Montour Falls, NY

Schuyler Hospital Inc and Long Term Care Unit

3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

220 Steuben Street, Montour Falls, NY

(607) 535-8611

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

113

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1973-01-01

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

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.65

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.05

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.43

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.13

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.70

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.21

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.70

CMS adjusted RN staffing hours

Adjusted total hours

4.41

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,793

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

Performance score

47.71

Composite VBP score used to determine payment impact.

Payment multiplier

1.0013

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.19

Performance 19.49% · Measure score 4.19 · Achievement 4.19 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

5.58

Performance 6.17% · Measure score 5.58 · Achievement 5.58 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

6.02

Baseline 33.33% · Performance 39.08% · Measure score 6.02 · Achievement 6.02 · Improvement 0

Adjusted total nurse staffing

3.29

Baseline 4.11 hours · Performance 4.01 hours · Measure score 3.29 · Achievement 3.29 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.59%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 7.08%
Discharge to community	38.49%	50.57% 12.1 pts worse	No Different than the National Rate · Eligible stays 34 · Observed rate 29.41% · Lower 95% interval 26.83%
Medicare spending per beneficiary	0.96	1.02 0.1 pts better
Drug regimen review with follow-up	98.11%	95.27% 2.8 pts better	Numerator 52 · Denominator 53
Falls with major injury	1.89%	0.77% 1.1 pts worse	Numerator 1 · Denominator 53
Discharge self-care score	52.38%	53.69% 1.3 pts worse	Numerator 22 · Denominator 42
Discharge mobility score	45.24%	50.94% 5.7 pts worse	Numerator 19 · Denominator 42
Pressure ulcers or injuries, new or worsened	5.66%	2.29% 3.4 pts worse	Numerator 3 · Denominator 53 · Adjusted rate 6.35%
Healthcare-associated infections requiring hospitalization	6.17%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 30 · Observed rate 0% · Lower 95% interval 2.93%
Staff COVID-19 vaccination coverage	3.33%	8.2% 4.9 pts worse	Numerator 4 · Denominator 120
Staff flu vaccination coverage	70.32%	42% 28.3 pts better	Numerator 109 · Denominator 155
Discharge function score	64.29%	56.45% 7.8 pts better	Numerator 27 · Denominator 42
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	51.52%	25.2% 26.3 pts better	Numerator 17 · Denominator 33

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 0.8 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.6	1.3 1.3 pts worse	1.8 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	93.9%	91.2% 2.7 pts better	93.4% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 89.2% · Q3 96.7% · Q4 99.0% · 4Q avg 93.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.6%	95.3% 0.3 pts better	95.5% 0.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6%
Percentage of long-stay residents experiencing one or more falls with major injury	8.4%	3.0% 5.4 pts worse	3.3% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.4% · Q3 8.7% · Q4 10.4% · 4Q avg 8.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.9%	18.5% 11.6 pts better	11.4% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 17.9% · Q3 7.1% · Q4 3.3% · 4Q avg 6.9%
Percentage of long-stay residents who lose too much weight	9.5%	6.1% 3.4 pts worse	5.4% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 7.5% · Q3 10.1% · Q4 4.3% · 4Q avg 9.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.6%	13.5% 2.1 pts worse	19.6% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.3% · Q3 13.5% · Q4 11.7% · 4Q avg 15.6%
Percentage of long-stay residents who received an antipsychotic medication	18.7%	14.8% 3.9 pts worse	16.7% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 15.3% · Q3 19.5% · Q4 20.5% · 4Q avg 18.7% · 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	11.8%	15.1% 3.3 pts better	16.3% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 23.5% · Q3 4.3% · Q4 5.6% · 4Q avg 11.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.2%	15.5% 1.3 pts better	14.9% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 23.7% · Q3 12.0% · Q4 3.5% · 4Q avg 14.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.6% 0.4 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.4% 1.1 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.3%	20.8% 8.5 pts worse	19.8% 9.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 37.2% · Q3 30.2% · Q4 22.9% · 4Q avg 29.3%
Percentage of long-stay residents with pressure ulcers	5.1%	6.9% 1.8 pts better	5.1% About the same	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 6.0% · Q3 1.1% · Q4 4.8% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	81.0%	76.7% 4.3 pts better	81.7% 0.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 79.2% · Q3 82.8% · Q4 87.5% · 4Q avg 81.0%
Percentage of short-stay residents who had an outpatient emergency department visit	14.6%	9.7% 4.9 pts worse	12.0% 2.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.3% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.9%	1.2% 0.7 pts worse	1.6% 0.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.3% · Q4 1.9% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	77.3%	78.8% 1.5 pts worse	79.7% 2.4 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 77.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	14.0%	20.6% 6.6 pts better	23.9% 9.9 pts better	Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 11.1% · Expected 18.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-03-28 · Fire 2024-03-28

7 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

2 fire-safety deficiencies

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

Cycle 2 Health 2021-12-17 · Fire 2021-12-17

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2019-05-17 · Fire 2019-05-17

11 health deficiencies

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

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-03-28

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-05-27

E · Potential for more than minimal harm 2024-03-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-27

E · Potential for more than minimal harm 2021-12-17

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2022-02-15

C · Minimal harm 2021-12-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-02-15

D · Potential for more than minimal harm 2019-05-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-07-15

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-03-28

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-05-27

E · Potential for more than minimal harm 2024-03-28

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-05-27

D · Potential for more than minimal harm 2024-03-28

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-05-27

D · Potential for more than minimal harm 2024-03-28

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 2024-05-27

D · Potential for more than minimal harm 2024-03-28

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-05-27

D · Potential for more than minimal harm 2024-03-28

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 2024-05-27

B · Minimal harm 2024-03-28

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-05-27

D · Potential for more than minimal harm 2021-12-17

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 2022-02-15

D · Potential for more than minimal harm 2019-05-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2019-07-15

D · Potential for more than minimal harm 2019-05-17

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 2019-07-15

D · Potential for more than minimal harm 2019-05-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-07-15

D · Potential for more than minimal harm 2019-05-17

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2019-07-15

D · Potential for more than minimal harm 2019-05-17

F756 · Pharmacy Service Deficiencies

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 2019-07-15

D · Potential for more than minimal harm 2019-05-17

F758 · Pharmacy Service Deficiencies

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 2019-07-15

D · Potential for more than minimal harm 2019-05-17

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2019-07-15

D · Potential for more than minimal harm 2019-05-17

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2019-07-15

B · Minimal harm 2019-05-17

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 2019-07-15

B · Minimal harm 2019-05-17

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 2019-07-15

B · Minimal harm 2019-05-17

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 2019-07-15

Penalties and ownership

What sits behind the stars

Ownership

Cayuga Health System Inc

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2014-09-23

Benjamin, Michelle

W-2 Managing Employee · Individual

0% 1 facilities 2008-02-25

Blowers, Suzanne