Cycle 1
Health 2024-11-04 · Fire 2024-11-04
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Penn Yan, NY
Soldiers and Sailors Memorial Hospital Extended Ca
1-star overall rating with 1-star inspections with $21,733 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
418 North Main Street, Penn Yan, NY
(315) 531-2730
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
152
Certified beds
Average residents
124
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1969-06-15
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
Staffing
Hours and turnover
RN hours / resident day
0.36
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
1.89
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.30
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,149
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 33.33% · Performance 65.73% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.93
Baseline 3.92 hours · Performance 4.48 hours · Measure score 4.93 · Achievement 4.93 · Improvement 2.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.88% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 6.79% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.54 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.7% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 148 |
| Staff flu vaccination coverage | 82.88% |
42%
40.9 pts better
|
Numerator 121 · Denominator 146 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.0 |
1.3
3.7 pts worse
|
1.8
3.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.0 · Observed 4.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
91.2%
5.4 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 99.1% · Q3 97.2% · Q4 96.5% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.3%
3.8 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.2% |
3.0%
4.2 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.0% · Q3 5.5% · Q4 7.0% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 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 who lose too much weight | 4.5% |
6.1%
1.6 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.9% · Q3 3.9% · Q4 4.5% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
13.5%
5.4 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.5% · Q3 8.4% · Q4 8.8% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 39.9% |
14.8%
25.1 pts worse
|
16.7%
23.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 46.6% · Q3 39.5% · Q4 33.7% · 4Q avg 39.9% · 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 | 11.9% |
15.1%
3.2 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 21.7% · Q3 5.7% · Q4 7.0% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
15.5%
2.4 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 18.2% · Q3 8.8% · Q4 9.3% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.6%
0.7 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.4%
2.7 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.7% · Q3 3.7% · Q4 5.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
20.8%
2.9 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 19.6% · Q3 22.2% · Q4 23.5% · 4Q avg 23.7% |
| 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 6.6% · Q2 4.7% · Q3 3.1% · Q4 5.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.8% |
76.7%
23.9 pts worse
|
81.7%
28.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 48.4% · Q3 63.4% · Q4 47.1% · 4Q avg 52.8% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
78.8%
6 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-30 · Fire 2022-09-30
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-11-22 · Fire 2019-11-22
6 health deficiencies
Top issue: Pharmacy Service (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
2024-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-04
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-04
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 2024-12-18
D · Potential for more than minimal harm
2024-11-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-18
E · Potential for more than minimal harm
2022-09-30
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-11-01
E · Potential for more than minimal harm
2022-09-30
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-09-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-01
E · Potential for more than minimal harm
2019-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-20
Inspection history
Recent health citations
K · Immediate jeopardy
2024-11-04
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 2024-12-30
E · Potential for more than minimal harm
2024-11-04
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-04
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 2024-12-30
D · Potential for more than minimal harm
2024-11-04
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 2024-12-30
D · Potential for more than minimal harm
2024-11-04
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-11-04
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 2024-12-30
D · Potential for more than minimal harm
2022-09-30
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 2022-11-21
B · Minimal harm
2022-09-30
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2022-11-21
B · Minimal harm
2022-09-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-21
B · Minimal harm
2022-09-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-21
D · Potential for more than minimal harm
2019-11-22
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 2020-01-20
D · Potential for more than minimal harm
2019-11-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2020-01-20
D · Potential for more than minimal harm
2019-11-22
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2020-01-20
D · Potential for more than minimal harm
2019-11-22
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 2020-01-20
D · Potential for more than minimal harm
2019-11-22
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 2020-01-20
D · Potential for more than minimal harm
2019-11-22
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 2020-01-20
Penalties and ownership
What sits behind the stars
$21,733
2024-11-04
Fine
Fine · fine $21,733
Fine
Ownership
Abraham, Kylene
Corporate Director · Individual
Acevedo, Jose
Corporate Officer · Individual
Adams, James
Corporate Director · Individual
Anderson, Robert
Corporate Director · Individual
Beckley, Phillip
Corporate Officer · Individual
Burlingham, Robert
Operational/Managerial Control · Individual
Burrall, Thomas
Corporate Director · Individual
Cheney, James
Corporate Director · Individual
Collins, Craig
Corporate Director · Individual
Densmore, Craig
Corporate Director · Individual
Devaney, Chevanne
Corporate Director · Individual
Feinberg, Jason
Operational/Managerial Control · Individual
Finizio, Kathi
Operational/Managerial Control · Individual
Garrity, William
Operational/Managerial Control · Individual
Goldstein, Steven
Corporate Director · Individual
Griffin, Stephen
Corporate Director · Individual
Hallings, Ryan
Corporate Director · Individual
Koczent, Trisha
Operational/Managerial Control · Individual
Koczent, Trisha
Corporate Director · Individual
Mcmullen, Ann
Corporate Officer · Individual
Nardozzi, James
Corporate Director · Individual
Queiroz, Rodolfo
Corporate Director · Individual
Rotondo, Michael
Corporate Director · Individual
Stork, Susan
Corporate Director · Individual
Taubman, Mark
Corporate Director · Individual
Ward, Lance
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Penn Yan Manor Nursing Home Inc
Penn Yan, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Finger Lakes Health
Geneva, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Ontario Center for Rehabilitation and Healthcare
Canandaigua, NY
1-star overall rating with 1-star inspections with abuse icon flag with $117,878 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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