Cycle 1
Health 2023-11-08 · Fire 2023-11-08
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
13 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Getzville, NY
Beechwood Homes
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
2235 Millersport Highway, Getzville, NY
(716) 810-7000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
272
Certified beds
Average residents
185
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-05-01
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
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.03
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
3.71
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,471
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.6
Composite VBP score used to determine payment impact.
Payment multiplier
1.0036
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.34
Baseline 22.28% · Performance 19.74% · Measure score 4.34 · Achievement 3.65 · Improvement 4.34
Healthcare-associated infections
6.87
Baseline 5.58% · Performance 5.78% · Measure score 6.87 · Achievement 6.87 · Improvement 0
Total nurse turnover
4.75
Baseline 32.65% · Performance 44.25% · Measure score 4.75 · Achievement 4.75 · Improvement 0
Adjusted total nurse staffing
3.87
Baseline 4.05 hours · Performance 4.18 hours · Measure score 3.87 · Achievement 3.87 · Improvement 0.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.79% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 4.14% · Lower 95% interval 5.6% |
| Discharge to community | 58.22% |
50.57%
7.6 pts better
|
Better than the National Rate · Eligible stays 180 · Observed rate 58.33% · Lower 95% interval 51.3% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 97 · Denominator 97 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 97 |
| Discharge self-care score | 45.33% |
53.69%
8.4 pts worse
|
Numerator 34 · Denominator 75 |
| Discharge mobility score | 68% |
50.94%
17.1 pts better
|
Numerator 51 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 9.28% |
2.29%
7 pts worse
|
Numerator 9 · Denominator 97 · Adjusted rate 8.44% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 2.06% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 7.3% |
8.2%
0.9 pts worse
|
Numerator 29 · Denominator 397 |
| Staff flu vaccination coverage | 70.38% |
42%
28.4 pts better
|
Numerator 297 · Denominator 422 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 48 · Denominator 75 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 62 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 54.17% |
25.2%
29 pts better
|
Numerator 26 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.7
1.2 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.3 · Expected 1.2 · 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 0.5 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.2%
8.4 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
95.3%
1 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.0%
1.4 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.9% · Q3 4.7% · Q4 2.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
18.5%
18.1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
6.1%
2.3 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.1% · Q3 3.8% · Q4 1.9% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
13.5%
1.2 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 13.4% · Q3 13.8% · Q4 15.2% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
14.8%
0.8 pts worse
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 16.6% · Q3 14.9% · Q4 13.4% · 4Q avg 15.6% · 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 | 9.0% |
15.1%
6.1 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 14.9% · Q3 7.4% · Q4 2.4% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
15.5%
2 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 17.8% · Q3 11.3% · Q4 9.2% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.6%
1.5 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.3% · Q3 2.2% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.4%
About the same
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.6% · Q3 1.2% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
20.8%
5.1 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 34.1% · Q3 21.5% · Q4 19.7% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 9.0% |
6.9%
2.1 pts worse
|
5.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.3% · Q3 9.5% · Q4 9.6% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.3% |
76.7%
0.4 pts worse
|
81.7%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.1% · Q2 79.4% · Q3 89.6% · Q4 71.2% · 4Q avg 76.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.5% |
9.7%
6.2 pts better
|
12.0%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 2.9% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.9% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.2% |
78.8%
4.4 pts better
|
79.7%
3.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
20.6%
0.1 pts worse
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 17.4% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-14 · Fire 2022-01-14
3 health deficiencies
Top issue: Environmental (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-05-09 · Fire 2019-05-09
3 health deficiencies
Top issue: Environmental (1 deficiency)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-11-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-08
K261 · Egress Deficiencies
Fire Safety
Have properly spaced exits within rooms.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K321 · Smoke Deficiencies
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 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-08
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-05
E · Potential for more than minimal harm
2022-01-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-11
E · Potential for more than minimal harm
2022-01-14
K321 · Smoke Deficiencies
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 2022-03-11
E · Potential for more than minimal harm
2022-01-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-03-11
E · Potential for more than minimal harm
2022-01-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-11
D · Potential for more than minimal harm
2022-01-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-03-11
D · Potential for more than minimal harm
2022-01-14
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-03-11
E · Potential for more than minimal harm
2019-05-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-09
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-06-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-26
D · Potential for more than minimal harm
2023-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-05
D · Potential for more than minimal harm
2022-01-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-03-11
D · Potential for more than minimal harm
2022-01-14
F761 · Pharmacy Service Deficiencies
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 2022-03-11
B · Minimal harm
2022-01-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-03-11
D · Potential for more than minimal harm
2019-05-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-06-28
C · Minimal harm
2019-05-09
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 2019-06-28
Penalties and ownership
What sits behind the stars
Ownership
Anderson, Kristin
Corporate Officer · Individual
Chau, Teresa
Contracted Managing Employee · Individual
Cohn, Andrew
Corporate Director · Individual
Denning, Gayle
Corporate Director · Individual
Fleichauer, Dennis
Corporate Director · Individual
Grogan, Thomas
Corporate Director · Individual
Hunt, Stephen
Corporate Director · Individual
Karr, Mary Beth
Corporate Director · Individual
Mccune, Richard
Operational/Managerial Control · Individual
Mccune, Richard
W-2 Managing Employee · Individual
Murphy, Pamela
Corporate Director · Individual
O'neill, Daniel
Operational/Managerial Control · Individual
O'neill, Daniel
Corporate Officer · Individual
Reichard, David
Corporate Director · Individual
Seekins, Jeffrey
Corporate Director · Individual
Whitney, Robert
Corporate Director · Individual
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