3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Stamford, NY
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
28652 State Highway 23, Stamford, NY
(607) 652-7521
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1967-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.48
Registered nurse staffing
LPN hours / resident day
0.81
Licensed practical nurse staffing
Aide hours / resident day
1.78
Nurse aide staffing
Weekend hours
2.40
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.8 |
1.3
3.5 pts worse
|
1.8
3 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.3% |
91.2%
2.9 pts worse
|
93.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
95.3%
2.2 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.0%
2.5 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
18.5%
11.7 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 9.2% |
6.1%
3.1 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
13.5%
3.6 pts worse
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
14.8%
4.3 pts better
|
16.7%
6.2 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 | 7.5% |
15.1%
7.6 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
15.5%
3.5 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.6%
1.8 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.4%
0.1 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
20.8%
0.4 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
6.9%
1 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.1% |
76.7%
6.6 pts worse
|
81.7%
11.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
9.7%
1.6 pts worse
|
12.0%
0.7 pts better
|
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 assessed and appropriately given the seasonal influenza vaccine | 78.4% |
78.8%
0.4 pts worse
|
79.7%
1.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
20.6%
3.2 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-01
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-05-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-01
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-05-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-01
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-11-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-11-20
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2020-11-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-11-20
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-11-20
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-02-19
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-04-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-03-12
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-03-12
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-02-22
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 2019-02-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-02-22
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-02-22
Inspection history
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 2023-05-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-12-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-12-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-12-18
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-12-18
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-12-18
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-12-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-12-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-02-28
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-02-28
Health
Provide and implement an infection prevention and control program.
Corrected 2019-02-28
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-02-28
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-02-28
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 2019-02-28
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 2019-02-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-02-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-02-28
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-02-28
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-02-28
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-02-28
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 2019-02-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-02-28
Health
Dispose of garbage and refuse properly.
Corrected 2019-02-28
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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