Cycle 1
Health 2024-09-16 · Fire 2024-09-16
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Buffalo, NY
Highpointe On Michigan Health Care Facility
2-star overall rating with 1-star inspections with abuse icon flag with $129,149 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1031 Michigan Ave, Buffalo, NY
(716) 748-3101
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
300
Certified beds
Average residents
268
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-12-05
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
1.11
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.34
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.45
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.68
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.99
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,303
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0130
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.64
Baseline 17.18% · Performance 18.35% · Measure score 6.64 · Achievement 6.64 · Improvement 0
Healthcare-associated infections
5.96
Baseline 5.37% · Performance 6.05% · Measure score 5.96 · Achievement 5.96 · Improvement 0
Total nurse turnover
4.88
Performance 43.75% · Measure score 4.88 · Achievement 4.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.63
Baseline 3.41 hours · Performance 4.68 hours · Measure score 5.63 · Achievement 5.63 · Improvement 4.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 10.96% · Lower 95% interval 6.85% |
| Discharge to community | 45.11% |
50.57%
5.5 pts worse
|
No Different than the National Rate · Eligible stays 148 · Observed rate 32.43% · Lower 95% interval 37.26% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 106 · Denominator 107 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 107 |
| Discharge self-care score | 44.87% |
53.69%
8.8 pts worse
|
Numerator 35 · Denominator 78 |
| Discharge mobility score | 52.56% |
50.94%
1.6 pts better
|
Numerator 41 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 4.67% |
2.29%
2.4 pts worse
|
Numerator 5 · Denominator 107 · Adjusted rate 4.93% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 5.38% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 50.85% |
42%
8.9 pts better
|
Numerator 240 · Denominator 472 |
| Discharge function score | 48.72% |
56.45%
7.7 pts worse
|
Numerator 38 · Denominator 78 |
| Transfer of health information to provider | 92% |
95.95%
4 pts worse
|
Numerator 23 · Denominator 25 |
| Transfer of health information to patient | 81.4% |
96.28%
14.9 pts worse
|
Numerator 35 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 13.21% |
25.2%
12 pts worse
|
Numerator 7 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.2%
8.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.6% · Q3 99.6% · Q4 99.2% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
95.3%
2 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.0%
1.1 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 2.1% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
18.5%
16.6 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.4% · Q3 0.5% · Q4 1.4% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.1%
3.7 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.5% · Q3 1.8% · Q4 2.2% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
13.5%
4.1 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 7.9% · Q3 9.1% · Q4 11.4% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
14.8%
6.4 pts better
|
16.7%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.6% · Q3 6.9% · Q4 7.2% · 4Q avg 8.4% · 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 | 15.1% |
15.1%
About the same
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 19.2% · Q3 13.6% · Q4 11.3% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
15.5%
0.9 pts worse
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 13.7% · Q3 14.4% · Q4 18.2% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.6%
0.6 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.6% · Q3 1.5% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.4%
1.2 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 1.7% · Q4 3.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
20.8%
5.3 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 24.1% · Q3 21.6% · Q4 28.2% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
6.9%
1.9 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.3% · Q3 8.2% · Q4 7.8% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
76.7%
21.4 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 97.7% · Q3 97.5% · Q4 98.2% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
9.7%
3.4 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 7.4% · Expected 13.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.8% |
78.8%
About the same
|
79.7%
0.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
20.6%
3.6 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 22.2% · Expected 31.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-30 · Fire 2022-08-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2020-01-22 · Fire 2020-01-22
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-09-16
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-09-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-15
E · Potential for more than minimal harm
2022-08-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-28
E · Potential for more than minimal harm
2020-01-22
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2020-03-21
E · Potential for more than minimal harm
2020-01-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-03-21
D · Potential for more than minimal harm
2020-01-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-23
L · Immediate jeopardy
2024-09-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-15
G · Actual harm
2024-09-16
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 2024-11-15
F · Potential for more than minimal harm
2024-09-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-16
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-16
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 2024-11-15
D · Potential for more than minimal harm
2024-09-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-15
C · Minimal harm
2024-09-16
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 2024-11-15
C · Minimal harm
2024-09-16
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-05-22
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 2024-06-30
D · Potential for more than minimal harm
2022-08-30
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 2022-10-28
D · Potential for more than minimal harm
2022-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-08-30
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-08-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-08-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-08-30
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 2022-10-28
D · Potential for more than minimal harm
2022-08-30
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-28
E · Potential for more than minimal harm
2020-01-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2020-03-21
D · Potential for more than minimal harm
2020-01-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2020-03-21
D · Potential for more than minimal harm
2020-01-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-03-21
D · Potential for more than minimal harm
2020-01-22
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 2020-03-21
D · Potential for more than minimal harm
2020-01-22
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-03-21
D · Potential for more than minimal harm
2020-01-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-03-21
D · Potential for more than minimal harm
2020-01-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-03-21
D · Potential for more than minimal harm
2020-01-22
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 2020-03-21
Penalties and ownership
What sits behind the stars
$129,149
2024-09-16
Fine
Fine · fine $129,149
Fine
Ownership
Kaleida Health
5% Or Greater Direct Ownership Interest · Organization
Aquino, Nicholas
Corporate Director · Individual
Barkowski, Rakhi
Contracted Managing Employee · Individual
Barrett, Ian
Corporate Officer · Individual
Beauford, Thomas
Corporate Director · Individual
Boyd, Donald
Corporate Director · Individual
Boyd, Donald
Corporate Officer · Individual
Bryant, Shannon
Corporate Officer · Individual
Chevli, K
Corporate Director · Individual
Chisholm, Hugh
Corporate Officer · Individual
Chisholm, Hugh
W-2 Managing Employee · Individual
Clemo, Lorrie
Corporate Director · Individual
Crosby, Gary
Corporate Director · Individual
Drake, Matthew
Corporate Officer · Individual
Drake, Matthew
W-2 Managing Employee · Individual
Dunn, Jennifer
W-2 Managing Employee · Individual
Eddib, Abeer
Corporate Director · Individual
Hardy, Stephen
Corporate Officer · Individual
Hardy, Stephen
W-2 Managing Employee · Individual
Hart, Jonathan
W-2 Managing Employee · Individual
Hughes, Michael
Corporate Officer · Individual
Javed, Muhammed
Corporate Director · Individual
Maggio, William
Corporate Director · Individual
Matthews, George
Corporate Director · Individual
Mccrorey, Angela
W-2 Managing Employee · Individual
Mcevoy, Timothy
Corporate Director · Individual
Mineo, Michael
Corporate Officer · Individual
Nadler, Jamie
Corporate Officer · Individual
O'connell, Katie
W-2 Managing Employee · Individual
O'leary, Paul
Corporate Director · Individual
Ormond, Jo Ann
W-2 Managing Employee · Individual
Persons, John
Corporate Director · Individual
Prudential Huntoon Paige Associates, LLC.
5% Or Greater Mortgage Interest · Organization
Quint-Bouzid, Marjorie
Corporate Officer · Individual
Ross, Christopher
Corporate Director · Individual
Rusin, Mary Lou
Corporate Director · Individual
Silvestrini, Corin
W-2 Managing Employee · Individual
Snyder, Kenneth
Corporate Officer · Individual
Spaulding, Alyson
Corporate Officer · Individual
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Buffalo Center For Rehabilitation And Nursing
Buffalo, NY
1-star overall rating with 1-star inspections with abuse icon flag with $170,403 in total fines with 23 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Delaware Oaks Center For Rehabilitation And Nursi
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2-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Ellicott Center For Rehabilitation And Nursing
Buffalo, NY
1-star overall rating with 1-star inspections with $10,868 in total fines with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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