Cycle 1
Health 2025-04-11 · Fire 2025-04-11
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Rochester, NY
Edna Tina Wilson Living Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies
700 Island Cottage Road, Rochester, NY
(585) 368-6100
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
120
Certified beds
Average residents
119
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Rochester Regional Health
Operator or chain grouping
Approved since
1993-12-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
1.18
Licensed practical nurse staffing
Aide hours / resident day
2.35
Nurse aide staffing
Weekend hours
3.55
Weekend nurse staffing
RN turnover
8%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
1.3
1.2 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.2%
7.9 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
95.3%
3 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
18.5%
14.6 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.1%
1.2 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.1% |
13.5%
11.4 pts better
|
19.6%
17.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
14.8%
2 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.8% |
15.1%
2.7 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
15.5%
4.3 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.4%
0.5 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.5% |
20.8%
8.3 pts better
|
19.8%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
6.9%
1.3 pts better
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
76.7%
16.2 pts better
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.8%
21.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-16 · Fire 2023-06-16
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-09-17 · Fire 2021-09-17
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-06-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-06-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-25
B · Minimal harm
2023-06-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-08-25
E · Potential for more than minimal harm
2021-09-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-12
E · Potential for more than minimal harm
2021-09-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-12
E · Potential for more than minimal harm
2021-09-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-11-12
D · Potential for more than minimal harm
2021-09-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-11-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-09
D · Potential for more than minimal harm
2023-06-16
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 2023-08-11
D · Potential for more than minimal harm
2023-06-16
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 2023-08-11
D · Potential for more than minimal harm
2021-09-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-11-05
D · Potential for more than minimal harm
2021-09-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-05
Penalties and ownership
What sits behind the stars
Ownership
Alag, Karan
Corporate Director · Individual
Becker, Linda
Corporate Director · Individual
Bieber, Eric
Corporate Officer · Individual
Cooney-Miner, Dianne
Corporate Director · Individual
Crilly, Thomas
Corporate Officer · Individual
Destephano, Ralph
Corporate Director · Individual
Gallina, Karen
Corporate Director · Individual
Glastonbury, Howard
Corporate Officer · Individual
Holder, Nichole
W-2 Managing Employee · Individual
Hoyt, Shawn
W-2 Managing Employee · Individual
Loan, Sandra
W-2 Managing Employee · Individual
Mapstone, Jeffrey
Corporate Director · Individual
Meyers, Daniel
Corporate Director · Individual
Mulconry, Marcy
Corporate Director · Individual
Patton, Elizabeth
Corporate Director · Individual
Patton, Patricia
W-2 Managing Employee · Individual
Riedy, Dawn
Corporate Director · Individual
Riley, Thomas
Corporate Director · Individual
Sawyko, Leon
Corporate Director · Individual
Sengillo, Barbara
W-2 Managing Employee · Individual
Tedesco, Julia
Corporate Director · Individual
Veloski, John
W-2 Managing Employee · Individual
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#3
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
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