Cycle 1
Health 2024-11-15 · Fire 2024-11-15
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Clifton Springs, NY
Clifton Springs Hospital and Clinic Extended Care
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2 Coulter Road, Clifton Springs, NY
(315) 462-0557
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
105
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Rochester Regional Health
Operator or chain grouping
Approved since
1972-01-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 4 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.43
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
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,662
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.62
Baseline 20.19% · Performance 19.75% · Measure score 3.62 · Achievement 3.62 · Improvement 0.88
Healthcare-associated infections
3.14
Baseline 6.68% · Performance 6.90% · Measure score 3.14 · Achievement 3.14 · Improvement 0
Total nurse turnover
4.97
Performance 43.36% · Measure score 4.97 · Achievement 4.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.42
Baseline 3.68 hours · Performance 3.77 hours · Measure score 2.42 · Achievement 2.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.02% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 8.96% · Lower 95% interval 6.73% |
| Discharge to community | 52.08% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 39.44% · Lower 95% interval 37.78% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.55% |
95.27%
0.7 pts worse
|
Numerator 52 · Denominator 55 |
| Falls with major injury | 3.64% |
0.77%
2.9 pts worse
|
Numerator 2 · Denominator 55 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 21 · Denominator 45 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 15 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 2.17% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 66.18% |
42%
24.2 pts better
|
Numerator 137 · Denominator 207 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 27 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 28 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 52.17% |
25.2%
27 pts better
|
Numerator 12 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.3
1.3 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
91.2%
7.2 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.7% · Q3 99.0% · Q4 97.8% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
95.3%
3.7 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.0%
0.6 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.3% · Q3 5.2% · Q4 3.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
18.5%
13.4 pts better
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 7.7% · Q4 10.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.1%
1.1 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.6% · Q3 7.4% · Q4 9.0% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
13.5%
2.1 pts worse
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 14.1% · Q3 17.7% · Q4 15.6% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.0% |
14.8%
0.8 pts better
|
16.7%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 19.2% · Q3 15.5% · Q4 8.5% · 4Q avg 14.0% · 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 | 17.1% |
15.1%
2 pts worse
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 20.8% · Q3 20.3% · Q4 10.8% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
15.5%
2.2 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 23.9% · Q3 21.6% · Q4 15.7% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.6%
0.1 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.9% · Q3 0.0% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.4%
0.6 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
20.8%
8.5 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.7% · Q3 13.0% · Q4 26.3% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.9%
4.4 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 12.1% · Q3 13.1% · Q4 9.4% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.8% |
76.7%
8.1 pts better
|
81.7%
3.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.5% · Q2 91.8% · Q3 88.2% · Q4 76.3% · 4Q avg 84.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
9.7%
4 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 14.8% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.2% |
78.8%
9.4 pts better
|
79.7%
8.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
20.6%
9.1 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 35.2% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-03 · Fire 2023-03-03
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-05-18 · Fire 2021-05-18
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-11-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-14
B · Minimal harm
2024-11-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-14
D · Potential for more than minimal harm
2023-03-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-01
D · Potential for more than minimal harm
2021-05-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-05-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-05-18
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 2021-07-17
D · Potential for more than minimal harm
2021-05-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-07-17
B · Minimal harm
2021-05-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-07-17
B · Minimal harm
2021-05-18
F625 · Resident Rights Deficiencies
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 2021-07-17
Penalties and ownership
What sits behind the stars
Ownership
Adams, Holly
Corporate Director · Individual
Adams, Kerry
Corporate Director · Individual
Crilly, Thomas
Corporate Director · Individual
Crilly, Thomas
W-2 Managing Employee · Individual
Day, Nicholas
Corporate Director · Individual
Glastonbury, Howard
Corporate Officer · Individual
Hamilton, Yvonne
W-2 Managing Employee · Individual
Holder, Nichole
W-2 Managing Employee · Individual
Hoyt, Shawn
W-2 Managing Employee · Individual
Ignaczak, Stephen
Corporate Director · Individual
Mattoon, Lisa
Corporate Officer · Individual
Mirhadi, Kayvan
Corporate Director · Individual
Mueller, Sally
Corporate Director · Individual
Reiter, Jean
W-2 Managing Employee · Individual
Riccio, Dustin
Corporate Officer · Individual
Sobel, Sidney
Corporate Director · Individual
Stuck, Dina
Corporate Director · Individual
Woodhouse, Robert
Corporate Director · Individual
Young, William
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Ontario Center for Rehabilitation and Healthcare
Canandaigua, NY
1-star overall rating with 1-star inspections with abuse icon flag with $117,878 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Wayne Health Care
Newark, NY
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Newark Manor Nursing Home Inc
Newark, NY
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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