6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rochester, NY
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2021 Winton Road South, Rochester, NY
(585) 427-7760
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
362
Certified beds
Average residents
305
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
RN hours / resident day
0.58
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.84
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
5.30
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
159
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
80.81
Composite VBP score used to determine payment impact.
Payment multiplier
1.0260
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
9.20
Baseline 19.48% · Performance 17.17% · Measure score 9.20 · Achievement 9.20 · Improvement 8.92
Healthcare-associated infections
8.71
Baseline 4.97% · Performance 5.23% · Measure score 8.71 · Achievement 8.71 · Improvement 0
Total nurse turnover
7.70
Baseline 33.24% · Performance 32.20% · Measure score 7.70 · Achievement 7.70 · Improvement 0.74
Adjusted total nurse staffing
6.72
Baseline 5.18 hours · Performance 4.99 hours · Measure score 6.72 · Achievement 6.72 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.04% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 397 · Observed rate 6.3% · Lower 95% interval 6.81% |
| Discharge to community | 64.29% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 410 · Observed rate 61.71% · Lower 95% interval 58.14% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.54% |
95.27%
3.3 pts better
|
Numerator 203 · Denominator 206 |
| Falls with major injury | 1.46% |
0.77%
0.7 pts worse
|
Numerator 3 · Denominator 206 |
| Discharge self-care score | 65.7% |
53.69%
12 pts better
|
Numerator 113 · Denominator 172 |
| Discharge mobility score | 70.93% |
50.94%
20 pts better
|
Numerator 122 · Denominator 172 |
| Pressure ulcers or injuries, new or worsened | 4.85% |
2.29%
2.6 pts worse
|
Numerator 10 · Denominator 206 · Adjusted rate 6.46% |
| Healthcare-associated infections requiring hospitalization | 5.23% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 231 · Observed rate 2.6% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 5.55% |
8.2%
2.6 pts worse
|
Numerator 41 · Denominator 739 |
| Staff flu vaccination coverage | 45.5% |
42%
3.5 pts better
|
Numerator 415 · Denominator 912 |
| Discharge function score | 69.19% |
56.45%
12.7 pts better
|
Numerator 119 · Denominator 172 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 128 · Denominator 128 |
| Resident COVID-19 vaccinations up to date | 33.68% |
25.2%
8.5 pts better
|
Numerator 32 · Denominator 95 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
91.2%
5.7 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 98.0% · Q3 96.0% · Q4 97.7% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.3%
2.1 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.0%
2.8 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.6% · Q3 5.1% · Q4 7.8% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.9% |
18.5%
11.6 pts better
|
11.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.2% · Q3 7.6% · Q4 7.7% · 4Q avg 6.9% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
6.1%
2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.9% · Q3 2.6% · Q4 3.5% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
13.5%
4.6 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.9% · Q3 8.6% · Q4 9.4% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
14.8%
4.7 pts worse
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 21.1% · Q3 19.8% · Q4 18.4% · 4Q avg 19.5% · 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 | 18.9% |
15.1%
3.8 pts worse
|
16.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 20.8% · Q3 16.9% · Q4 19.0% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
15.5%
5.5 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 23.4% · Q3 18.4% · Q4 24.2% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.6%
About the same
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.1% · Q3 0.3% · Q4 0.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.4%
0.4 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.8% · Q3 1.6% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.1% |
20.8%
11.3 pts worse
|
19.8%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 33.5% · Q3 31.0% · Q4 34.0% · 4Q avg 32.1% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.9%
1.4 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 6.7% · Q3 3.8% · Q4 3.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
76.7%
11.9 pts better
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 89.0% · Q3 89.1% · Q4 85.0% · 4Q avg 88.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
9.7%
2.2 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 10.5% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.9% · Q3 0.6% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
78.8%
11.1 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
20.6%
1.2 pts worse
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 17.7% · Expected 19.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-02
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2026-02-02
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-02-02
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-16
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-10-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-16
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-16
Fire Safety
Develop a communication plan.
Corrected 2023-10-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-15
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-09-15
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 2021-09-15
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-09-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-15
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-02
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-02
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-02
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-09-15
Penalties and ownership
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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