Cycle 1
Health 2025-07-25 · Fire 2025-07-25
1 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Syracuse, NY
Upstate University Hosp At Community General T C U
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4900 Broad Road, Syracuse, NY
(315) 492-5786
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
16
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-07-24
CMS approved date
Coverage
Medicare
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
6.36
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
2.11
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
8.46
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
8.46
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
8.14
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
6.26
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.36
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
6.22
CMS adjusted RN staffing hours
Adjusted total hours
8.28
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,686
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.5
Baseline 22.87% · Performance 22.28% · Measure score 0.5 · Achievement 0 · Improvement 0.5
Healthcare-associated infections
5.46
Baseline 4.50% · Performance 6.20% · Measure score 5.46 · Achievement 5.46 · Improvement 0
Total nurse turnover
4.63
Performance 44.74% · Measure score 4.63 · Achievement 4.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 364 · Observed rate 7.97% · Lower 95% interval 8.16% |
| Discharge to community | 70.01% |
50.57%
19.4 pts better
|
Better than the National Rate · Eligible stays 374 · Observed rate 73.8% · Lower 95% interval 66.59% |
| Medicare spending per beneficiary | 0.54 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 99.59% |
95.27%
4.3 pts better
|
Numerator 244 · Denominator 245 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 245 |
| Discharge self-care score | 57.81% |
53.69%
4.1 pts better
|
Numerator 111 · Denominator 192 |
| Discharge mobility score | 72.4% |
50.94%
21.5 pts better
|
Numerator 139 · Denominator 192 |
| Pressure ulcers or injuries, new or worsened | 0.41% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 245 · Adjusted rate 0.77% |
| Healthcare-associated infections requiring hospitalization | 6.2% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 3.94% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 22.22% |
8.2%
14 pts better
|
Numerator 18 · Denominator 81 |
| Staff flu vaccination coverage | 70.59% |
42%
28.6 pts better
|
Numerator 24 · Denominator 34 |
| Discharge function score | 54.17% |
56.45%
2.3 pts worse
|
Numerator 104 · Denominator 192 |
| Transfer of health information to provider | 91.55% |
95.95%
4.4 pts worse
|
Numerator 65 · Denominator 71 |
| Transfer of health information to patient | 97.09% |
96.28%
0.8 pts better
|
Numerator 167 · Denominator 172 |
| Resident COVID-19 vaccinations up to date | 53.78% |
25.2%
28.6 pts better
|
Numerator 64 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
76.7%
20.5 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 96.6% · Q4 92.8% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
9.7%
1.8 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 2.4% · Q3 2.4% · Q4 1.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
78.8%
20.3 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
20.6%
3.4 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 18.2% · Expected 18.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-13 · Fire 2024-03-13
2 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-12-29 · Fire 2021-12-29
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Electrical (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-07-25
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-07-25
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-07-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-07-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-19
D · Potential for more than minimal harm
2024-03-13
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-03-13
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-03-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-03-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-12
D · Potential for more than minimal harm
2021-12-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-12-29
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-02-14
D · Potential for more than minimal harm
2021-12-29
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-01-24
Inspection history
Recent health citations
C · Minimal harm
2025-07-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Not marked corrected
E · Potential for more than minimal harm
2024-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-12
C · Minimal harm
2024-03-13
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-30
D · Potential for more than minimal harm
2021-12-29
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 2022-01-18
Penalties and ownership
What sits behind the stars
Ownership
Nys Office Of Mental Health
5% Or Greater Direct Ownership Interest · Organization
Corona, Robert
Corporate Officer · Individual
Corona, Robert
W-2 Managing Employee · Individual
Daoust, Nancy
Corporate Officer · Individual
Daoust, Nancy
W-2 Managing Employee · Individual
Wright, Stuart
Corporate Officer · Individual
Wright, Stuart
W-2 Managing Employee · Individual
Nearby options
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Van Duyn Center For Rehabilitation And Nursing
Syracuse, NY
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $498,455 in total fines with 31 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Loretto Health And Rehabilitation Center
Syracuse, NY
2-star overall rating with 1-star inspections with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Central Park Rehabilitation And Nursing Center
Syracuse, NY
1-star overall rating with 1-star inspections with 11 recent health deficiencies
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