16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Tonawanda, NY
1-star overall rating with 1-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
2799 Sheridan Drive, Tonawanda, NY
(716) 837-4466
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
100
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sapphire Care Group
Operator or chain grouping
Approved since
1972-01-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 2 health / 2 staffing / 5 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
0.65
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
2.13
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
3,528
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9970
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.59
Baseline 21.00% · Performance 21.16% · Measure score 0.59 · Achievement 0.59 · Improvement 0
Healthcare-associated infections
6.88
Baseline 10.73% · Performance 6.50% · Measure score 6.88 · Achievement 4.47 · Improvement 6.88
Total nurse turnover
7.26
Baseline 56.98% · Performance 34.02% · Measure score 7.26 · Achievement 7.26 · Improvement 6.65
Adjusted total nurse staffing
2.84
Baseline 3 hours · Performance 3.89 hours · Measure score 2.84 · Achievement 2.84 · Improvement 2.70
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 10.77% · Lower 95% interval 6.15% |
| Discharge to community | 42.97% |
50.57%
7.6 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 30.77% · Lower 95% interval 31.09% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 2 · Denominator 84 |
| Discharge self-care score | 63.27% |
53.69%
9.6 pts better
|
Numerator 31 · Denominator 49 |
| Discharge mobility score | 73.47% |
50.94%
22.5 pts better
|
Numerator 36 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 3 · Denominator 84 · Adjusted rate 3.18% |
| Healthcare-associated infections requiring hospitalization | 6.5% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 3.97% |
8.2%
4.2 pts worse
|
Numerator 6 · Denominator 151 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 73.47% |
56.45%
17 pts better
|
Numerator 36 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.02% |
25.2%
8.2 pts worse
|
Numerator 8 · Denominator 47 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 2.1% |
3.0%
0.9 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.4% · Q4 3.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 82.3% |
18.5%
63.8 pts worse
|
11.4%
70.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.3% · Q2 83.6% · Q3 88.6% · Q4 84.0% · 4Q avg 82.3% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.1%
0.1 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.5% · Q3 5.3% · Q4 3.2% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
13.5%
3.4 pts worse
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 19.0% · Q3 12.5% · Q4 14.6% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
14.8%
1.7 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 16.4% · Q3 12.1% · Q4 15.6% · 4Q avg 16.5% · 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 | 8.4% |
15.1%
6.7 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.9% · Q3 12.3% · Q4 7.9% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
15.5%
4 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 13.5% · Q3 12.0% · Q4 13.2% · 4Q avg 11.5% · 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 | 21.4% |
20.8%
0.6 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 27.3% · Q3 18.4% · Q4 26.8% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.9%
1.1 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.9% · Q3 7.2% · Q4 5.8% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
76.7%
22.1 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 98.3% · Q4 98.4% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.0% |
9.7%
7.3 pts worse
|
12.0%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 20.0% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.8%
21.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
20.6%
6.3 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 35.6% · Expected 31.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Nutrition and Dietary (5 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-02
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-05-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-20
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-20
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-07-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-20
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-20
Fire Safety
Use approved construction type or materials.
Corrected 2023-11-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-30
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-10-30
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 2023-10-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-30
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-30
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-11-20
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-30
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-10-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-30
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-10-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-30
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-30
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-30
Fire Safety
Use approved construction type or materials.
Not marked corrected
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-01-06
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-01-06
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-01-06
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 2022-01-06
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-06
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-01-06
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-01-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-06
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-01-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-06
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-01-06
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-01-06
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-01-06
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2022-01-06
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-20
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 2025-05-20
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-20
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-07-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-20
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-20
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-05-20
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-20
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-20
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 2025-05-20
Health
Provide or obtain dental services for each resident.
Corrected 2025-05-20
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-20
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-01-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-30
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-10-30
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-30
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-10-30
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-30
Health
Provide activities to meet all resident's needs.
Corrected 2023-10-30
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-10-30
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-01-06
Health
Keep all essential equipment working safely.
Corrected 2022-01-06
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-01-06
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-01-06
Health
Respond appropriately to all alleged violations.
Corrected 2022-01-06
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-06
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-01-06
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Limited Partnership Interest · Individual
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