Cycle 1
Health 2024-05-24 · Fire 2024-05-24
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Medina, NY
Medina Memorial Hospital S N F
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
200 Ohio Street, Medina, NY
(585) 798-2000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-08-27
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,588
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
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
1.05
Baseline 33.33% · Performance 59.38% · Measure score 1.05 · Achievement 1.05 · Improvement 0
Adjusted total nurse staffing
3.59
Baseline 4.16 hours · Performance 4.10 hours · Measure score 3.59 · Achievement 3.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 4 · 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 3 · 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 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · 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 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.26% |
8.2%
2.9 pts worse
|
Numerator 5 · Denominator 95 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 97 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.8% |
91.2%
7.4 pts worse
|
93.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.7% · Q3 100.0% · Q4 41.4% · 4Q avg 83.8% |
| 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 | 1.7% |
3.0%
1.3 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 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 who lose too much weight | 1.9% |
6.1%
4.2 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.7% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.8% |
13.5%
5.7 pts better
|
19.6%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.7% · Q3 11.1% · Q4 10.3% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
14.8%
10.7 pts worse
|
16.7%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 22.7% · Q3 30.0% · Q4 30.8% · 4Q avg 25.5% · 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 | 26.2% |
15.1%
11.1 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
15.5%
1.3 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.0% · Q3 7.4% · Q4 25.9% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.6%
1.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.7% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
1.4%
3.8 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 7.4% · Q4 10.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
20.8%
6.6 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 37.7% · Q3 26.0% · Q4 14.5% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.9%
2.8 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.6% · Q3 4.2% · Q4 5.1% · 4Q avg 4.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-02 · Fire 2022-08-02
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-01-06 · Fire 2020-01-06
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
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
2024-05-24
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-05-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-17
E · Potential for more than minimal harm
2022-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-25
E · Potential for more than minimal harm
2022-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-24
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-06-17
F · Potential for more than minimal harm
2022-08-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-02
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 2022-09-12
B · Minimal harm
2022-08-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-09-16
D · Potential for more than minimal harm
2020-01-06
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 2020-03-06
D · Potential for more than minimal harm
2020-01-06
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 2020-03-06
D · Potential for more than minimal harm
2020-01-06
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2020-03-06
Penalties and ownership
What sits behind the stars
Ownership
Blount, Shannon
Corporate Officer · Individual
Condo, Lori
W-2 Managing Employee · Individual
Elman, Richard
Corporate Director · Individual
Foley, Kevin
Corporate Director · Individual
Hewitt, Cynthia
Corporate Officer · Individual
Johnson, Lynn
Corporate Director · Individual
Mark, Lance
Corporate Director · Individual
Mcgaffick, April
Corporate Officer · Individual
Meland, Dawn
Corporate Officer · Individual
Misiti, Joseph
Corporate Director · Individual
Monti, David
Corporate Officer · Individual
Shurtz, Marc
Corporate Officer · Individual
Sponaugle, Dale
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Orchard Rehabilitation & Nursing Center
Medina, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Villages Of Orleans Health And Rehab Center
Albion, NY
1-star overall rating with 1-star inspections with $71,112 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Absolut Ctr For Nursing & Rehab Gasport L L C
Gasport, NY
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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