Cycle 1
Health 2025-01-08 · Fire 2025-01-08
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Kenmore, NY
Mcauley Residence
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1503 Military Road, Kenmore, NY
(716) 447-6600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
138
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-09-23
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
1.03
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.41
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,020
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.62
Baseline 20.82% · Performance 20.22% · Measure score 2.62 · Achievement 2.62 · Improvement 1.09
Healthcare-associated infections
6.77
Baseline 5.88% · Performance 5.81% · Measure score 6.77 · Achievement 6.77 · Improvement 0.23
Total nurse turnover
1.13
Baseline 50.00% · Performance 59.07% · Measure score 1.13 · Achievement 1.13 · Improvement 0
Adjusted total nurse staffing
3.19
Baseline 4.32 hours · Performance 3.98 hours · Measure score 3.19 · Achievement 3.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.78% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 247 · Observed rate 12.55% · Lower 95% interval 10.07% |
| Discharge to community | 62.34% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 266 · Observed rate 61.28% · Lower 95% interval 56.69% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.42% |
95.27%
4.2 pts better
|
Numerator 170 · Denominator 171 |
| Falls with major injury | 0.58% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 171 |
| Discharge self-care score | 68.46% |
53.69%
14.8 pts better
|
Numerator 102 · Denominator 149 |
| Discharge mobility score | 70.47% |
50.94%
19.5 pts better
|
Numerator 105 · Denominator 149 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 4 · Denominator 170 · Adjusted rate 3.62% |
| Healthcare-associated infections requiring hospitalization | 5.81% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 3.27% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 1.64% |
8.2%
6.6 pts worse
|
Numerator 4 · Denominator 244 |
| Staff flu vaccination coverage | 63.84% |
42%
21.8 pts better
|
Numerator 203 · Denominator 318 |
| Discharge function score | 69.13% |
56.45%
12.7 pts better
|
Numerator 103 · Denominator 149 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.81% |
96.28%
1.5 pts better
|
Numerator 134 · Denominator 137 |
| Resident COVID-19 vaccinations up to date | 15.49% |
25.2%
9.7 pts worse
|
Numerator 11 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.7
1.4 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.8 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.2%
8.2 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.4% · Q3 4.4% · Q4 2.1% · 4Q avg 2.8% · 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 2.8% · Q2 3.9% · Q3 5.2% · Q4 2.3% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
6.1%
1.5 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.1% · Q3 4.3% · Q4 2.7% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
13.5%
1.1 pts worse
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 19.8% · Q3 13.9% · Q4 10.7% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
14.8%
8.7 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.7% · Q3 5.7% · Q4 7.0% · 4Q avg 6.1% · 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 | 17.7% |
15.1%
2.6 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
15.5%
2.2 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 14.5% · Q3 13.3% · Q4 9.0% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.4%
1.7 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.4% · Q3 1.1% · Q4 3.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
20.8%
7.5 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 21.4% · Q3 24.8% · Q4 29.5% · 4Q avg 28.3% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.9%
0.3 pts better
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.3% · Q3 7.0% · Q4 6.2% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
76.7%
22.8 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.4% · Q3 99.8% · Q4 99.6% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
9.7%
1.8 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.5% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
78.8%
17.5 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
20.6%
0.1 pts worse
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 16.4% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-15 · Fire 2023-05-15
4 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-12-15 · Fire 2021-12-15
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-08
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-01-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-01
D · Potential for more than minimal harm
2025-01-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-02-14
E · Potential for more than minimal harm
2023-05-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-13
E · Potential for more than minimal harm
2023-05-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-13
E · Potential for more than minimal harm
2023-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-13
E · Potential for more than minimal harm
2023-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-08
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 2025-03-05
D · Potential for more than minimal harm
2025-01-08
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-03-05
D · Potential for more than minimal harm
2023-09-14
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 2023-11-01
D · Potential for more than minimal harm
2023-05-15
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 2023-07-13
D · Potential for more than minimal harm
2023-05-15
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 2023-05-09
D · Potential for more than minimal harm
2023-05-15
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 2023-06-30
C · Minimal harm
2023-05-15
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 2023-07-13
D · Potential for more than minimal harm
2021-12-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-12-28
Penalties and ownership
What sits behind the stars
Ownership
Agnello, Alexis
Corporate Director · Individual
Durno, John
Operational/Managerial Control · Individual
Edwards, Russell
Operational/Managerial Control · Individual
Edwards, Russell
Corporate Officer · Individual
Gleason, Thomas
Operational/Managerial Control · Individual
Gleason, Thomas
Corporate Director · Individual
Macholz, David
Corporate Officer · Individual
Markiewicz, Joyce
Corporate Officer · Individual
Sette-Camara, Leonardo
Corporate Director · Individual
Snyder, Brian
Operational/Managerial Control · Individual
Zapfel, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
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Schofield Residence
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4-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Safire Rehabilitation Of Northtowns, L L C
Tonawanda, NY
1-star overall rating with 1-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Degraff Memorial Hospital-Skilled Nursing Facility
North Tonawanda, NY
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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