6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Rochester, NY
2-star overall rating with 3-star inspections with $8,979 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2102 Latta Road, Rochester, NY
(585) 225-0920
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
40
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hurlbut Care
Operator or chain grouping
Approved since
1978-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 4 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
RN hours / resident day
0.38
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.44
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
0.21
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
9,315
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.01
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
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.04
Baseline 69.05% · Performance 66.67% · Measure score 0.04 · Achievement 0 · Improvement 0.04
Adjusted total nurse staffing
4.76
Baseline 3.93 hours · Performance 4.43 hours · Measure score 4.76 · Achievement 4.76 · Improvement 2.23
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.97% |
8.2%
2.2 pts worse
|
Numerator 4 · Denominator 67 |
| Staff flu vaccination coverage | 41.98% |
42%
About the same
|
Numerator 34 · Denominator 81 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
91.2%
8 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.2% |
95.3%
7.1 pts worse
|
95.5%
7.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
3.0%
3.7 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.9% · Q3 7.1% · Q4 7.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
18.5%
15 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.8% · Q3 3.7% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.1%
1 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.4% · Q3 7.4% · Q4 7.7% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.4% |
13.5%
10.1 pts better
|
19.6%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 3.7% · Q4 7.7% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
14.8%
5.5 pts worse
|
16.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 23.1% · Q4 16.7% · 4Q avg 20.3% · 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 | 20.3% |
15.1%
5.2 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
15.5%
4.3 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 29.6% · Q3 19.2% · Q4 20.0% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
0.6%
2.3 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 4.2% · Q4 4.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.4%
1.1 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.4% · Q3 0.0% · Q4 3.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.0% |
20.8%
11.2 pts worse
|
19.8%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 21.2% · Q3 32.7% · Q4 38.0% · 4Q avg 32.0% |
| Percentage of long-stay residents with pressure ulcers | 12.8% |
6.9%
5.9 pts worse
|
5.1%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 10.6% · Q3 12.6% · Q4 18.8% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.8% |
76.7%
0.1 pts better
|
81.7%
4.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 82.9% · Q3 77.5% · Q4 70.0% · 4Q avg 76.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.2%
0.8 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.2% |
78.8%
9.6 pts worse
|
79.7%
10.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.2% |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-02
Fire Safety
Have exits that are accessible at all times.
Not marked corrected
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-04-29
Inspection history
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-02
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 2025-06-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-02
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-02
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2025-03-16
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-03-16
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-16
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-06
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-06
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 2023-10-06
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-06
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 2023-10-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-29
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 2022-04-29
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-04-29
Penalties and ownership
Fine · fine $8,979
Fine
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Nearby options
Rochester, NY
5-star overall rating with 5-star inspections with 2 recent health deficiencies
Rochester, NY
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $842,850 in total fines with 28 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Rochester, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies
Jump out