Cycle 1
Health 2024-10-15 · Fire 2024-10-15
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fairport, NY
Crest Manor Living and Rehabilitation Center
1-star overall rating with 1-star inspections with $41,360 in total fines with 17 recent health deficiencies
6745 Pittsford-Palmyra Road, Fairport, NY
(585) 223-3633
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-01-01
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
0.41
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.64
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
2.83
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
92%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
80%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,243
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.58
Baseline 18.44% · Performance 21.16% · Measure score 0.58 · Achievement 0.58 · Improvement 0
Healthcare-associated infections
4.71
Baseline 6.03% · Performance 6.43% · Measure score 4.71 · Achievement 4.71 · Improvement 0
Total nurse turnover
0
Baseline 61.63% · Performance 65.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.09 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 12.77% · Lower 95% interval 7.81% |
| Discharge to community | 47.69% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 37.66% · Lower 95% interval 37.45% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 120 · Denominator 120 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 120 |
| Discharge self-care score | 53.57% |
53.69%
0.1 pts worse
|
Numerator 45 · Denominator 84 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 40 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 2 · Denominator 120 · Adjusted rate 1.65% |
| Healthcare-associated infections requiring hospitalization | 6.43% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 6.12% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 5.04% |
8.2%
3.2 pts worse
|
Numerator 6 · Denominator 119 |
| Staff flu vaccination coverage | 40.47% |
42%
1.5 pts worse
|
Numerator 87 · Denominator 215 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 44 · Denominator 84 |
| Transfer of health information to provider | 96.97% |
95.95%
1 pts better
|
Numerator 32 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 6 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.2% |
91.2%
30 pts worse
|
93.4%
32.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.4% · Q2 59.3% · Q3 65.4% · Q4 62.7% · 4Q avg 61.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.6% |
95.3%
8.7 pts worse
|
95.5%
8.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.0%
2.5 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 65.3% |
18.5%
46.8 pts worse
|
11.4%
53.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.1% · Q2 68.6% · Q3 62.5% · Q4 64.6% · 4Q avg 65.3% |
| Percentage of long-stay residents who lose too much weight | 19.0% |
6.1%
12.9 pts worse
|
5.4%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 15.8% · Q3 19.6% · Q4 22.9% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.3% |
13.5%
7.2 pts better
|
19.6%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 7.0% · Q3 7.8% · Q4 2.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
14.8%
2.8 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 14.6% · Q3 13.0% · Q4 7.0% · 4Q avg 12.0% · 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 | 11.8% |
15.1%
3.3 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
15.5%
5.2 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 14.5% · Q3 2.1% · Q4 4.0% · 4Q avg 10.3% · 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 | 1.0% |
1.4%
0.4 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
20.8%
5.3 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.2% · Q2 17.0% · Q3 2.1% · Q4 11.6% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
6.9%
3.5 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.9% · Q3 10.5% · Q4 14.1% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 32.3% |
76.7%
44.4 pts worse
|
81.7%
49.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 26.1% · Q3 37.8% · Q4 37.1% · 4Q avg 32.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
9.7%
2.5 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 8.2% · Expected 12.7% · 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 | 34.2% |
78.8%
44.6 pts worse
|
79.7%
45.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
20.6%
7.5 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 36.1% · Expected 30.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-18 · Fire 2023-04-18
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-09-27 · Fire 2021-09-27
7 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2024-10-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-02
G · Actual harm
2024-10-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-15
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-15
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 2024-12-02
E · Potential for more than minimal harm
2024-10-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-10-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-10-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-15
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 2024-12-02
D · Potential for more than minimal harm
2024-10-15
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 2024-12-02
D · Potential for more than minimal harm
2024-10-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-15
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 2024-12-02
D · Potential for more than minimal harm
2024-10-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-15
F758 · Pharmacy Service Deficiencies
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 2024-12-02
D · Potential for more than minimal harm
2024-05-16
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 2024-07-12
E · Potential for more than minimal harm
2024-01-16
F836 · Administration Deficiencies
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 2024-03-14
E · Potential for more than minimal harm
2024-01-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-01-16
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-01-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-14
E · Potential for more than minimal harm
2023-04-18
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 2023-06-17
E · Potential for more than minimal harm
2023-04-18
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 2023-06-17
E · Potential for more than minimal harm
2023-04-18
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 2023-06-17
E · Potential for more than minimal harm
2023-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-17
D · Potential for more than minimal harm
2023-04-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-06-17
D · Potential for more than minimal harm
2023-04-18
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 2023-06-17
D · Potential for more than minimal harm
2023-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-17
D · Potential for more than minimal harm
2023-04-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-17
E · Potential for more than minimal harm
2021-09-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-11-26
E · Potential for more than minimal harm
2021-09-27
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 2021-11-26
D · Potential for more than minimal harm
2021-09-27
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 2021-11-26
Penalties and ownership
What sits behind the stars
$41,360
2024-10-15
Fine
Fine · fine $41,360
Fine
Ownership
Cme Jm Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Farkas, Jennifer
5% Or Greater Indirect Ownership Interest · Individual
Brown, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Gibber, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Lebovics, Michael
5% Or Greater Indirect Ownership Interest · Individual
Ajb LLC
Operational/Managerial Control · Organization
Brown, Avrohom
Operational/Managerial Control · Individual
Brown, Avrohom
Corporate Officer · Individual
Buslovich, Steven
Contracted Managing Employee · Individual
Krull, Jerome
Operational/Managerial Control · Individual
Roesch, Burnedette
Operational/Managerial Control · Individual
Roesch, Burnedette
W-2 Managing Employee · Individual
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#3
Highlands Living Center
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2-star overall rating with 2-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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