Cycle 1
Health 2024-11-19 · Fire 2024-11-19
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Saratoga Springs, NY
Wesley Health Care Center Inc
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
131 Lawrence Street, Saratoga Springs, NY
(518) 587-3600
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
356
Certified beds
Average residents
284
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.42
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,760
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0090
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.69
Baseline 16.34% · Performance 19.26% · Measure score 4.69 · Achievement 4.69 · Improvement 0
Healthcare-associated infections
7.99
Baseline 4.84% · Performance 5.45% · Measure score 7.99 · Achievement 7.99 · Improvement 0
Total nurse turnover
4.62
Baseline 39.07% · Performance 44.80% · Measure score 4.62 · Achievement 4.62 · Improvement 0
Adjusted total nurse staffing
4.36
Baseline 3.23 hours · Performance 4.32 hours · Measure score 4.36 · Achievement 4.36 · Improvement 3.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.95% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 350 · Observed rate 10% · Lower 95% interval 8.12% |
| Discharge to community | 56.57% |
50.57%
6 pts better
|
No Different than the National Rate · Eligible stays 330 · Observed rate 51.21% · Lower 95% interval 49.62% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 92.35% |
95.27%
2.9 pts worse
|
Numerator 169 · Denominator 183 |
| Falls with major injury | 1.64% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 183 |
| Discharge self-care score | 44.08% |
53.69%
9.6 pts worse
|
Numerator 67 · Denominator 152 |
| Discharge mobility score | 48.03% |
50.94%
2.9 pts worse
|
Numerator 73 · Denominator 152 |
| Pressure ulcers or injuries, new or worsened | 4.37% |
2.29%
2.1 pts worse
|
Numerator 8 · Denominator 183 · Adjusted rate 4.99% |
| Healthcare-associated infections requiring hospitalization | 5.45% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 208 · Observed rate 3.85% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 7.02% |
8.2%
1.2 pts worse
|
Numerator 29 · Denominator 413 |
| Staff flu vaccination coverage | 57.25% |
42%
15.2 pts better
|
Numerator 312 · Denominator 545 |
| Discharge function score | 48.68% |
56.45%
7.8 pts worse
|
Numerator 74 · Denominator 152 |
| Transfer of health information to provider | 96.55% |
95.95%
0.6 pts better
|
Numerator 28 · Denominator 29 |
| Transfer of health information to patient | 95.7% |
96.28%
0.6 pts worse
|
Numerator 89 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 41.11% |
25.2%
15.9 pts better
|
Numerator 37 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.7% |
91.2%
10.5 pts worse
|
93.4%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.7% · Q2 80.7% · Q3 83.1% · Q4 81.4% · 4Q avg 80.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
95.3%
0.9 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.5% |
3.0%
4.5 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 8.0% · Q3 6.5% · Q4 5.8% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
18.5%
14.8 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.9% · Q3 2.8% · Q4 0.9% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 10.8% |
6.1%
4.7 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 16.3% · Q3 9.5% · Q4 9.7% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
13.5%
6.6 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 21.3% · Q3 21.5% · Q4 18.3% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
14.8%
0.7 pts worse
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 13.3% · Q3 16.0% · Q4 18.2% · 4Q avg 15.5% · 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 | 13.3% |
15.1%
1.8 pts better
|
16.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 16.3% · Q3 15.5% · Q4 8.6% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
15.5%
0.8 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 15.8% · Q3 22.8% · Q4 15.1% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.6%
0.6 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.3% · Q3 1.4% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.4%
0.9 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.7% · Q3 2.9% · Q4 1.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
20.8%
10.1 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.4% · Q2 31.2% · Q3 30.3% · Q4 23.0% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
6.9%
0.7 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 6.8% · Q3 8.1% · Q4 6.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
76.7%
9.7 pts better
|
81.7%
4.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 86.1% · Q3 88.2% · Q4 91.7% · 4Q avg 86.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
9.7%
0.6 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 7.8% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.1% |
78.8%
6.3 pts better
|
79.7%
5.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
20.6%
2.4 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 16.2% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-05 · Fire 2021-10-05
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2019-04-17 · Fire 2019-04-17
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-11-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Not marked corrected
F · Potential for more than minimal harm
2024-11-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-11-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-05
F · Potential for more than minimal harm
2024-11-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-11-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-11-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-11-19
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-11-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-05
F · Potential for more than minimal harm
2021-10-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-11-30
F · Potential for more than minimal harm
2021-10-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-10-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-11
E · Potential for more than minimal harm
2021-10-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-30
C · Minimal harm
2021-10-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-11-30
C · Minimal harm
2021-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-11
F · Potential for more than minimal harm
2019-04-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-06-16
E · Potential for more than minimal harm
2019-04-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-06-16
E · Potential for more than minimal harm
2019-04-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-06-16
E · Potential for more than minimal harm
2019-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-16
E · Potential for more than minimal harm
2019-04-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-19
E · Potential for more than minimal harm
2019-04-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-06-16
E · Potential for more than minimal harm
2019-04-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-06-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-11-19
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 2024-12-30
D · Potential for more than minimal harm
2024-11-19
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 2024-11-20
D · Potential for more than minimal harm
2024-11-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-19
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-12-16
D · Potential for more than minimal harm
2024-11-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-11-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-30
D · Potential for more than minimal harm
2023-08-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-08-11
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-10-04
D · Potential for more than minimal harm
2021-10-05
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 2021-11-16
D · Potential for more than minimal harm
2021-10-05
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 2021-11-30
D · Potential for more than minimal harm
2021-10-05
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-10-05
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2021-11-30
D · Potential for more than minimal harm
2019-04-17
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 2019-06-07
D · Potential for more than minimal harm
2019-04-17
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 2019-05-31
D · Potential for more than minimal harm
2019-04-17
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-04-17
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-06-16
D · Potential for more than minimal harm
2019-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-07
Penalties and ownership
What sits behind the stars
Ownership
Amato, Shelly
Corporate Officer · Individual
Boucher, Jesse
Corporate Director · Individual
Damm-O'brien, Deborah
Corporate Director · Individual
Jlr Physical,occupational And Speech Therapy
Operational/Managerial Control · Organization
Lahoff, Katherine
Operational/Managerial Control · Individual
Lahoff, Katherine
Corporate Officer · Individual
Martin, Raymond
Corporate Director · Individual
Mirza, Ali
Operational/Managerial Control · Individual
Nealon, Brian
Operational/Managerial Control · Individual
Nealon, Brian
Corporate Officer · Individual
Pancoe, Brooke
Corporate Director · Individual
Tully, Kevin
Corporate Director · Individual
United Methodist Health And Housing Inc.
Operational/Managerial Control · Organization
Walker, Marc
Operational/Managerial Control · Individual
Wesley Health Care Center, Inc.
Operational/Managerial Control · Organization
Nearby options
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1-star overall rating with 1-star inspections with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
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#3
Glens Falls Center For Rehabilitation And Nursing
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3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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