Cycle 1
Health 2024-01-09 · Fire 2024-01-09
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rochester, NY
Church Home of the Protestant Episcopal Church
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
505 Mt. Hope Avenue, Rochester, NY
(585) 546-8400
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
182
Certified beds
Average residents
142
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-09-01
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
0.44
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.86
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.95
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,476
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.87% · Performance 21.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.62
Baseline 5.56% · Performance 6.75% · Measure score 3.62 · Achievement 3.62 · Improvement 0
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
5.27
Baseline 4.78 hours · Performance 4.58 hours · Measure score 5.27 · Achievement 5.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 7.5% · Lower 95% interval 7.27% |
| Discharge to community | 55.37% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 52.05% · Lower 95% interval 44.7% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 31 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 65.52% |
53.69%
11.8 pts better
|
Numerator 19 · Denominator 29 |
| Discharge mobility score | 75.86% |
50.94%
24.9 pts better
|
Numerator 22 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 3.69% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 8.99% |
8.2%
0.8 pts better
|
Numerator 31 · Denominator 345 |
| Staff flu vaccination coverage | 65.04% |
42%
23 pts better
|
Numerator 253 · Denominator 389 |
| Discharge function score | 79.31% |
56.45%
22.9 pts better
|
Numerator 23 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.5 · Expected 0.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.3
1 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
91.2%
5.1 pts worse
|
93.4%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 87.3% · Q3 85.5% · Q4 81.3% · 4Q avg 86.1% |
| 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 | 3.0% |
3.0%
About the same
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 3.1% · Q4 3.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 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 who lose too much weight | 4.8% |
6.1%
1.3 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.1% · Q3 10.3% · Q4 2.9% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.5% |
13.5%
9 pts better
|
19.6%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.2% · Q3 2.0% · Q4 5.7% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.8% |
14.8%
9 pts worse
|
16.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 26.2% · Q3 24.0% · Q4 21.4% · 4Q avg 23.8% · 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 | 18.0% |
15.1%
2.9 pts worse
|
16.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 23.4% · Q3 14.8% · Q4 11.0% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.1% |
15.5%
15.6 pts worse
|
14.9%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 33.0% · Q3 28.7% · Q4 33.7% · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
0.6%
2 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.9% · Q3 2.1% · Q4 2.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.4%
0.1 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 0.0% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.2% |
20.8%
10.4 pts worse
|
19.8%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 30.9% · Q3 29.3% · Q4 29.2% · 4Q avg 31.2% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.9%
2.5 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.9% · Q3 3.7% · Q4 4.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
76.7%
15.4 pts better
|
81.7%
10.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 93.1% · Q3 89.5% · Q4 93.0% · 4Q avg 92.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
9.7%
2.8 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 10.7% · Expected 9.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
78.8%
7.4 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.1% |
20.6%
11.5 pts better
|
23.9%
14.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 7.1% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-11 · Fire 2022-03-11
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2019-10-08 · Fire 2019-10-08
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-08
E · Potential for more than minimal harm
2022-03-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-05
C · Minimal harm
2022-03-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-05
D · Potential for more than minimal harm
2019-10-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-10-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-10-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-01-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-09
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 2024-03-08
D · Potential for more than minimal harm
2024-01-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-09
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-03-08
E · Potential for more than minimal harm
2022-03-11
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 2022-05-05
D · Potential for more than minimal harm
2022-03-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-11
F584 · Resident Rights Deficiencies
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 2022-05-05
D · Potential for more than minimal harm
2022-03-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-05-05
D · Potential for more than minimal harm
2019-10-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-10-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-10-08
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 2019-12-01
Penalties and ownership
What sits behind the stars
Ownership
Berk, Mary
Corporate Director · Individual
Episcopal Senior Life Communities, Inc.
Operational/Managerial Control · Organization
Marcello, Lisa
Operational/Managerial Control · Individual
Marcello, Lisa
Corporate Officer · Individual
Teugeman, Amanda
Corporate Officer · Individual
Wendland, Melissa
Corporate Director · Individual
Yates, Richard
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
St. John's Health Care Corporation
Rochester, NY
1-star overall rating with 1-star inspections with $141,034 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Kirkhaven
Rochester, NY
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Unity Living Center
Rochester, NY
3-star overall rating with 2-star inspections with $12,868 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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