Cycle 1
Health 2024-10-03 · Fire 2024-10-03
5 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
North Tonawanda, NY
Degraff Memorial Hospital-Skilled Nursing Facility
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
445 Tremont Street, North Tonawanda, NY
(716) 690-2080
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
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
1984-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.26
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
2.28
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.33
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.30
CMS adjusted RN staffing hours
Adjusted total hours
4.76
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,508
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.41
Composite VBP score used to determine payment impact.
Payment multiplier
1.0033
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.27
Baseline 20.94% · Performance 18.99% · Measure score 5.27 · Achievement 5.27 · Improvement 4.49
Healthcare-associated infections
6.34
Baseline 5.86% · Performance 5.94% · Measure score 6.34 · Achievement 6.34 · Improvement 0
Total nurse turnover
2.73
Baseline 35.09% · Performance 52.52% · Measure score 2.73 · Achievement 2.73 · Improvement 0
Adjusted total nurse staffing
5.42
Baseline 2.89 hours · Performance 4.60 hours · Measure score 5.42 · Achievement 5.36 · Improvement 5.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 7.5% · Lower 95% interval 6.58% |
| Discharge to community | 51.77% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 52.56% · Lower 95% interval 43.47% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 42 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 41.94% |
53.69%
11.8 pts worse
|
Numerator 13 · Denominator 31 |
| Discharge mobility score | 45.16% |
50.94%
5.8 pts worse
|
Numerator 14 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 8.89% |
2.29%
6.6 pts worse
|
Numerator 4 · Denominator 45 · Adjusted rate 7.15% |
| Healthcare-associated infections requiring hospitalization | 5.94% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 0% · Lower 95% interval 2.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 59.29% |
42%
17.3 pts better
|
Numerator 67 · Denominator 113 |
| Discharge function score | 51.61% |
56.45%
4.8 pts worse
|
Numerator 16 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 86.36% |
96.28%
9.9 pts worse
|
Numerator 19 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 32.14% |
25.2%
6.9 pts better
|
Numerator 9 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.4 · 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 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
95.3%
1.9 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.0%
1.9 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
18.5%
16.6 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 4.3% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.1%
2.4 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.3% · Q3 4.5% · Q4 4.5% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
13.5%
5.4 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.2% · Q3 7.5% · Q4 8.8% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.2% |
14.8%
5.6 pts better
|
16.7%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 8.6% · Q3 6.8% · Q4 8.3% · 4Q avg 9.2% · 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 | 10.0% |
15.1%
5.1 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
15.5%
8.2 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 4.6% · Q3 14.5% · Q4 3.4% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.6%
About the same
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.4%
0.8 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 1.5% · Q4 2.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
20.8%
1 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 19.4% · Q3 21.7% · Q4 27.4% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
6.9%
2.1 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 7.7% · Q3 5.2% · Q4 3.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
76.7%
23 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
9.7%
3.4 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 6.1% · Expected 10.7% · 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 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
78.8%
17.5 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
20.6%
3.3 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 15.2% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-22 · Fire 2023-02-22
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-05-14 · Fire 2021-05-14
5 health deficiencies
Top issue: Quality of Life and Care (4 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
2024-10-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-03
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
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 2026-01-19
F · Potential for more than minimal harm
2024-10-03
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 2024-12-02
F · Potential for more than minimal harm
2024-10-03
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-03
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 2024-11-15
D · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2021-05-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-05-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-05-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-05-14
F688 · Quality of Life and Care Deficiencies
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 2021-07-10
B · Minimal harm
2021-05-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-07-10
Penalties and ownership
What sits behind the stars
Ownership
Kaleida Health
5% Or Greater Direct Ownership Interest · Organization
Aquino, Nicholas
Corporate Director · Individual
Barrett, Ian
Corporate Officer · Individual
Beauford, Thomas
Corporate Director · Individual
Boyd, Donald
Corporate Director · Individual
Boyd, Donald
Corporate Officer · Individual
Bryant, Shannon
Corporate Officer · Individual
Chevli, K
Corporate Director · Individual
Chisholm, Hugh
Corporate Officer · Individual
Chisholm, Hugh
W-2 Managing Employee · Individual
Clemo, Lorrie
Corporate Director · Individual
Crosby, Gary
Corporate Director · Individual
Drake, Matthew
Corporate Officer · Individual
Drake, Matthew
W-2 Managing Employee · Individual
Dunn, Jennifer
W-2 Managing Employee · Individual
Eddib, Abeer
Corporate Director · Individual
Hardy, Stephen
Corporate Officer · Individual
Hardy, Stephen
W-2 Managing Employee · Individual
Hart, Jonathan
W-2 Managing Employee · Individual
Hughes, Michael
Corporate Officer · Individual
Javed, Muhammed
Corporate Director · Individual
Maggio, William
Corporate Director · Individual
Matthews, George
Corporate Director · Individual
Mccrorey, Angela
W-2 Managing Employee · Individual
Mcevoy, Timothy
Corporate Director · Individual
Mineo, Michael
Corporate Officer · Individual
Nadler, Jamie
Corporate Officer · Individual
O'connell, Katie
W-2 Managing Employee · Individual
O'leary, Paul
Corporate Director · Individual
Ormond, Jo Ann
W-2 Managing Employee · Individual
Pal, Amandeep
Contracted Managing Employee · Individual
Persons, John
Corporate Director · Individual
Prudential Huntoon Paige Associates Ltc Isaoa
5% Or Greater Mortgage Interest · Organization
Quint-Bouzid, Marjorie
Corporate Officer · Individual
Quint-Bouzid, Marjorie
W-2 Managing Employee · Individual
Ross, Christopher
Corporate Director · Individual
Rusin, Mary Lou
Corporate Director · Individual
Silvestrini, Corin
W-2 Managing Employee · Individual
Snyder, Kenneth
Corporate Officer · Individual
Spaulding, Alyson
Corporate Officer · Individual
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#2
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#3
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1-star overall rating with 1-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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