Cycle 1
Health 2024-12-20 · Fire 2024-12-20
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rochester, NY
Monroe Community Hospital
1-star overall rating with 1-star inspections with $216,450 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
435 East Henrietta Road, Rochester, NY
(585) 760-6500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
566
Certified beds
Average residents
393
Average occupied residents
Ownership
Government
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
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,265
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9936
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.21
Baseline 21.03% · Performance 20.41% · Measure score 2.21 · Achievement 2.21 · Improvement 1.06
Healthcare-associated infections
4.71
Baseline 7.09% · Performance 6.43% · Measure score 4.71 · Achievement 4.71 · Improvement 2.65
Total nurse turnover
6.42
Baseline 42.46% · Performance 37.44% · Measure score 6.42 · Achievement 6.42 · Improvement 2.35
Adjusted total nurse staffing
2.92
Baseline 3.65 hours · Performance 3.91 hours · Measure score 2.92 · Achievement 2.92 · Improvement 0.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 6.1% · Lower 95% interval 6.35% |
| Discharge to community | 49.24% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 37.31% · Lower 95% interval 38.1% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 81 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 81 |
| Discharge self-care score | 54.72% |
53.69%
1 pts better
|
Numerator 29 · Denominator 53 |
| Discharge mobility score | 60.38% |
50.94%
9.4 pts better
|
Numerator 32 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 4.94% |
2.29%
2.7 pts worse
|
Numerator 4 · Denominator 81 · Adjusted rate 3.97% |
| Healthcare-associated infections requiring hospitalization | 6.43% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 6.67% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 2.63% |
8.2%
5.6 pts worse
|
Numerator 27 · Denominator 1028 |
| Staff flu vaccination coverage | 35.69% |
42%
6.3 pts worse
|
Numerator 368 · Denominator 1031 |
| Discharge function score | 62.26% |
56.45%
5.8 pts better
|
Numerator 33 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 45.45% |
25.2%
20.3 pts better
|
Numerator 20 · Denominator 44 |
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 2.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
91.2%
2.6 pts better
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 98.9% · Q3 91.9% · Q4 85.4% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.3%
2.7 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.0%
About the same
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.7% · Q3 2.8% · Q4 1.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
18.5%
15.9 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.5% · Q3 2.0% · Q4 1.9% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
6.1%
1.7 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 8.5% · Q3 10.1% · Q4 6.3% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
13.5%
4 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 8.7% · Q3 9.5% · Q4 9.4% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
14.8%
3.9 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 17.1% · Q3 18.3% · Q4 21.7% · 4Q avg 18.7% · 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 | 20.2% |
15.1%
5.1 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 25.4% · Q3 17.6% · Q4 14.0% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
15.5%
0.9 pts better
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 15.3% · Q3 14.6% · Q4 10.0% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.6%
0.8 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.1% · Q3 0.9% · Q4 0.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.4%
About the same
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.6% · Q3 0.3% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
20.8%
4.7 pts better
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 16.0% · Q3 12.3% · Q4 16.1% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
6.9%
4.1 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 14.5% · Q3 11.4% · Q4 8.4% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
76.7%
20.1 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 97.8% · Q3 98.4% · Q4 95.5% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
9.7%
2.2 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 8.8% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.9% · Q3 1.8% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
78.8%
15.8 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.1% |
20.6%
4.5 pts better
|
23.9%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 21.2% · Expected 31.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-01 · Fire 2023-05-01
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-07-15 · Fire 2021-07-15
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-20
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 2025-02-18
D · Potential for more than minimal harm
2024-12-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-18
F · Potential for more than minimal harm
2023-05-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-01
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-01
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-30
C · Minimal harm
2023-05-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-06-30
C · Minimal harm
2023-05-01
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-06-30
E · Potential for more than minimal harm
2021-07-15
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 2021-08-20
D · Potential for more than minimal harm
2021-07-15
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-15
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-08-20
Inspection history
Recent health citations
L · Immediate jeopardy
2025-10-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-05
J · Immediate jeopardy
2025-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-05
G · Actual harm
2025-09-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-11
E · Potential for more than minimal harm
2024-12-20
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 2025-02-18
D · Potential for more than minimal harm
2024-12-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-12-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-18
D · Potential for more than minimal harm
2023-09-18
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 2023-11-17
D · Potential for more than minimal harm
2023-05-01
F657 · Resident Assessment and Care Planning Deficiencies
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 2023-06-30
D · Potential for more than minimal harm
2023-05-01
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 2023-06-30
J · Immediate jeopardy
2021-07-15
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 2021-09-03
D · Potential for more than minimal harm
2021-07-15
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 2021-09-03
Penalties and ownership
What sits behind the stars
$13,520
2025-09-12
Fine
Fine · fine $13,520
Fine
$202,930
2025-09-12
Fine
Fine · fine $202,930
Fine
Ownership
County Of Monroe
5% Or Greater Direct Ownership Interest · Organization
Mann, Karie
W-2 Managing Employee · Individual
Tallo, Alyssa
Corporate Officer · Individual
Tallo, Alyssa
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Woodside Manor Nursing Home Inc
Rochester, NY
4-star overall rating with 4-star inspections with 7 recent health deficiencies
#2
The Hurlbut
Rochester, NY
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Highlands at Brighton
Rochester, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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