6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Rochester, NY
5-star overall rating with 4-star inspections with 6 recent health deficiencies
1555 Long Pond Road, Rochester, NY
(585) 723-7205
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
118
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Rochester Regional Health
Operator or chain grouping
Approved since
1972-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 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
0.62
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.98
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.78
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.98
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
5.10
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
4,996
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.18% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.47
Baseline 5.81% · Performance 7.40% · Measure score 1.47 · Achievement 1.47 · Improvement 0
Total nurse turnover
5.95
Baseline 50.47% · Performance 39.36% · Measure score 5.95 · Achievement 5.95 · Improvement 3.84
Adjusted total nurse staffing
7.71
Baseline 4.74 hours · Performance 5.27 hours · Measure score 7.71 · Achievement 7.71 · Improvement 4.62
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 229 · Observed rate 10.92% · Lower 95% interval 8.4% |
| Discharge to community | 57.19% |
50.57%
6.6 pts better
|
Better than the National Rate · Eligible stays 235 · Observed rate 54.47% · Lower 95% interval 51.28% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 114 · Denominator 115 |
| Falls with major injury | 0.87% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 115 |
| Discharge self-care score | 41.3% |
53.69%
12.4 pts worse
|
Numerator 38 · Denominator 92 |
| Discharge mobility score | 30.43% |
50.94%
20.5 pts worse
|
Numerator 28 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 5 · Denominator 115 · Adjusted rate 5.36% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 7.14% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 0.36% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 281 |
| Staff flu vaccination coverage | 52.43% |
42%
10.4 pts better
|
Numerator 205 · Denominator 391 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 46 · Denominator 92 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 20 · Denominator 22 |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 70 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 42.86% |
25.2%
17.7 pts better
|
Numerator 27 · Denominator 63 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.3
1.1 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
91.2%
2.3 pts better
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 92.8% · Q3 91.6% · Q4 94.3% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
95.3%
2.4 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.9% |
3.0%
4.9 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.0% · Q3 7.2% · Q4 11.4% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
18.5%
17.2 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.6% · Q3 0.0% · Q4 1.3% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
6.1%
2.7 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 10.0% · Q3 11.0% · Q4 1.3% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
13.5%
5.1 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 7.1% · Q3 11.0% · Q4 9.1% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
14.8%
2.1 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 7.0% · Q3 10.9% · Q4 13.4% · 4Q avg 12.7% · 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 | 17.1% |
15.1%
2 pts worse
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 13.9% · Q3 8.5% · Q4 14.6% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
15.5%
0.2 pts worse
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 11.3% · Q3 6.3% · Q4 14.1% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
20.8%
4.8 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 13.4% · Q3 10.2% · Q4 5.9% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 11.1% |
6.9%
4.2 pts worse
|
5.1%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.9% · Q3 9.4% · Q4 7.0% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.1% |
76.7%
1.4 pts better
|
81.7%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.3% · Q2 78.1% · Q3 77.2% · Q4 76.0% · 4Q avg 78.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.9% |
9.7%
5.8 pts better
|
12.0%
8.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.9% · Observed 3.6% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
78.8%
11.1 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
20.6%
4.6 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 23.4% · Expected 22.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Nursing and Physician Services (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-10-17
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-28
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 2024-06-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-28
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-17
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-10-17
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 2022-10-17
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2022-10-17
Health
Post nurse staffing information every day.
Corrected 2022-10-17
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-04-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-05
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2020-04-05
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-04-05
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-04-05
Penalties and ownership
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Nearby options
Rochester, NY
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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3-star overall rating with 2-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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
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