Cycle 1
Health 2025-04-18 · Fire 2025-04-18
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Dunkirk, NY
Dunkirk Rehabilitation & Nursing Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
447 449 Lake Shore Drive West, Dunkirk, NY
(716) 366-6710
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1977-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.26
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
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,710
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.58
Composite VBP score used to determine payment impact.
Payment multiplier
1.0095
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.31
Baseline 65.00% · Performance 29.73% · Measure score 8.31 · Achievement 8.31 · Improvement 8.28
Adjusted total nurse staffing
2.61
Baseline 3.15 hours · Performance 3.82 hours · Measure score 2.61 · Achievement 2.61 · Improvement 2.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 6.51% |
| Discharge to community | 53.95% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 45.71% · Lower 95% interval 40.03% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.69% |
8.2%
6.5 pts worse
|
Numerator 1 · Denominator 59 |
| Staff flu vaccination coverage | 84.52% |
42%
42.5 pts better
|
Numerator 71 · Denominator 84 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · 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 |
|---|---|---|---|---|
| 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 | 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 | 2.2% |
3.0%
0.8 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.1% · Q4 2.9% · 4Q avg 2.2% · 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 | 4.4% |
6.1%
1.7 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 3.1% · Q4 8.8% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
13.5%
1.2 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 14.3% · Q3 12.5% · Q4 11.8% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
14.8%
0.7 pts worse
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 13.0% · Q3 9.1% · Q4 24.0% · 4Q avg 15.5% · 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 | 28.2% |
15.1%
13.1 pts worse
|
16.3%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
15.5%
3.3 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 21.9% · Q3 29.0% · Q4 12.9% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.6%
0.3 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · 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 | 17.2% |
20.8%
3.6 pts better
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 20.9% · Q3 8.5% · Q4 13.7% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
6.9%
5.1 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.9% · Q3 0.0% · Q4 3.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
76.7%
23.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 3.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
78.8%
16.2 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-03-11 · Fire 2022-03-11
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-28
E · Potential for more than minimal harm
2023-12-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-12-01
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-22
E · Potential for more than minimal harm
2022-03-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-18
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 2025-05-28
D · Potential for more than minimal harm
2023-12-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-12-01
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 2024-01-22
J · Immediate jeopardy
2022-03-11
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2022-04-19
F · Potential for more than minimal harm
2022-03-11
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-04-19
F · Potential for more than minimal harm
2022-03-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-11
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 2022-04-19
D · Potential for more than minimal harm
2022-03-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-11
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 2022-04-19
Penalties and ownership
What sits behind the stars
Ownership
Zagelbaum, Batia
5% Or Greater Direct Ownership Interest · Individual
Beim, Esther
5% Or Greater Direct Ownership Interest · Individual
Walden, Chaya
5% Or Greater Direct Ownership Interest · Individual
Creedon, Teresa
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
Operational/Managerial Control · Individual
Barth, Alexander
Corporate Officer · Individual
Ostrovitsky, Israel
Corporate Officer · Individual
Patel, Arun
Operational/Managerial Control · Individual
Trovato, Sarah
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Chautauqua Nursing And Rehabilitation Center
Dunkirk, NY
4-star overall rating with 4-star inspections with $8,926 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Heritage Village Rehab And Skilled Nursing Inc.
Gerry, NY
2-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Gowanda Rehabilitation And Nursing Center
Gowanda, NY
2-star overall rating with 2-star inspections with $61,162 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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