Cycle 1
Health 2025-09-10 · Fire 2025-09-10
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Webster, NY
St. Ann's Community
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
920 Cherry Ridge Boulevard, Webster, NY
(585) 697-6800
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-03-20
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
0.57
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.97
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
3.68
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,838
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.35
Performance 54.08% · Measure score 2.35 · Achievement 2.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.33
Baseline 4.88 hours · Performance 4.59 hours · Measure score 5.33 · Achievement 5.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.85% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 117 |
| Staff flu vaccination coverage | 27.59% |
42%
14.4 pts worse
|
Numerator 40 · Denominator 145 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
91.2%
5.5 pts worse
|
93.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.1% · Q2 85.1% · Q3 87.0% · Q4 82.9% · 4Q avg 85.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
95.3%
0.9 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.0%
3.6 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 7.5% · Q3 5.8% · Q4 2.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 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 who lose too much weight | 3.7% |
6.1%
2.4 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.1% · Q3 3.4% · Q4 3.4% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
13.5%
2.9 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 9.2% · Q3 8.5% · Q4 11.5% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
14.8%
2.2 pts better
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 18.2% · Q3 8.6% · Q4 9.3% · 4Q avg 12.6% · 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 | 29.0% |
15.1%
13.9 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.3% · Q2 25.0% · Q3 15.1% · Q4 32.8% · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.2% |
15.5%
18.7 pts worse
|
14.9%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 35.0% · Q3 25.0% · Q4 37.5% · 4Q avg 34.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.6%
About the same
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.4%
1.2 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.5% · Q3 0.0% · Q4 4.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.7% |
20.8%
17.9 pts worse
|
19.8%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 44.2% · Q3 37.2% · Q4 32.9% · 4Q avg 38.7% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.9%
About the same
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.7% · Q3 7.8% · Q4 7.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.3% |
76.7%
16.4 pts worse
|
81.7%
21.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 65.0% · 4Q avg 60.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-29 · Fire 2022-08-29
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-10
E · Potential for more than minimal harm
2024-05-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-05
C · Minimal harm
2024-05-08
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-07-05
E · Potential for more than minimal harm
2022-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-08-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-08-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-10
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 2025-11-10
D · Potential for more than minimal harm
2025-09-10
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2025-11-10
E · Potential for more than minimal harm
2024-05-08
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 2024-07-05
D · Potential for more than minimal harm
2024-05-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-22
D · Potential for more than minimal harm
2024-05-08
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 2024-07-05
D · Potential for more than minimal harm
2023-09-13
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 2023-11-01
E · Potential for more than minimal harm
2022-08-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-08-29
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 2022-10-21
D · Potential for more than minimal harm
2022-08-29
F584 · Resident Rights Deficiencies
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 2022-10-21
D · Potential for more than minimal harm
2022-08-29
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 2022-10-21
Penalties and ownership
What sits behind the stars
Ownership
Barnes, Rene
Operational/Managerial Control · Individual
Bourg, Robert
Corporate Officer · Individual
Brown, Kevin
Corporate Officer · 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
Maplewood Nursing Home Inc
Webster, NY
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Penfield Place
Penfield, NY
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Blossom Health Care Center Inc.
Rochester, NY
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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