Cycle 1
Health 2024-04-16 · Fire 2024-04-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rochester, NY
St. Ann's Community
4-star overall rating with 4-star inspections with $55,495 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1500 Portland Avenue, Rochester, NY
(585) 697-6000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
470
Certified beds
Average residents
367
Average occupied residents
Ownership
Non-Profit
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
0.43
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
290
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0242
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.73
Baseline 17.86% · Performance 17.85% · Measure score 7.73 · Achievement 7.73 · Improvement 0
Healthcare-associated infections
10
Baseline 7.42% · Performance 4.70% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
6.08
Baseline 37.98% · Performance 38.84% · Measure score 6.08 · Achievement 6.08 · Improvement 0
Adjusted total nurse staffing
5.93
Baseline 5.69 hours · Performance 4.77 hours · Measure score 5.93 · Achievement 5.93 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.46% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 267 · Observed rate 6.37% · Lower 95% interval 6.7% |
| Discharge to community | 51.15% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 261 · Observed rate 47.51% · Lower 95% interval 44.72% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.79% |
95.27%
0.5 pts worse
|
Numerator 182 · Denominator 192 |
| Falls with major injury | 0.52% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 192 |
| Discharge self-care score | 47.9% |
53.69%
5.8 pts worse
|
Numerator 80 · Denominator 167 |
| Discharge mobility score | 61.68% |
50.94%
10.7 pts better
|
Numerator 103 · Denominator 167 |
| Pressure ulcers or injuries, new or worsened | 4.69% |
2.29%
2.4 pts worse
|
Numerator 9 · Denominator 192 · Adjusted rate 5.54% |
| Healthcare-associated infections requiring hospitalization | 4.7% |
7.12%
2.4 pts better
|
No Different than the National Rate · Eligible stays 168 · Observed rate 1.19% · Lower 95% interval 2.66% |
| Staff COVID-19 vaccination coverage | 5.13% |
8.2%
3.1 pts worse
|
Numerator 41 · Denominator 800 |
| Staff flu vaccination coverage | 44.77% |
42%
2.8 pts better
|
Numerator 407 · Denominator 909 |
| Discharge function score | 57.49% |
56.45%
1 pts better
|
Numerator 96 · Denominator 167 |
| Transfer of health information to provider | 97.5% |
95.95%
1.5 pts better
|
Numerator 117 · Denominator 120 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 16.13% |
25.2%
9.1 pts worse
|
Numerator 15 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.3
1 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 72.7% |
91.2%
18.5 pts worse
|
93.4%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.6% · Q2 70.1% · Q3 70.1% · Q4 71.1% · 4Q avg 72.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.9% |
95.3%
10.4 pts worse
|
95.5%
10.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
3.0%
3.3 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.8% · Q3 6.9% · Q4 5.7% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
18.5%
13.5 pts better
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.3% · Q3 4.4% · Q4 4.6% · 4Q avg 5.0% |
| 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 5.8% · Q2 7.3% · Q3 4.7% · Q4 5.2% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
13.5%
3.1 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 11.2% · Q3 11.9% · Q4 10.1% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
14.8%
1.1 pts worse
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 18.5% · Q3 14.8% · Q4 13.7% · 4Q avg 15.9% · 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 | 26.5% |
15.1%
11.4 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 23.9% · Q3 24.1% · Q4 26.6% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
15.5%
15.1 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 34.5% · Q3 27.4% · Q4 30.3% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.6%
0.3 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.8% · Q3 0.6% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.4%
0.2 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.3% · Q3 1.3% · Q4 1.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.7% |
20.8%
13.9 pts worse
|
19.8%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 39.3% · Q3 33.3% · Q4 31.5% · 4Q avg 34.7% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.9%
1.6 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.0% · Q3 7.7% · Q4 7.6% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.0% |
76.7%
33.7 pts worse
|
81.7%
38.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 33.8% · Q3 47.3% · Q4 66.7% · 4Q avg 43.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.7% |
9.7%
6 pts better
|
12.0%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.7% · Observed 3.3% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.8% |
78.8%
55 pts worse
|
79.7%
55.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
20.6%
4.2 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 14.0% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-22 · Fire 2022-09-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-01-07 · Fire 2020-01-07
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-04-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-07
E · Potential for more than minimal harm
2022-09-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-09-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-09-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-09-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-09-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-09-22
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 2022-11-21
E · Potential for more than minimal harm
2020-01-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-03-07
E · Potential for more than minimal harm
2020-01-07
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 2020-03-07
E · Potential for more than minimal harm
2020-01-07
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 2020-03-07
E · Potential for more than minimal harm
2020-01-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-07
E · Potential for more than minimal harm
2020-01-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-07
E · Potential for more than minimal harm
2020-01-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-07
Inspection history
Recent health citations
G · Actual harm
2025-01-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-20
D · Potential for more than minimal harm
2024-04-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-16
F690 · Quality of Life and Care Deficiencies
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 2024-06-07
D · Potential for more than minimal harm
2024-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-07
E · Potential for more than minimal harm
2022-09-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-02-07
E · Potential for more than minimal harm
2022-09-22
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 2022-12-01
D · Potential for more than minimal harm
2022-09-22
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 2022-12-01
D · Potential for more than minimal harm
2022-09-22
F836 · Administration Deficiencies
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 2022-12-01
D · Potential for more than minimal harm
2020-01-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-01-07
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 2020-03-07
D · Potential for more than minimal harm
2020-01-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-01-07
F761 · Pharmacy Service Deficiencies
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 2020-03-07
D · Potential for more than minimal harm
2020-01-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2020-03-07
Penalties and ownership
What sits behind the stars
$51,301
2025-01-07
Fine
Fine · fine $51,301
Fine
$4,194
2023-08-28
Fine
Fine · fine $4,194
Fine
Ownership
Bourg, Robert
Corporate Officer · Individual
Brown, Kevin
Corporate Officer · Individual
Kuhn, Kari
Operational/Managerial Control · Individual
Mcrae, Michael
Operational/Managerial Control · Individual
Mcrae, Michael
Corporate Officer · Individual
Petrone, Kim
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Pearl Nursing Center of Rochester
Rochester, NY
1-star overall rating with 1-star inspections with 16 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
#2
The Brook at High Falls Nursing Home and Rehabilit
Rochester, NY
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lilac Manor Rehabilitation and Nursing Center
Rochester, NY
1-star overall rating with 1-star inspections with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out