3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Avon, NY
2-star overall rating with 2-star inspections with $96,857 in total fines with 3 recent health deficiencies
215 Clinton Street, Avon, NY
(585) 226-2225
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
40
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hurlbut Care
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.62
Registered nurse staffing
LPN hours / resident day
0.72
Licensed practical nurse staffing
Aide hours / resident day
1.87
Nurse aide staffing
Weekend hours
2.81
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
91.2%
5.3 pts worse
|
93.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.3%
2.1 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.0%
3 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
18.5%
17.8 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.8% |
6.1%
2.7 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.7% |
13.5%
5.8 pts better
|
19.6%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
14.8%
2.8 pts worse
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.1% |
15.1%
6 pts worse
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.2% |
15.5%
6.7 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.6%
0.5 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
1.4%
4.6 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.2% |
20.8%
18.4 pts worse
|
19.8%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
6.9%
4.4 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.9% |
76.7%
23.8 pts worse
|
81.7%
28.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
Survey summary
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-03-24
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-11-15
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 2021-11-15
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-11-15
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-11-15
Inspection history
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-22
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-15
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-11-15
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-11-15
Penalties and ownership
Fine · fine $32,975
Fine
Fine · fine $63,882
Fine
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
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