
D · Potential for more than minimal harm
2021-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-01
Penalties and ownership
What sits behind the stars
$15,591
2024-12-03
Fine
Fine · fine $15,591
Fine
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$13,409
2023-12-11
Fine
Fine · fine $13,409
Fine
Ownership
Zagelbaum, Ephraim
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Yechiel
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Yoel
5% Or Greater Direct Ownership Interest · Individual
Amidon, Jeffrey
Operational/Managerial Control · Individual
Barth, Alexander
Corporate Officer · Individual
Revoir, Edith
Operational/Managerial Control · Individual
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