Cycle 1
Health 2025-06-27 · Fire 2025-06-27
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waterloo, NY
Seneca Nursing & Rehabilitation Center, LLC
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
200 Douglas Drive, Waterloo, NY
(315) 539-9202
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hurlbut Care
Operator or chain grouping
Approved since
1973-10-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 4 health / 2 staffing / 3 quality stars
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
0.36
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,526
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.07
Performance 19.55% · Measure score 4.07 · Achievement 4.07 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 7.04% · Performance 8.66% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.95
Baseline 51.79% · Performance 47.54% · Measure score 3.95 · Achievement 3.95 · Improvement 1.08
Adjusted total nurse staffing
0
Baseline 3.13 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.24% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 16.07% · Lower 95% interval 8.71% |
| Discharge to community | 46.48% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 38.46% · Lower 95% interval 35.08% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 40 |
| Discharge self-care score | 23.33% |
53.69%
30.4 pts worse
|
Numerator 7 · Denominator 30 |
| Discharge mobility score | 26.67% |
50.94%
24.3 pts worse
|
Numerator 8 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 2.27% |
| Healthcare-associated infections requiring hospitalization | 8.66% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 13.33% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 2.83% |
8.2%
5.4 pts worse
|
Numerator 3 · Denominator 106 |
| Staff flu vaccination coverage | 69.42% |
42%
27.4 pts better
|
Numerator 84 · Denominator 121 |
| Discharge function score | 36.67% |
56.45%
19.8 pts worse
|
Numerator 11 · Denominator 30 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 55% |
25.2%
29.8 pts better
|
Numerator 11 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
91.2%
6.5 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.4% · Q3 100.0% · Q4 94.7% · 4Q avg 97.7% |
| 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 | 5.0% |
3.0%
2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.5% · Q3 5.8% · Q4 3.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
18.5%
7.1 pts better
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.6% · Q3 10.6% · Q4 7.5% · 4Q avg 11.4% |
| 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 2.4% · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
13.5%
5.6 pts worse
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 20.5% · Q3 20.0% · Q4 19.6% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
14.8%
7 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 7.5% · Q3 8.9% · Q4 10.2% · 4Q avg 7.8% · 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 | 11.7% |
15.1%
3.4 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 13.9% · Q3 7.4% · Q4 12.3% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
15.5%
5.8 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 14.0% · Q3 7.0% · Q4 6.2% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.4%
2.8 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 2.0% · Q4 10.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.7% |
20.8%
11.9 pts worse
|
19.8%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 34.8% · Q3 32.4% · Q4 29.5% · 4Q avg 32.7% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
6.9%
3.7 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 1.6% · Q4 4.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.9% |
76.7%
4.2 pts better
|
81.7%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.4% · Q2 79.4% · Q3 78.1% · Q4 79.2% · 4Q avg 80.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
9.7%
3.9 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.9% · Expected 11.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.1% |
78.8%
7.3 pts better
|
79.7%
6.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
20.6%
1.6 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 22.2% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-28 · Fire 2023-06-28
3 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-09-10 · Fire 2021-09-10
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-06-27
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 2025-08-15
D · Potential for more than minimal harm
2025-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-15
E · Potential for more than minimal harm
2023-06-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-15
F · Potential for more than minimal harm
2021-09-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-10-29
F · Potential for more than minimal harm
2021-09-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-10-29
E · Potential for more than minimal harm
2021-09-10
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2021-10-29
C · Minimal harm
2021-09-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-27
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 2025-08-15
E · Potential for more than minimal harm
2025-06-27
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 2025-08-15
D · Potential for more than minimal harm
2025-06-27
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 2025-08-15
D · Potential for more than minimal harm
2025-06-27
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 2025-08-15
D · Potential for more than minimal harm
2025-06-27
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 2025-08-15
B · Minimal harm
2025-06-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-15
D · Potential for more than minimal harm
2023-06-28
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 2023-08-15
D · Potential for more than minimal harm
2023-06-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-15
E · Potential for more than minimal harm
2021-09-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-10-29
E · Potential for more than minimal harm
2021-09-10
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 2021-10-29
E · Potential for more than minimal harm
2021-09-10
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 2021-10-29
E · Potential for more than minimal harm
2021-09-10
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 2021-10-29
D · Potential for more than minimal harm
2021-09-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-10-29
D · Potential for more than minimal harm
2021-09-10
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 2021-10-29
Penalties and ownership
What sits behind the stars
Ownership
Hurlbut, Robert
5% Or Greater Direct Ownership Interest · Individual
Curletta, Mark
Operational/Managerial Control · Individual
Curletta, Mark
Corporate Officer · Individual
Hurlbut Health Consulting, LLC
Operational/Managerial Control · Organization
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#3
Auburn Rehabilitation & Nursing Center
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1-star overall rating with 1-star inspections with $10,901 in total fines with 12 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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