Cycle 1
Health 2024-10-01 · Fire 2024-10-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
18 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Buffalo, NY
St Catherine Laboure Health Care Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
2157 Main Street, Buffalo, NY
(716) 862-2000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
80
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-06-10
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.38
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
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.56
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,682
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
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
3.46
Baseline 49.06% · Performance 49.54% · Measure score 3.46 · Achievement 3.46 · Improvement 0
Adjusted total nurse staffing
5.17
Baseline 4.43 hours · Performance 4.55 hours · Measure score 5.17 · Achievement 5.17 · Improvement 0.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 7.07% |
| Discharge to community | 51.95% |
50.57%
1.4 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 46.43% · Lower 95% interval 37.23% |
| Medicare spending per beneficiary | 0.44 |
1.02
0.6 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 12 · Denominator 24 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 12 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 93 · Denominator 93 |
| Staff flu vaccination coverage | 44.69% |
42%
2.7 pts better
|
Numerator 80 · Denominator 179 |
| Discharge function score | 54.17% |
56.45%
2.3 pts worse
|
Numerator 13 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 96.0% |
91.2%
4.8 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 95.0% · Q3 96.8% · Q4 95.7% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.4% |
95.3%
0.1 pts better
|
95.5%
0.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.0%
1 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 1.7% · Q3 1.6% · Q4 0.0% · 4Q avg 2.0% · 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 | 6.3% |
6.1%
0.2 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.5% · Q3 3.5% · Q4 8.2% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
13.5%
0.1 pts worse
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.2% · Q3 15.9% · Q4 16.4% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
14.8%
2.5 pts worse
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 21.3% · Q3 20.8% · Q4 10.9% · 4Q avg 17.3% · 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 | 14.8% |
15.1%
0.3 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.7% · Q3 12.5% · Q4 17.5% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
15.5%
3.3 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 21.4% · Q3 15.8% · Q4 20.3% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.6%
0.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.4%
1.4 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.3% · Q3 1.6% · Q4 1.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
20.8%
9.2 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 29.8% · Q3 26.1% · Q4 37.1% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
6.9%
3.5 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.0% · Q3 10.8% · Q4 13.9% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.7% |
76.7%
14 pts better
|
81.7%
9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.3% · Q2 89.7% · Q3 93.9% · Q4 93.8% · 4Q avg 90.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.4% |
9.7%
6.3 pts better
|
12.0%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.4% · Observed 3.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
78.8%
11.4 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.8% |
20.6%
18.2 pts worse
|
23.9%
14.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.8% · Observed 37.5% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-14 · Fire 2023-02-14
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-09-10 · Fire 2021-09-10
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
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 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K902 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-01
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-01
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-01
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-01
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-20
E · Potential for more than minimal harm
2023-02-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-02-14
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-04-07
E · Potential for more than minimal harm
2021-09-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-03
E · Potential for more than minimal harm
2021-09-10
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 2021-11-03
E · Potential for more than minimal harm
2021-09-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-11-03
E · Potential for more than minimal harm
2021-09-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-01
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 2024-11-26
D · Potential for more than minimal harm
2023-02-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-02-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-07
D · Potential for more than minimal harm
2021-09-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-03
Penalties and ownership
What sits behind the stars
Ownership
Agnello, Alexis
Corporate Officer · Individual
Edwards, Russell
Corporate Officer · Individual
Felstead, Keith
Corporate Officer · Individual
Fiutko, Marcia Ann
Corporate Officer · Individual
Gleason, Thomas
Operational/Managerial Control · Individual
Godfrey, David
Corporate Officer · Individual
Macholz, David
Operational/Managerial Control · Individual
Macholz, David
Corporate Officer · Individual
Markiewicz, Joyce
Corporate Officer · Individual
Sette-Camara, Leonardo
Corporate Officer · Individual
Sisters Of Charity Hospital Of Buffalo New York
Operational/Managerial Control · Organization
Snyder, Brian
Operational/Managerial Control · Individual
Toczek, Jeffrey
Operational/Managerial Control · Individual
Zapfel, Robert
Corporate Officer · Individual
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#3
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