5 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Gasport, NY
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4540 Lincoln Drive, Gasport, NY
(716) 772-2631
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
83
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Absolut Care
Operator or chain grouping
Approved since
1976-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
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
0.22
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.19
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
0.22
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
5,247
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.17
Performance 20.43% · Measure score 2.17 · Achievement 2.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.49
Baseline 5.38% · Performance 6.49% · Measure score 4.49 · Achievement 4.49 · Improvement 0
Total nurse turnover
4.67
Baseline 42.10% · Performance 44.58% · Measure score 4.67 · Achievement 4.67 · Improvement 0
Adjusted total nurse staffing
3.42
Baseline 3.31 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 2.49
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 54 · Observed rate 12.96% · Lower 95% interval 7.19% |
| Discharge to community | 39.44% |
50.57%
11.1 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 30.43% · Lower 95% interval 26.23% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 88.37% |
95.27%
6.9 pts worse
|
Numerator 38 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 67.65% |
53.69%
14 pts better
|
Numerator 23 · Denominator 34 |
| Discharge mobility score | 85.29% |
50.94%
34.4 pts better
|
Numerator 29 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 6.98% |
2.29%
4.7 pts worse
|
Numerator 3 · Denominator 43 · Adjusted rate 6.6% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 2.94% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 14.06% |
8.2%
5.9 pts better
|
Numerator 18 · Denominator 128 |
| Staff flu vaccination coverage | 62.42% |
42%
20.4 pts better
|
Numerator 93 · Denominator 149 |
| Discharge function score | 79.41% |
56.45%
23 pts better
|
Numerator 27 · Denominator 34 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.93% |
25.2%
0.7 pts better
|
Numerator 7 · Denominator 27 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
91.2%
6.2 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.5% · Q4 91.4% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.1% |
95.3%
11.2 pts worse
|
95.5%
11.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.0%
4.1 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 12.1% · Q3 6.0% · Q4 2.9% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
18.5%
12.9 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 11.7% · Q3 3.3% · Q4 1.5% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
6.1%
0.2 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 8.1% · Q3 4.5% · Q4 9.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
13.5%
2.4 pts worse
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 17.2% · Q3 16.4% · Q4 14.7% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.8% |
14.8%
11 pts worse
|
16.7%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 22.9% · Q3 29.8% · Q4 22.8% · 4Q avg 25.8% · 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 | 14.3% |
15.1%
0.8 pts better
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 17.0% · Q3 8.0% · Q4 22.2% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
15.5%
0.8 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 12.7% · Q3 18.5% · Q4 16.7% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.4%
1.2 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.6% · Q3 3.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
20.8%
2.7 pts better
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 22.0% · Q3 19.2% · Q4 4.3% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
6.9%
2.4 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.6% · Q3 4.8% · Q4 4.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
76.7%
7 pts better
|
81.7%
2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 96.2% · Q3 78.9% · Q4 54.7% · 4Q avg 83.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
9.7%
4.6 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 15.6% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.2%
2.5 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.9% · Q3 3.8% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
78.8%
13.1 pts better
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
20.6%
2.7 pts worse
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 21.9% · Expected 22.3% · Used in QM five-star |
Survey summary
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-02
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-11-08
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-08
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-02
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-28
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-02
Health
Implement a program that monitors antibiotic use.
Corrected 2024-09-02
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-11-08
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-11-08
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 2022-11-08
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 2020-12-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-12-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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