Pittsford, NY

Highlands Living Center

2-star overall rating with 2-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

500 Hahnemann Trail, Pittsford, NY

(585) 383-1700

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

122

Certified beds

Average residents

115

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1995-07-10

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.46

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.15

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

1.91

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.52

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.61

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.10

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.29

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

0.48

CMS adjusted RN staffing hours

Adjusted total hours

3.70

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

66%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,845

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

Performance score

31.55

Composite VBP score used to determine payment impact.

Payment multiplier

0.9866

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.55

Baseline 20.87% · Performance 19.32% · Measure score 4.55 · Achievement 4.55 · Improvement 3.53

Healthcare-associated infections

4.01

Baseline 7.17% · Performance 6.64% · Measure score 4.01 · Achievement 4.01 · Improvement 1.95

Total nurse turnover

0

Baseline 51.97% · Performance 64.86% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

4.06

Baseline 4.44 hours · Performance 4.23 hours · Measure score 4.06 · Achievement 4.06 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.9%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 73 · Observed rate 6.85% · Lower 95% interval 6.1%
Discharge to community	43.04%	50.57% 7.5 pts worse	No Different than the National Rate · Eligible stays 71 · Observed rate 35.21% · Lower 95% interval 34.05%
Medicare spending per beneficiary	0.82	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 40 · Denominator 40
Falls with major injury	2.5%	0.77% 1.7 pts worse	Numerator 1 · Denominator 40
Discharge self-care score	60%	53.69% 6.3 pts better	Numerator 18 · Denominator 30
Discharge mobility score	30%	50.94% 20.9 pts worse	Numerator 9 · Denominator 30
Pressure ulcers or injuries, new or worsened	2.5%	2.29% 0.2 pts worse	Numerator 1 · Denominator 40 · Adjusted rate 2.69%
Healthcare-associated infections requiring hospitalization	6.64%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 3.38%
Staff COVID-19 vaccination coverage	9.64%	8.2% 1.4 pts better	Numerator 19 · Denominator 197
Staff flu vaccination coverage	56.31%	42% 14.3 pts better	Numerator 125 · Denominator 222
Discharge function score	46.67%	56.45% 9.8 pts worse	Numerator 14 · Denominator 30
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	45%	25.2% 19.8 pts better	Numerator 9 · Denominator 20

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.7 About the same	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	1.3 0.4 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	21.9%	91.2% 69.3 pts worse	93.4% 71.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 26.0% · Q3 18.2% · Q4 17.6% · 4Q avg 21.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.5%	95.3% 1.8 pts worse	95.5% 2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.5%	3.0% 0.5 pts better	3.3% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 2.0% · Q4 3.7% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.5%	18.5% 14 pts better	11.4% 6.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 7.8% · Q4 4.0% · 4Q avg 4.5%
Percentage of long-stay residents who lose too much weight	7.2%	6.1% 1.1 pts worse	5.4% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.5% · Q3 5.6% · Q4 6.9% · 4Q avg 7.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.3%	13.5% 7.2 pts better	19.6% 13.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.2% · Q3 6.5% · Q4 6.8% · 4Q avg 6.3%
Percentage of long-stay residents who received an antipsychotic medication	19.0%	14.8% 4.2 pts worse	16.7% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 21.6% · Q3 20.5% · Q4 17.8% · 4Q avg 19.0% · 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	27.9%	15.1% 12.8 pts worse	16.3% 11.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 39.2% · Q2 29.7% · Q3 27.3% · Q4 18.5% · 4Q avg 27.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	28.2%	15.5% 12.7 pts worse	14.9% 13.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 38.8% · Q3 16.3% · Q4 15.6% · 4Q avg 28.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.6% 0.2 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	1.4% 1.4 pts worse	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 5.0% · Q3 1.0% · Q4 3.7% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.1%	20.8% 7.3 pts worse	19.8% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 37.8% · Q3 26.8% · Q4 21.5% · 4Q avg 28.1%
Percentage of long-stay residents with pressure ulcers	11.8%	6.9% 4.9 pts worse	5.1% 6.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.7% · Q3 13.1% · Q4 17.6% · 4Q avg 11.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	27.7%	76.7% 49 pts worse	81.7% 54 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 33.0% · Q3 18.4% · Q4 29.7% · 4Q avg 27.7%
Percentage of short-stay residents who had an outpatient emergency department visit	6.1%	9.7% 3.6 pts better	12.0% 5.9 pts better	Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.7% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.5%	1.2% 1.3 pts worse	1.6% 0.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.0% · Q3 1.6% · Q4 4.2% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	61.1%	78.8% 17.7 pts worse	79.7% 18.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 61.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.3%	20.6% 10.7 pts worse	23.9% 7.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 25.7% · Expected 19.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-19 · Fire 2025-02-19

8 health deficiencies

Top issue: Environmental (2 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2023-06-09 · Fire 2023-06-09

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2021-09-02 · Fire 2021-09-02

3 health deficiencies

Top issue: Infection Control (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-02-19

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-31

C · Minimal harm 2025-02-19

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2025-03-31

E · Potential for more than minimal harm 2023-06-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-09

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-08-01

E · Potential for more than minimal harm 2023-06-09

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2023-08-01

D · Potential for more than minimal harm 2023-06-09

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-08-01

C · Minimal harm 2023-06-09

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-08-01

F · Potential for more than minimal harm 2021-09-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-11-13

E · Potential for more than minimal harm 2021-09-02

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2021-11-13

E · Potential for more than minimal harm 2021-09-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-11-13

E · Potential for more than minimal harm 2021-09-02

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2021-11-13

D · Potential for more than minimal harm 2021-09-02

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2021-11-13

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-19

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-04-15

E · Potential for more than minimal harm 2025-02-19

F919 · Environmental Deficiencies

Health

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

Corrected 2025-04-15

E · Potential for more than minimal harm 2025-02-19

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-04-15

D · Potential for more than minimal harm 2025-02-19

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 2025-04-15

D · Potential for more than minimal harm 2025-02-19

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 2025-04-15

D · Potential for more than minimal harm 2025-02-19

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-04-15

D · Potential for more than minimal harm 2025-02-19

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-04-15

D · Potential for more than minimal harm 2025-02-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-15

E · Potential for more than minimal harm 2023-06-09

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-07-26

E · Potential for more than minimal harm 2023-06-09

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 2023-08-24

E · Potential for more than minimal harm 2023-06-09

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 2023-07-26

E · Potential for more than minimal harm 2023-06-09

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-07-26

D · Potential for more than minimal harm 2023-06-09

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-07-26

D · Potential for more than minimal harm 2023-06-09

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2023-07-26

E · Potential for more than minimal harm 2021-09-02

F885 · Infection Control Deficiencies

Health

Report COVID19 data to residents and families.

Corrected 2021-10-07

D · Potential for more than minimal harm 2021-09-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-10-07

B · Minimal harm 2021-09-02

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2021-10-07

Penalties and ownership

What sits behind the stars

Ownership

Busari, Samuel

Operational/Managerial Control · Individual

0% 1 facilities 2021-07-14

Busari, Samuel