6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waterloo, NY
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
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
Staffing
RN hours / resident day
0.36
Registered nurse staffing
LPN hours / resident day
1.11
Licensed practical nurse staffing
Aide hours / resident day
2.39
Nurse aide staffing
Weekend hours
2.99
Weekend nurse staffing
RN turnover
60%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 11.7% |
15.1%
3.4 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 86.1% |
78.8%
7.3 pts better
|
79.7%
6.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
Survey summary
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 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
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-08-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-19
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
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-15
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-15
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-10-29
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-10-29
Fire Safety
Develop a communication plan.
Corrected 2021-10-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-29
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-15
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-15
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-15
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-10-29
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
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
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
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-10-29
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
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
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