Cycle 1
Health 2024-08-16 · Fire 2024-08-16
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Watertown, NY
Samaritan Senior Village, Inc
1-star overall rating with 2-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
22691 Campus Drive, Watertown, NY
(315) 782-6800
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
162
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-04-05
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
0.49
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.49
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
0.49
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
0.09
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.09
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
0.57
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,376
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9978
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.84
Baseline 18.42% · Performance 18.26% · Measure score 6.84 · Achievement 6.84 · Improvement 0.65
Healthcare-associated infections
6.69
Baseline 5.52% · Performance 5.83% · Measure score 6.69 · Achievement 6.69 · Improvement 0
Total nurse turnover
0.9
Performance 60.00% · Measure score 0.9 · Achievement 0.9 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.42
Baseline 3.93 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 0.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.91% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 8.38% · Lower 95% interval 6.81% |
| Discharge to community | 33.6% |
50.57%
17 pts worse
|
Worse than the National Rate · Eligible stays 167 · Observed rate 26.35% · Lower 95% interval 27.18% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.15% |
95.27%
2.9 pts better
|
Numerator 106 · Denominator 108 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 108 |
| Discharge self-care score | 46.59% |
53.69%
7.1 pts worse
|
Numerator 41 · Denominator 88 |
| Discharge mobility score | 59.09% |
50.94%
8.2 pts better
|
Numerator 52 · Denominator 88 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 3 · Denominator 108 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 5.83% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 3.45% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 6.85% |
8.2%
1.3 pts worse
|
Numerator 17 · Denominator 248 |
| Staff flu vaccination coverage | 68.45% |
42%
26.5 pts better
|
Numerator 230 · Denominator 336 |
| Discharge function score | 64.77% |
56.45%
8.3 pts better
|
Numerator 57 · Denominator 88 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 22.41% |
25.2%
2.8 pts worse
|
Numerator 13 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
91.2%
6.3 pts worse
|
93.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 82.8% · Q3 87.1% · Q4 86.3% · 4Q avg 84.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
95.3%
5.5 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.0%
2.6 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.6% · Q3 4.5% · Q4 7.8% · 4Q avg 5.6% · 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 0.7% · Q2 3.5% · Q3 1.4% · Q4 0.7% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
6.1%
2.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 5.2% · Q4 4.3% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
13.5%
0.4 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 14.9% · Q3 10.4% · Q4 12.2% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
14.8%
0.6 pts better
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 13.6% · Q3 14.5% · Q4 13.5% · 4Q avg 14.2% · 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 | 24.0% |
15.1%
8.9 pts worse
|
16.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 23.6% · Q3 11.5% · Q4 35.6% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.8% |
15.5%
13.3 pts worse
|
14.9%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 27.5% · Q3 27.6% · Q4 35.2% · 4Q avg 28.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.6%
1.1 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 3.3% · Q4 1.7% · 4Q avg 1.7% · 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 0.7% · Q2 0.7% · Q3 1.9% · Q4 0.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
20.8%
9.2 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 32.9% · Q3 29.8% · Q4 29.9% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
6.9%
0.2 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 7.3% · Q3 6.3% · Q4 4.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
76.7%
0.6 pts worse
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.3% · Q2 78.6% · Q3 78.0% · Q4 71.7% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
9.7%
0.3 pts worse
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 4.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.6% |
78.8%
11.2 pts worse
|
79.7%
12.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.1% |
20.6%
8.5 pts better
|
23.9%
11.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 12.2% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-24 · Fire 2022-06-24
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-10-11 · Fire 2019-10-11
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-16
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 2024-10-11
D · Potential for more than minimal harm
2024-08-16
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-11
E · Potential for more than minimal harm
2022-06-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-17
D · Potential for more than minimal harm
2019-10-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-10-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-16
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 2024-10-14
E · Potential for more than minimal harm
2024-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-08-16
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 2024-10-14
E · Potential for more than minimal harm
2024-08-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-16
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 2024-10-14
D · Potential for more than minimal harm
2024-08-16
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-16
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 2024-10-14
D · Potential for more than minimal harm
2024-08-16
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 2024-10-14
D · Potential for more than minimal harm
2024-08-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
D · Potential for more than minimal harm
2023-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
E · Potential for more than minimal harm
2022-06-24
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 2022-08-17
D · Potential for more than minimal harm
2022-06-24
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-24
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 2022-08-17
D · Potential for more than minimal harm
2022-06-24
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 2022-08-17
D · Potential for more than minimal harm
2019-10-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-12-10
D · Potential for more than minimal harm
2019-10-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-12-10
D · Potential for more than minimal harm
2019-10-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-12-10
D · Potential for more than minimal harm
2019-10-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-12-10
D · Potential for more than minimal harm
2019-10-11
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 2019-12-10
Penalties and ownership
What sits behind the stars
Ownership
Alexander, Collene
Corporate Director · Individual
Carman, Thomas
Corporate Officer · Individual
Carman, Thomas
W-2 Managing Employee · Individual
Fenlon, Kathleen
Corporate Director · Individual
Kellogg, Collins
Corporate Director · Individual
Kraeger, Paul
Corporate Officer · Individual
Manufacturers & Traders Trust Company
5% Or Greater Mortgage Interest · Organization
Morrow, Barbara
Corporate Director · Individual
Morrow, Barbara
W-2 Managing Employee · Individual
Treadwell-Woods, Joan
Corporate Director · Individual
Vars, Addison
Corporate Director · Individual
Villa, Daniel
Corporate Director · Individual
Walton, Peter
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Samaritan Keep Nursing Home Inc
Watertown, NY
1-star overall rating with 1-star inspections with $62,117 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Carthage Center For Rehabilitation And Nursing
Carthage, NY
1-star overall rating with 1-star inspections with 12 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
Lewis County General Hospital-Nursing Home Unit
Lowville, NY
2-star overall rating with 2-star inspections with $160,046 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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