5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
West Seneca, NY
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2987 Seneca Street, West Seneca, NY
(716) 828-0500
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
160
Certified beds
Average residents
146
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Mcguire Group
Operator or chain grouping
Approved since
1977-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 3 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
0.34
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.16
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
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
7,228
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.05
Baseline 19.73% · Performance 19.09% · Measure score 5.05 · Achievement 5.05 · Improvement 1.86
Healthcare-associated infections
1.81
Baseline 5.38% · Performance 7.29% · Measure score 1.81 · Achievement 1.81 · Improvement 0
Total nurse turnover
3.37
Baseline 68.02% · Performance 51.30% · Measure score 3.37 · Achievement 3.03 · Improvement 3.37
Adjusted total nurse staffing
1.91
Baseline 4.63 hours · Performance 3.62 hours · Measure score 1.91 · Achievement 1.91 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 170 · Observed rate 8.24% · Lower 95% interval 6.96% |
| Discharge to community | 52.04% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 160 · Observed rate 47.5% · Lower 95% interval 45.67% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 100 · Denominator 100 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 100 |
| Discharge self-care score | 51.85% |
53.69%
1.8 pts worse
|
Numerator 42 · Denominator 81 |
| Discharge mobility score | 69.14% |
50.94%
18.2 pts better
|
Numerator 56 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 1% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 100 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 7.06% · Lower 95% interval 4.35% |
| Staff COVID-19 vaccination coverage | 9.48% |
8.2%
1.3 pts better
|
Numerator 22 · Denominator 232 |
| Staff flu vaccination coverage | 58.85% |
42%
16.9 pts better
|
Numerator 133 · Denominator 226 |
| Discharge function score | 65.43% |
56.45%
9 pts better
|
Numerator 53 · Denominator 81 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.31% |
96.28%
2 pts better
|
Numerator 58 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 26.79% |
25.2%
1.6 pts better
|
Numerator 15 · Denominator 56 |
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 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
91.2%
2.8 pts worse
|
93.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 85.6% · Q3 89.9% · Q4 89.7% · 4Q avg 88.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
95.3%
1.6 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.0%
0.4 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.5% · Q3 2.5% · Q4 6.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
18.5%
16.7 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 2.6% · Q4 0.9% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
6.1%
0.3 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.6% · Q3 5.5% · Q4 8.2% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
13.5%
1.2 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 10.5% · Q3 12.3% · Q4 13.4% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
14.8%
0.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 16.5% · Q3 14.0% · Q4 15.2% · 4Q avg 15.0% · 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 | 16.3% |
15.1%
1.2 pts worse
|
16.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 14.0% · Q3 14.6% · Q4 17.1% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
15.5%
3.7 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 9.8% · Q3 10.9% · Q4 15.2% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.6%
0.2 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.4%
0.5 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
20.8%
3.7 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 26.5% · Q3 22.7% · Q4 23.6% · 4Q avg 24.5% |
| 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 5.4% · Q2 6.4% · Q3 9.0% · Q4 5.4% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
76.7%
10.3 pts better
|
81.7%
5.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.4% · Q2 87.4% · Q3 89.4% · Q4 93.6% · 4Q avg 87.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
9.7%
1.1 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 7.5% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.7% · Q3 0.7% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
78.8%
6.9 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
20.6%
0.6 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 17.5% · Expected 20.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 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
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-24
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-02-13
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-13
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-16
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-16
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 2024-12-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-10
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-12-31
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-02-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-04-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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