Fairport, NY

Fairport Rehabilitation and Nursing Center

2-star overall rating with 2-star inspections with 13 recent health deficiencies

4646 Fairport Nine Mile Point Road, Fairport, NY

(585) 377-0350

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

196

Certified beds

Average residents

140

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1977-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.26

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.33

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.32

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.91

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.59

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.59

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.11

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.28

CMS adjusted RN staffing hours

Adjusted total hours

4.19

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

78%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

72%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,370

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.86

Composite VBP score used to determine payment impact.

Payment multiplier

0.9833

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.50% · Performance 23.25% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.15

Baseline 6.30% · Performance 7.19% · Measure score 2.15 · Achievement 2.15 · Improvement 0

Total nurse turnover

Baseline 48.18% · Performance 65.58% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

7.39

Baseline 4.47 hours · Performance 5.18 hours · Measure score 7.39 · Achievement 7.39 · Improvement 4.92

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.16%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 63 · Observed rate 6.35% · Lower 95% interval 7.11%
Discharge to community	40.7%	50.57% 9.9 pts worse	No Different than the National Rate · Eligible stays 69 · Observed rate 34.78% · Lower 95% interval 31.23%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 156 · Denominator 156
Falls with major injury	1.28%	0.77% 0.5 pts worse	Numerator 2 · Denominator 156
Discharge self-care score	47.01%	53.69% 6.7 pts worse	Numerator 55 · Denominator 117
Discharge mobility score	54.7%	50.94% 3.8 pts better	Numerator 64 · Denominator 117
Pressure ulcers or injuries, new or worsened	3.85%	2.29% 1.6 pts worse	Numerator 6 · Denominator 156 · Adjusted rate 3.8%
Healthcare-associated infections requiring hospitalization	7.19%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 74 · Observed rate 6.76% · Lower 95% interval 3.87%
Staff COVID-19 vaccination coverage	11.87%	8.2% 3.7 pts better	Numerator 33 · Denominator 278
Staff flu vaccination coverage	35.37%	42% 6.6 pts worse	Numerator 81 · Denominator 229
Discharge function score	62.39%	56.45% 5.9 pts better	Numerator 73 · Denominator 117
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 38 · Denominator 38
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 58 · Denominator 58
Resident COVID-19 vaccinations up to date	24.53%	25.2% 0.7 pts worse	Numerator 26 · Denominator 106

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.7 0.3 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 2.1 · Expected 2.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.4	1.3 0.1 pts worse	1.8 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	77.5%	91.2% 13.7 pts worse	93.4% 15.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 83.0% · Q3 69.2% · Q4 67.7% · 4Q avg 77.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.8%	95.3% 1.5 pts worse	95.5% 1.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of long-stay residents experiencing one or more falls with major injury	7.1%	3.0% 4.1 pts worse	3.3% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.9% · Q3 4.3% · Q4 7.3% · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	35.9%	18.5% 17.4 pts worse	11.4% 24.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 21.0% · Q3 35.7% · Q4 56.0% · 4Q avg 35.9%
Percentage of long-stay residents who lose too much weight	10.7%	6.1% 4.6 pts worse	5.4% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 13.7% · Q3 11.2% · Q4 6.9% · 4Q avg 10.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.3%	13.5% 2.2 pts better	19.6% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.8% · Q3 11.8% · Q4 18.2% · 4Q avg 11.3%
Percentage of long-stay residents who received an antipsychotic medication	11.8%	14.8% 3 pts better	16.7% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 17.7% · Q3 8.3% · Q4 7.9% · 4Q avg 11.8% · 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	7.0%	15.1% 8.1 pts better	16.3% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 7.5% · Q3 1.6% · Q4 4.6% · 4Q avg 7.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.7%	15.5% 8.8 pts better	14.9% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.8% · Q3 5.5% · Q4 9.9% · 4Q avg 6.7% · 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	0.2%	1.4% 1.2 pts better	1.7% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	33.8%	20.8% 13 pts worse	19.8% 14 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 36.7% · Q3 39.6% · Q4 26.7% · 4Q avg 33.8%
Percentage of long-stay residents with pressure ulcers	7.1%	6.9% 0.2 pts worse	5.1% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 8.2% · Q3 10.0% · Q4 5.8% · 4Q avg 7.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	38.1%	76.7% 38.6 pts worse	81.7% 43.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 51.7% · Q2 31.0% · Q3 31.8% · Q4 34.2% · 4Q avg 38.1%
Percentage of short-stay residents who had an outpatient emergency department visit	10.2%	9.7% 0.5 pts worse	12.0% 1.8 pts better	Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.3% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.1%	1.2% 0.1 pts better	1.6% 0.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.0% · Q3 0.0% · Q4 1.3% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	65.1%	78.8% 13.7 pts worse	79.7% 14.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 65.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.9%	20.6% 1.7 pts better	23.9% 5 pts better	Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 17.4% · Expected 21.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-13 · Fire 2025-05-13

13 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-11-20 · Fire 2023-11-20

9 health deficiencies

Top issue: Administration (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-02-17 · Fire 2022-02-17

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-13

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-07-11

E · Potential for more than minimal harm 2025-05-13

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-07-11

E · Potential for more than minimal harm 2025-05-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-07-11

E · Potential for more than minimal harm 2025-05-13

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2025-07-11

E · Potential for more than minimal harm 2025-05-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-11

E · Potential for more than minimal harm 2025-05-13

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-08-08

D · Potential for more than minimal harm 2025-05-13

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 2025-07-11

D · Potential for more than minimal harm 2025-05-13

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-07-11

D · Potential for more than minimal harm 2025-05-13

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 2025-07-11

D · Potential for more than minimal harm 2025-05-13

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-07-11

D · Potential for more than minimal harm 2025-05-13

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 2025-07-11

D · Potential for more than minimal harm 2025-05-13

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2025-07-11

B · Minimal harm 2025-05-13

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-07-11

D · Potential for more than minimal harm 2023-11-30

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-01-19

D · Potential for more than minimal harm 2023-11-30

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-01-31