9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rochester, NY
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
989 Blossom Road, Rochester, NY
(585) 482-3500
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-11-01
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
RN hours / resident day
0.42
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.16
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
2.65
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
5,534
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.09
Baseline 21.00% · Performance 20.93% · Measure score 1.09 · Achievement 1.09 · Improvement 0
Healthcare-associated infections
8.74
Baseline 8.48% · Performance 5.26% · Measure score 8.74 · Achievement 8.62 · Improvement 8.74
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0.93
Baseline 2.84 hours · Performance 3.26 hours · Measure score 0.93 · Achievement 0.63 · Improvement 0.93
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.39% |
10.72%
3.7 pts worse
|
No Different than the National Rate · Eligible stays 158 · Observed rate 20.25% · Lower 95% interval 10.67% |
| Discharge to community | 34.56% |
50.57%
16 pts worse
|
Worse than the National Rate · Eligible stays 113 · Observed rate 22.12% · Lower 95% interval 25.01% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 111 · Denominator 111 |
| Falls with major injury | 0.9% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 111 |
| Discharge self-care score | 43.06% |
53.69%
10.6 pts worse
|
Numerator 31 · Denominator 72 |
| Discharge mobility score | 40.28% |
50.94%
10.7 pts worse
|
Numerator 29 · Denominator 72 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 111 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.26% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 1.39% · Lower 95% interval 2.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | 32.89% |
42%
9.1 pts worse
|
Numerator 49 · Denominator 149 |
| Discharge function score | 43.06% |
56.45%
13.4 pts worse
|
Numerator 31 · Denominator 72 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 43.14% |
25.2%
17.9 pts better
|
Numerator 22 · Denominator 51 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.7
1.1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.3
1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
91.2%
7.7 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.5% · Q3 100.0% · Q4 98.6% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.0%
1 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.5% · Q3 2.9% · Q4 2.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 79.6% |
18.5%
61.1 pts worse
|
11.4%
68.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.3% · Q2 76.2% · Q3 87.3% · Q4 81.2% · 4Q avg 79.6% |
| Percentage of long-stay residents who lose too much weight | 11.0% |
6.1%
4.9 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.7% · Q3 10.9% · Q4 10.4% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
13.5%
5.1 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 7.5% · Q3 7.4% · Q4 7.1% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
14.8%
1.5 pts worse
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 22.7% · Q3 15.2% · Q4 17.0% · 4Q avg 16.3% · 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 | 4.7% |
15.1%
10.4 pts better
|
16.3%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.4% |
15.5%
7.1 pts better
|
14.9%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 7.7% · Q3 1.5% · Q4 3.0% · 4Q avg 8.4% · 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 | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 29.0% |
20.8%
8.2 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 32.5% · Q3 27.1% · Q4 22.0% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.9%
0.9 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.5% · Q3 9.3% · Q4 9.7% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.6% |
76.7%
9.1 pts worse
|
81.7%
14.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.0% · Q2 64.0% · Q3 74.5% · Q4 80.3% · 4Q avg 67.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
9.7%
5.2 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 16.9% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.2%
1.1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.7% |
78.8%
14.1 pts worse
|
79.7%
15 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
20.6%
12.4 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 34.8% · Expected 25.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (5 deficiencies)
12 fire-safety deficiencies
Top issue: Services (3 deficiencies)
Top issue: Infection Control (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-27
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2024-11-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-15
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-02
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-02-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-03
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-02-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-02
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-03-02
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-03
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-02-03
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-03-02
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-12-21
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2020-12-21
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2020-12-21
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2020-12-21
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2020-12-21
Fire Safety
Provide family notifications of emergency plan.
Corrected 2020-12-21
Fire Safety
Establish emergency prep training and testing.
Corrected 2020-12-21
Inspection history
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 2024-11-15
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-11-15
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-11-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-15
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-15
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-11-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-15
Health
Keep all essential equipment working safely.
Corrected 2024-11-15
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-02-15
Health
Keep all essential equipment working safely.
Corrected 2023-02-03
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-03-02
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-03
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-02-03
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-03
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-03
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-02-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-03
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 2023-02-03
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2023-02-03
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-02-03
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-02-03
Health
Post nurse staffing information every day.
Corrected 2023-02-03
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-03
Health
Provide and implement an infection prevention and control program.
Corrected 2020-12-21
Health
Implement a program that monitors antibiotic use.
Corrected 2020-12-21
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2020-12-21
Health
Respond appropriately to all alleged violations.
Corrected 2020-12-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-12-21
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 2020-12-21
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-12-21
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 2020-12-21
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2020-12-21
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2020-12-21
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2020-12-21
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
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