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
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 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
0.47
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.55
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
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.76
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,067
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0064
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
5.02
Baseline 52.94% · Performance 43.15% · Measure score 5.02 · Achievement 5.02 · Improvement 2.99
Adjusted total nurse staffing
5.37
Baseline 4.09 hours · Performance 4.61 hours · Measure score 5.37 · Achievement 5.37 · Improvement 2.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · 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 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.99% |
8.2%
5.2 pts worse
|
Numerator 6 · Denominator 201 |
| Staff flu vaccination coverage | 59.56% |
42%
17.6 pts better
|
Numerator 218 · Denominator 366 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
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 · Adjusted 1.3 · Observed 0.8 · Expected 1.2 · Used in QM five-star |
| 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 · Adjusted 0.1 · Observed 0.1 · Expected 1.2 · Used in QM five-star |
| 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 · Q1 99.1% · Q2 100.0% · Q3 99.1% · Q4 98.3% · 4Q avg 99.1% |
| 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 · 4Q avg 98.3% |
| 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 2.6% · Q2 1.7% · Q3 1.8% · Q4 2.6% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 4.3% · Q2 3.6% · Q3 3.6% · Q4 3.8% · 4Q avg 3.9% |
| 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 · Q1 4.0% · Q2 6.1% · Q3 6.4% · Q4 3.2% · 4Q avg 4.9% |
| 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 · Q1 2.0% · Q2 2.0% · Q3 2.1% · Q4 2.2% · 4Q avg 2.1% |
| 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 · Q1 10.2% · Q2 11.6% · Q3 14.9% · Q4 14.5% · 4Q avg 12.8% · 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 | 17.8% |
15.1%
2.7 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 14.0% · Q3 17.4% · Q4 21.2% · 4Q avg 17.8% · Used in QM five-star |
| 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 · Q1 29.0% · Q2 15.9% · Q3 16.1% · Q4 17.4% · 4Q avg 19.8% · 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 | 0.9% |
1.4%
0.5 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| 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 · Q1 16.9% · Q2 10.5% · Q3 13.2% · Q4 9.5% · 4Q avg 12.5% |
| 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 · Q1 3.3% · Q2 5.4% · Q3 5.5% · Q4 8.0% · 4Q avg 5.6% · Used in QM five-star |
| 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 · Q2 93.3% · Q3 96.9% · Q4 90.0% · 4Q avg 92.9% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
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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