3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Canton, NY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
205 State Street Road, Canton, NY
(315) 386-4541
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
160
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-01-01
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
Staffing
RN hours / resident day
0.65
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.71
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
6,861
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.21
Baseline 18.70% · Performance 18.09% · Measure score 7.21 · Achievement 7.21 · Improvement 3.18
Healthcare-associated infections
0.99
Baseline 5.65% · Performance 7.54% · Measure score 0.99 · Achievement 0.99 · Improvement 0
Total nurse turnover
2.84
Baseline 53.19% · Performance 52.08% · Measure score 2.84 · Achievement 2.84 · Improvement 0
Adjusted total nurse staffing
1.56
Baseline 3.55 hours · Performance 3.52 hours · Measure score 1.56 · Achievement 1.56 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.69% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 184 · Observed rate 7.07% · Lower 95% interval 6.82% |
| Discharge to community | 60.63% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 154 · Observed rate 57.14% · Lower 95% interval 53.24% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 127 · Denominator 127 |
| Falls with major injury | 1.57% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 127 |
| Discharge self-care score | 43.81% |
53.69%
9.9 pts worse
|
Numerator 46 · Denominator 105 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 63 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 2.36% |
2.29%
0.1 pts worse
|
Numerator 3 · Denominator 127 · Adjusted rate 2.45% |
| Healthcare-associated infections requiring hospitalization | 7.54% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 7.56% · Lower 95% interval 4.71% |
| Staff COVID-19 vaccination coverage | 4.6% |
8.2%
3.6 pts worse
|
Numerator 8 · Denominator 174 |
| Staff flu vaccination coverage | 83.26% |
42%
41.3 pts better
|
Numerator 179 · Denominator 215 |
| Discharge function score | 59.05% |
56.45%
2.6 pts better
|
Numerator 62 · Denominator 105 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 50 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 58.33% |
25.2%
33.1 pts better
|
Numerator 42 · Denominator 72 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.3
0.5 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
95.3%
3.6 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.0%
2.4 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.0% · Q3 4.7% · Q4 6.0% · 4Q avg 5.4% · 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 | 4.1% |
6.1%
2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.0% · Q3 4.8% · Q4 3.9% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.7% |
13.5%
3.8 pts better
|
19.6%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 8.3% · Q3 10.6% · Q4 9.9% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.9% |
14.8%
13.1 pts worse
|
16.7%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 30.0% · Q3 27.6% · Q4 22.9% · 4Q avg 27.9% · 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 | 19.0% |
15.1%
3.9 pts worse
|
16.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 28.3% · Q3 16.1% · Q4 8.6% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
15.5%
7.9 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 22.4% · Q3 21.2% · Q4 20.3% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.6%
About the same
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.1% |
1.4%
7.7 pts worse
|
1.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 11.2% · Q3 15.5% · Q4 6.3% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
20.8%
4.3 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 24.0% · Q3 25.9% · Q4 23.1% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.9%
1.1 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.8% · Q3 7.7% · Q4 7.8% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
76.7%
11.8 pts better
|
81.7%
6.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 88.9% · Q3 94.3% · Q4 89.7% · 4Q avg 88.5% |
| 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 12.3% · Expected 10.1% · 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% · Q4 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 | 89.4% |
78.8%
10.6 pts better
|
79.7%
9.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
20.6%
3.1 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 15.8% · Expected 21.5% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-16
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-01
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-05
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 2022-08-05
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-05
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-07-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-08-27
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-08-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-30
Inspection history
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 2024-10-08
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-08
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 2024-10-08
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 2022-08-05
Health
Respond appropriately to all alleged violations.
Corrected 2022-08-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-05
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-07-30
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 2019-07-30
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-07-22
Penalties and ownership
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
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