Cycle 1
Health 2024-04-25 · Fire 2024-04-25
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Penn Yan, NY
Penn Yan Manor Nursing Home Inc
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
655 North Liberty Street, Penn Yan, NY
(315) 536-2311
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-01-01
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
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,704
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
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
5.28
Performance 42.10% · Measure score 5.28 · Achievement 5.28 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.52
Baseline 3.62 hours · Performance 3.23 hours · Measure score 0.52 · Achievement 0.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 69 · Denominator 69 |
| Staff flu vaccination coverage | 61.43% |
42%
19.4 pts better
|
Numerator 43 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 46.6% |
91.2%
44.6 pts worse
|
93.4%
46.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.7% · Q2 44.4% · Q3 43.5% · Q4 51.2% · 4Q avg 46.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
3.0%
3.7 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.7% · Q3 6.5% · Q4 7.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
18.5%
17.9 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
6.1%
4.4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 2.2% · Q4 2.3% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
13.5%
1.1 pts worse
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 13.3% · Q3 15.2% · Q4 14.0% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
14.8%
1.4 pts worse
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 16.7% · Q3 15.0% · Q4 16.2% · 4Q avg 16.2% · 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 | 14.1% |
15.1%
1 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.4% · Q3 13.9% · Q4 14.4% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
15.5%
3 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.5% · Q3 19.5% · Q4 15.8% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.6%
1.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.2% |
1.4%
7.8 pts worse
|
1.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 11.9% · Q3 15.6% · Q4 7.0% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
20.8%
4.9 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 33.8% · Q3 17.5% · Q4 23.7% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.9%
1.4 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.7% · Q3 4.2% · Q4 12.5% · 4Q avg 5.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-05 · Fire 2022-08-05
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-11-12 · Fire 2019-11-12
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-04-25
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-04-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-04-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-06-21
F · Potential for more than minimal harm
2022-08-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-08-05
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-08-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-08-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-04
C · Minimal harm
2022-08-05
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-10-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-25
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-06-21
E · Potential for more than minimal harm
2022-08-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-08-05
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-10-04
D · Potential for more than minimal harm
2022-08-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-10-04
D · Potential for more than minimal harm
2022-08-05
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 2022-10-04
D · Potential for more than minimal harm
2022-08-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-04
D · Potential for more than minimal harm
2019-11-12
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 2019-12-31
D · Potential for more than minimal harm
2019-11-12
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 2019-12-31
D · Potential for more than minimal harm
2019-11-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-12-27
D · Potential for more than minimal harm
2019-11-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-11-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-12-31
B · Minimal harm
2019-11-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-12-13
B · Minimal harm
2019-11-12
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-12-13
B · Minimal harm
2019-11-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-12-20
Penalties and ownership
What sits behind the stars
Ownership
Feinberg, Jason
Operational/Managerial Control · Individual
Fish, Jessica
Operational/Managerial Control · Individual
Powers, Greg
Corporate Director · Individual
Snyder, Lauren
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Soldiers and Sailors Memorial Hospital Extended Ca
Penn Yan, NY
1-star overall rating with 1-star inspections with $21,733 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Finger Lakes Health
Geneva, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Ontario Center for Rehabilitation and Healthcare
Canandaigua, NY
1-star overall rating with 1-star inspections with abuse icon flag with $117,878 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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