Cycle 1
Health 2024-07-26 · Fire 2024-07-26
3 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Elmira, NY
St. Joseph's Hospital - Skilled Nursing Facility
3-star overall rating with 4-star inspections with $4,194 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
555 St. Joseph's Boulevard, Elmira, NY
(607) 733-6541
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
82
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,808
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.50
Baseline 18.93% · Performance 20.27% · Measure score 2.50 · Achievement 2.50 · Improvement 0
Healthcare-associated infections
2.89
Baseline 5.45% · Performance 6.97% · Measure score 2.89 · Achievement 2.89 · Improvement 0
Total nurse turnover
7.76
Baseline 35.95% · Performance 31.94% · Measure score 7.76 · Achievement 7.76 · Improvement 3.11
Adjusted total nurse staffing
3.88
Baseline 4.27 hours · Performance 4.18 hours · Measure score 3.88 · Achievement 3.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.29% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 13.1% · Lower 95% interval 8.78% |
| Discharge to community | 49.69% |
50.57%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 48.72% · Lower 95% interval 39.01% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 6.67% |
0.77%
5.9 pts worse
|
Numerator 2 · Denominator 30 |
| Discharge self-care score | 30.43% |
53.69%
23.3 pts worse
|
Numerator 7 · Denominator 23 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 10 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 23.08% |
8.2%
14.9 pts better
|
Numerator 24 · Denominator 104 |
| Staff flu vaccination coverage | 70.53% |
42%
28.5 pts better
|
Numerator 67 · Denominator 95 |
| Discharge function score | 39.13% |
56.45%
17.3 pts worse
|
Numerator 9 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
1.3
2.2 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
91.2%
3.7 pts worse
|
93.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 83.3% · Q3 97.3% · Q4 88.2% · 4Q avg 87.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
95.3%
0.8 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.0%
3.6 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 5.6% · Q3 10.8% · Q4 7.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
18.5%
18.1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
6.1%
4.7 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.7% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
13.5%
5.9 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 21.1% · Q3 20.5% · Q4 16.2% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
14.8%
3.6 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 15.8% · Q3 19.0% · Q4 22.0% · 4Q avg 18.4% · 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 31.7% · Q2 28.8% · Q3 15.4% · Q4 22.2% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
15.5%
4.7 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 22.2% · Q3 18.8% · Q4 13.4% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.6%
0.8 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.0% · Q3 0.0% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
1.4%
3.1 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.2% · Q3 4.1% · Q4 2.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
20.8%
0.8 pts worse
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 22.6% · Q3 15.8% · Q4 28.4% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
6.9%
1.4 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 11.4% · Q3 4.7% · Q4 6.5% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.5% |
76.7%
19.2 pts worse
|
81.7%
24.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.3% · Q2 72.3% · Q3 62.8% · Q4 48.4% · 4Q avg 57.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
9.7%
4 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.2%
2.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 3.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.6% |
78.8%
2.2 pts worse
|
79.7%
3.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.4% |
20.6%
6.2 pts better
|
23.9%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 13.0% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-01 · Fire 2022-04-01
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-01-24 · Fire 2020-01-24
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-26
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-07-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-15
E · Potential for more than minimal harm
2022-04-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-05-31
D · Potential for more than minimal harm
2020-01-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-04-03
C · Minimal harm
2020-01-24
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2020-04-03
C · Minimal harm
2020-01-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-04-03
C · Minimal harm
2020-01-24
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2020-04-03
C · Minimal harm
2020-01-24
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2020-04-03
C · Minimal harm
2020-01-24
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2020-04-03
C · Minimal harm
2020-01-24
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-04-03
C · Minimal harm
2020-01-24
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2020-04-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-26
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 2024-09-15
D · Potential for more than minimal harm
2024-07-26
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-09-15
B · Minimal harm
2024-07-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-15
G · Actual harm
2022-04-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-05-30
E · Potential for more than minimal harm
2022-04-01
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 2022-05-30
B · Minimal harm
2022-04-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-05-30
E · Potential for more than minimal harm
2020-01-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-04-03
E · Potential for more than minimal harm
2020-01-24
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 2020-04-03
D · Potential for more than minimal harm
2020-01-24
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-01-24
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 2020-04-03
D · Potential for more than minimal harm
2020-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-03
Penalties and ownership
What sits behind the stars
$4,194
2023-06-05
Fine
Fine · fine $4,194
Fine
Ownership
Burke, Daniel
Corporate Director · Individual
Dalrymple, David
Corporate Director · Individual
Deschamps, Christine
Corporate Director · Individual
Eberhard, S.
Corporate Director · Individual
Farley, H.
Corporate Officer · Individual
Farley, H.
W-2 Managing Employee · Individual
Hagan, Mark
Corporate Director · Individual
Herzl-Betz, Kenneth
Corporate Director · Individual
Hosey, Michael
Corporate Director · Individual
Kintz, Ronald
Corporate Officer · Individual
Kyles, Roy
Corporate Director · Individual
Lambert, Robert
Corporate Officer · Individual
Lambert, Robert
W-2 Managing Employee · Individual
Lynch, Ben
Corporate Director · Individual
Manning, Joseph
Corporate Director · Individual
Martin, Gregg
W-2 Managing Employee · Individual
Mcnamara, Robert
Corporate Director · Individual
Mitchell, Mary
Corporate Director · Individual
O'mara, John
Corporate Director · Individual
Oconnor, Kevin
Corporate Director · Individual
Quick, Donald
Corporate Director · Individual
Rogers, Patrick
Corporate Director · Individual
Rustici, Marc
Operational/Managerial Control · Individual
Sartori, Melinda
Corporate Director · Individual
Schenone, Roger
Corporate Director · Individual
Streeter, Margaret
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Chemung County Health Center - Nursing Facility
Elmira, NY
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Elcor Nursing and Rehabilitation Center
Horseheads, NY
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Bethany Nursing Home & Health Related Facility Inc
Horseheads, NY
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out