Webster, NY

Maplewood Nursing Home Inc

5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

100 Daniel Drive, Webster, NY

(585) 872-1800

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

74

Certified beds

Average residents

72

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1976-11-22

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

0.83

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

3.47

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

5.71

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

2.23

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

5.08

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.54

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.93

CMS adjusted RN staffing hours

Adjusted total hours

6.42

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

359

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

Performance score

72.13

Composite VBP score used to determine payment impact.

Payment multiplier

1.0234

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

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

4.43

Baseline 44.19% · Performance 45.59% · Measure score 4.43 · Achievement 4.43 · Improvement 0

Adjusted total nurse staffing

10

Baseline 5.75 hours · Performance 5.90 hours · Measure score 10 · Achievement 10 · Improvement 9

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 9 · 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 8 · 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 8 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 8 · 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 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	7.37%	8.2% 0.8 pts worse	Numerator 16 · Denominator 217
Staff flu vaccination coverage	89.62%	42% 47.6 pts better	Numerator 285 · Denominator 318
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.7 0.8 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.7	1.3 0.6 pts better	1.8 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	91.2% 8.8 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.3% 4.7 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	12.0%	3.0% 9 pts worse	3.3% 8.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 12.2% · Q3 13.2% · Q4 8.6% · 4Q avg 12.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.5%	18.5% 13 pts better	11.4% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.0% · Q3 8.2% · Q4 6.3% · 4Q avg 5.5%
Percentage of long-stay residents who lose too much weight	1.2%	6.1% 4.9 pts better	5.4% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 1.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	1.6%	13.5% 11.9 pts better	19.6% 18 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 1.7% · Q4 1.6% · 4Q avg 1.6%
Percentage of long-stay residents who received an antipsychotic medication	8.3%	14.8% 6.5 pts better	16.7% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 9.5% · Q3 6.9% · Q4 3.5% · 4Q avg 8.3% · 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	17.8%	15.1% 2.7 pts worse	16.3% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 16.0% · Q3 21.9% · Q4 4.5% · 4Q avg 17.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	20.0%	15.5% 4.5 pts worse	14.9% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 18.2% · Q3 20.4% · Q4 14.3% · 4Q avg 20.0% · 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 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · 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 1.4% · Q2 4.1% · Q3 2.9% · Q4 1.4% · 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 53.0% · Q2 33.7% · Q3 23.2% · Q4 17.5% · 4Q avg 32.0%
Percentage of long-stay residents with pressure ulcers	5.7%	6.9% 1.2 pts better	5.1% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.5% · Q3 4.8% · Q4 3.2% · 4Q avg 5.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.0%	76.7% 16.3 pts better	81.7% 11.3 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 93.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-23 · Fire 2025-05-23

4 health deficiencies

Top issue: Administration (1 deficiency)

3 fire-safety deficiencies

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

Cycle 2 Health 2024-03-13 · Fire 2024-03-13

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-06-03 · Fire 2022-06-03

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

4 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 2025-05-23

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-05-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-05-23

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-07-15

E · Potential for more than minimal harm 2024-03-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-06-11

E · Potential for more than minimal harm 2024-03-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-05-10

E · Potential for more than minimal harm 2022-06-03

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 2022-08-09

E · Potential for more than minimal harm 2022-06-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-08-09

E · Potential for more than minimal harm 2022-06-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-08-09

D · Potential for more than minimal harm 2022-06-03

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2022-08-09

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-05-23

F761 · Pharmacy Service Deficiencies

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 2025-07-15

D · Potential for more than minimal harm 2025-05-23

F811 · Nutrition and Dietary Deficiencies

Health

Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-05-23

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2025-07-17

B · Minimal harm 2025-05-23

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-07-15

D · Potential for more than minimal harm 2024-03-13

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-05-10

B · Minimal harm 2024-03-13

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 2024-05-10

B · Minimal harm 2024-03-13

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-05-10

F · Potential for more than minimal harm 2022-06-03

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 2022-08-09

Penalties and ownership