Cycle 1
Health 2024-04-26 · Fire 2024-04-26
3 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Wellsville, NY
Highland Park Rehabilitation And Nursing Center
5-star overall rating with 5-star inspections with $4,938 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
160 Seneca St, Wellsville, NY
(585) 593-3750
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
80
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1967-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 2 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
0.56
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
1.99
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.67
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
0.18
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,201
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.44
Baseline 16.77% · Performance 20.30% · Measure score 2.44 · Achievement 2.44 · Improvement 0
Healthcare-associated infections
0
Baseline 6.70% · Performance 9.06% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 48.15% · Performance 69.70% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.59
Baseline 3.36 hours · Performance 3.24 hours · Measure score 0.59 · Achievement 0.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.72% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 5.96% · Lower 95% interval 6% |
| Discharge to community | 56.07% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 52.11% · Lower 95% interval 48.6% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 128 · Denominator 128 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 128 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 52 · Denominator 92 |
| Discharge mobility score | 48.91% |
50.94%
2 pts worse
|
Numerator 45 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 8 · Denominator 128 · Adjusted rate 5.17% |
| Healthcare-associated infections requiring hospitalization | 9.06% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 12.09% · Lower 95% interval 5.44% |
| Staff COVID-19 vaccination coverage | 3.33% |
8.2%
4.9 pts worse
|
Numerator 5 · Denominator 150 |
| Staff flu vaccination coverage | 79.49% |
42%
37.5 pts better
|
Numerator 124 · Denominator 156 |
| Discharge function score | 60.87% |
56.45%
4.4 pts better
|
Numerator 56 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | 97.67% |
96.28%
1.4 pts better
|
Numerator 42 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 11.76% |
25.2%
13.4 pts worse
|
Numerator 8 · Denominator 68 |
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 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.3
0.8 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
91.2%
6 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
95.3%
3.2 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 3.3% · Q4 4.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 33.3% |
18.5%
14.8 pts worse
|
11.4%
21.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 35.6% · Q3 37.7% · Q4 25.4% · 4Q avg 33.3% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.1%
0.5 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 8.3% · Q3 8.3% · Q4 6.2% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
13.5%
1.9 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.7% · Q3 9.8% · Q4 16.4% · 4Q avg 11.6% |
| 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 10.0% · Q2 17.0% · Q3 13.7% · Q4 20.8% · 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 | 7.2% |
15.1%
7.9 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 11.4% · Q3 0.0% · Q4 5.6% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
15.5%
11.7 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.3% · Q3 1.7% · Q4 4.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.6%
0.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.4%
0.2 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 1.7% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
20.8%
1.2 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 20.8% · Q3 29.8% · Q4 18.8% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.9%
1.6 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.6% · Q3 7.2% · Q4 3.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
76.7%
16.4 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 91.1% · Q3 98.7% · Q4 98.5% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.5% |
9.7%
10.8 pts worse
|
12.0%
8.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 18.2% · Expected 9.9% · 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 0.0% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.4% |
78.8%
13.6 pts better
|
79.7%
12.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
20.6%
2.6 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 16.2% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-01 · Fire 2022-04-01
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-06-21 · Fire 2019-06-21
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Electrical (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-26
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-04-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-04-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-04-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-12
D · Potential for more than minimal harm
2022-04-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-04-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-23
E · Potential for more than minimal harm
2019-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-06
E · Potential for more than minimal harm
2019-06-21
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2019-08-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-12
C · Minimal harm
2024-04-26
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-06-12
D · Potential for more than minimal harm
2022-04-01
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 2022-05-23
B · Minimal harm
2022-04-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-05-23
B · Minimal harm
2022-04-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-05-23
D · Potential for more than minimal harm
2019-06-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-08-06
Penalties and ownership
What sits behind the stars
$1,764
2023-08-07
Fine
Fine · fine $1,764
Fine
$3,174
2023-07-17
Fine
Fine · fine $3,174
Fine
Ownership
Koenig, Uri
5% Or Greater Direct Ownership Interest · Individual
Steif, Efraim
5% Or Greater Direct Ownership Interest · Individual
Augenstein, Jack
Corporate Officer · Individual
Steif, Efraim
Operational/Managerial Control · Individual
Wuertzer, Amy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Wellsville Manor Care Center
Wellsville, NY
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Cuba Memorial Hospital Inc SNF
Cuba, NY
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Maple City Rehabilitation and Nursing Center
Hornell, NY
1-star overall rating with 1-star inspections with $62,207 in total fines with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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