Rome, NY

Rome Memorial Hospital, Inc - R H C F

4-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

1500 North James Street, Rome, NY

(315) 338-7318

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 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

74

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1976-11-01

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

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.52

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.20

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.07

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.79

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.73

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.25

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.16

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.22

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.55

CMS adjusted RN staffing hours

Adjusted total hours

3.99

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,073

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

46.16

Composite VBP score used to determine payment impact.

Payment multiplier

0.9995

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.43

Baseline 17.62% · Performance 18.45% · Measure score 6.43 · Achievement 6.43 · Improvement 0

Healthcare-associated infections

5.02

Baseline 5.81% · Performance 6.33% · Measure score 5.02 · Achievement 5.02 · Improvement 0

Total nurse turnover

2.65

Baseline 43.40% · Performance 52.86% · Measure score 2.65 · Achievement 2.65 · Improvement 0

Adjusted total nurse staffing

4.37

Baseline 4.78 hours · Performance 4.32 hours · Measure score 4.37 · Achievement 4.37 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.7%	10.72% About the same	No Different than the National Rate · Eligible stays 89 · Observed rate 8.99% · Lower 95% interval 7.1%
Discharge to community	52.95%	50.57% 2.4 pts better	No Different than the National Rate · Eligible stays 101 · Observed rate 49.5% · Lower 95% interval 44.9%
Medicare spending per beneficiary	0.69	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 107 · Denominator 107
Falls with major injury	1.87%	0.77% 1.1 pts worse	Numerator 2 · Denominator 107
Discharge self-care score	62.35%	53.69% 8.7 pts better	Numerator 53 · Denominator 85
Discharge mobility score	63.53%	50.94% 12.6 pts better	Numerator 54 · Denominator 85
Pressure ulcers or injuries, new or worsened	2.8%	2.29% 0.5 pts worse	Numerator 3 · Denominator 107 · Adjusted rate 2.64%
Healthcare-associated infections requiring hospitalization	6.33%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 76 · Observed rate 3.95% · Lower 95% interval 3.36%
Staff COVID-19 vaccination coverage	3.05%	8.2% 5.1 pts worse	Numerator 5 · Denominator 164
Staff flu vaccination coverage	89.42%	42% 47.4 pts better	Numerator 169 · Denominator 189
Discharge function score	63.53%	56.45% 7.1 pts better	Numerator 54 · Denominator 85
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 25 · Denominator 25
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 57 · Denominator 57
Resident COVID-19 vaccinations up to date	82.09%	25.2% 56.9 pts better	Numerator 55 · Denominator 67

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	1.7 0.6 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.5	1.3 1.2 pts worse	1.8 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	84.1%	91.2% 7.1 pts worse	93.4% 9.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 87.2% · Q3 76.5% · Q4 85.2% · 4Q avg 84.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.0%	95.3% 5.3 pts worse	95.5% 5.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 90.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.0%	3.0% 1 pts worse	3.3% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.4% · Q3 3.9% · Q4 5.6% · 4Q avg 4.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.6%	18.5% 16.9 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.1% · Q4 2.2% · 4Q avg 1.6%
Percentage of long-stay residents who lose too much weight	4.7%	6.1% 1.4 pts better	5.4% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 9.3% · Q3 6.0% · Q4 0.0% · 4Q avg 4.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.0%	13.5% 15.5 pts worse	19.6% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 29.8% · Q3 31.4% · Q4 24.5% · 4Q avg 29.0%
Percentage of long-stay residents who received an antipsychotic medication	11.3%	14.8% 3.5 pts better	16.7% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.8% · Q3 10.3% · Q4 18.2% · 4Q avg 11.3% · 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	18.7%	15.1% 3.6 pts worse	16.3% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q3 10.9% · Q4 13.4% · 4Q avg 18.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.0%	15.5% 0.5 pts better	14.9% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 22.7% · Q3 10.4% · Q4 7.8% · 4Q avg 15.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.6% 0.2 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.0%	1.4% 0.4 pts better	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.9%	20.8% 0.9 pts better	19.8% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 29.4% · Q3 19.7% · Q4 15.2% · 4Q avg 19.9%
Percentage of long-stay residents with pressure ulcers	9.2%	6.9% 2.3 pts worse	5.1% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 14.0% · Q3 4.8% · Q4 4.5% · 4Q avg 9.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	79.8%	76.7% 3.1 pts better	81.7% 1.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 67.6% · Q2 72.8% · Q3 83.3% · Q4 91.6% · 4Q avg 79.8%
Percentage of short-stay residents who had an outpatient emergency department visit	13.8%	9.7% 4.1 pts worse	12.0% 1.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 11.5% · Expected 9.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.2% 0.9 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.7%	78.8% 2.1 pts worse	79.7% 3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.4%	20.6% 4.2 pts better	23.9% 7.5 pts better	Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 13.5% · Expected 19.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-08 · Fire 2025-01-08

2 health deficiencies

Top issue: Resident Assessment and Care Planning (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-04-14 · Fire 2023-04-14

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2021-04-15 · Fire 2021-04-15

2 health deficiencies

Top issue: Infection Control (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-01-08

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2025-03-03

E · Potential for more than minimal harm 2025-01-08

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-04-09

D · Potential for more than minimal harm 2025-01-08

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 2025-03-31

D · Potential for more than minimal harm 2025-01-08

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-03

D · Potential for more than minimal harm 2025-01-08

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-03-03

C · Minimal harm 2025-01-08

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-03-03

E · Potential for more than minimal harm 2023-04-14

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-06-21

D · Potential for more than minimal harm 2023-04-14

K909 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum piping is labeled.

Corrected 2023-05-30

F · Potential for more than minimal harm 2021-04-15

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2021-04-28

D · Potential for more than minimal harm 2021-04-15

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 2021-04-27

D · Potential for more than minimal harm 2021-04-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-04-27

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-01-08

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-03-03

D · Potential for more than minimal harm 2025-01-08

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2025-03-03

E · Potential for more than minimal harm 2023-04-14

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 2023-05-19

D · Potential for more than minimal harm 2023-04-14

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-05-19

D · Potential for more than minimal harm 2023-04-14

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-05-31

D · Potential for more than minimal harm 2023-04-14

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-05-19

D · Potential for more than minimal harm 2023-04-14

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2023-05-05

D · Potential for more than minimal harm 2023-04-14

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 2023-05-05

E · Potential for more than minimal harm 2021-04-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-06-10

D · Potential for more than minimal harm 2021-04-15

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 2021-06-10

Penalties and ownership

What sits behind the stars

Ownership

Rowlands, Dewey

5% Or Greater Indirect Ownership Interest · Individual

5% 1 facilities 2015-12-09

Burns, Darlene