Cycle 1
Health 2024-05-08 · Fire 2024-05-08
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Eden, NY
Eden Rehabilitation Nursing Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2806 George Street, Eden, NY
(716) 992-3987
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1978-07-01
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
0.88
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,519
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9926
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
5.94
Baseline 38.46% · Performance 39.39% · Measure score 5.94 · Achievement 5.94 · Improvement 0
Adjusted total nurse staffing
1.98
Baseline 3.66 hours · Performance 3.64 hours · Measure score 1.98 · Achievement 1.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | 42.42% |
50.57%
8.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 31.03% · Lower 95% interval 28.83% |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 1 · Denominator 23 · Adjusted rate 4.39% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.61% |
8.2%
6.6 pts worse
|
Numerator 1 · Denominator 62 |
| Staff flu vaccination coverage | 71.95% |
42%
30 pts better
|
Numerator 59 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 6.2% |
3.0%
3.2 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.2% · Q3 8.8% · Q4 6.2% · 4Q avg 6.2% · 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 | 8.3% |
6.1%
2.2 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.3% · Q3 18.8% · Q4 0.0% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.5% |
13.5%
6 pts better
|
19.6%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.9% · Q3 6.2% · Q4 10.3% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
14.8%
4.6 pts worse
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 24.0% · Q3 19.2% · Q4 17.4% · 4Q avg 19.4% · 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 | 29.6% |
15.1%
14.5 pts worse
|
16.3%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.9% |
15.5%
10.4 pts worse
|
14.9%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 20.7% · Q3 35.5% · Q4 15.4% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.6%
1.3 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 3.7% · Q4 1.5% · 4Q avg 1.9% · 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 | 30.7% |
20.8%
9.9 pts worse
|
19.8%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 17.1% · Q3 35.6% · Q4 46.6% · 4Q avg 30.7% |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
6.9%
3.3 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 12.1% · Q3 13.1% · Q4 9.1% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
76.7%
20 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 100.0% · Q3 95.7% · Q4 97.8% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
9.7%
5.1 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.2% · Expected 10.2% · 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 | 98.0% |
78.8%
19.2 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
20.6%
1.6 pts worse
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 20.8% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-17 · Fire 2022-08-17
1 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2019-12-04 · Fire 2019-12-04
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-05-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-05-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-05-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-01
E · Potential for more than minimal harm
2022-08-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-08-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-08-17
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-09-28
E · Potential for more than minimal harm
2019-12-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-01-15
E · Potential for more than minimal harm
2019-12-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-15
E · Potential for more than minimal harm
2019-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-08
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-08
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 2024-07-01
D · Potential for more than minimal harm
2023-12-13
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 2024-01-30
E · Potential for more than minimal harm
2022-08-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-09-28
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
Corporate Officer · Individual
Creedon, Teresa
Operational/Managerial Control · Individual
Ostrovitsky, Israel
Operational/Managerial Control · Individual
Trovato, Sarah
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Autumn View Health Care Facility L L C
Hamburg, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Elderwood At Hamburg
Hamburg, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Father Baker Manor
Orchard Park, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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