Cycle 1
Health 2025-06-09 · Fire 2025-06-09
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Rochester, NY
St. John's Health Care Corporation
1-star overall rating with 1-star inspections with $141,034 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
150 Highland Avenue, Rochester, NY
(585) 760-1300
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
455
Certified beds
Average residents
334
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-06-19
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
0.50
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,055
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.11
Baseline 18.63% · Performance 20.46% · Measure score 2.11 · Achievement 2.11 · Improvement 0
Healthcare-associated infections
0.51
Baseline 5.18% · Performance 7.68% · Measure score 0.51 · Achievement 0.51 · Improvement 0
Total nurse turnover
6.08
Baseline 49.26% · Performance 38.83% · Measure score 6.08 · Achievement 6.08 · Improvement 3.77
Adjusted total nurse staffing
2.49
Baseline 4.06 hours · Performance 3.79 hours · Measure score 2.49 · Achievement 2.49 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.8% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 227 · Observed rate 9.69% · Lower 95% interval 8.5% |
| Discharge to community | 56.44% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 200 · Observed rate 51% · Lower 95% interval 49.33% |
| Medicare spending per beneficiary | 0.61 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 78.24% |
95.27%
17 pts worse
|
Numerator 133 · Denominator 170 |
| Falls with major injury | 1.76% |
0.77%
1 pts worse
|
Numerator 3 · Denominator 170 |
| Discharge self-care score | 47.41% |
53.69%
6.3 pts worse
|
Numerator 64 · Denominator 135 |
| Discharge mobility score | 62.96% |
50.94%
12 pts better
|
Numerator 85 · Denominator 135 |
| Pressure ulcers or injuries, new or worsened | 8.24% |
2.29%
6 pts worse
|
Numerator 14 · Denominator 170 · Adjusted rate 9.7% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 7.58% · Lower 95% interval 5.27% |
| Staff COVID-19 vaccination coverage | 5.03% |
8.2%
3.2 pts worse
|
Numerator 28 · Denominator 557 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 75 · Denominator 135 |
| Transfer of health information to provider | 84.62% |
95.95%
11.3 pts worse
|
Numerator 22 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 98 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 37.86% |
25.2%
12.7 pts better
|
Numerator 39 · Denominator 103 |
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 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 35.3% |
91.2%
55.9 pts worse
|
93.4%
58.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.0% · Q2 27.7% · Q3 28.4% · Q4 42.6% · 4Q avg 35.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.5% |
95.3%
2.8 pts worse
|
95.5%
3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.0%
1.5 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.2% · Q3 3.4% · Q4 5.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
18.5%
13.8 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.7% · Q3 4.5% · Q4 6.1% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
6.1%
0.3 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.7% · Q3 7.0% · Q4 6.3% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
13.5%
7 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 4.4% · Q3 6.8% · Q4 7.4% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
14.8%
0.1 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 15.8% · Q3 13.6% · Q4 13.2% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.3% · Q4 0.4% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.4% |
15.1%
17.3 pts worse
|
16.3%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 43.4% · Q3 24.9% · Q4 31.1% · 4Q avg 32.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.6% |
15.5%
19.1 pts worse
|
14.9%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.7% · Q2 36.7% · Q3 27.8% · Q4 32.6% · 4Q avg 34.6% · 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 0.3% · Q2 1.0% · Q3 0.5% · Q4 0.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.4%
1.8 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.3% · Q3 4.2% · Q4 4.3% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
20.8%
11.1 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 38.7% · Q3 27.0% · Q4 29.8% · 4Q avg 31.9% |
| 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 8.8% · Q2 6.7% · Q3 6.8% · Q4 5.6% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.6% |
76.7%
41.1 pts worse
|
81.7%
46.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 24.2% · Q3 34.2% · Q4 52.5% · 4Q avg 35.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
9.7%
4.6 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 4.6% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.4% · Q3 1.0% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.5% |
78.8%
30.3 pts worse
|
79.7%
31.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
20.6%
3 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.6% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-13 · Fire 2023-12-13
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2021-11-08 · Fire 2021-11-08
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-06-09
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 2025-08-08
E · Potential for more than minimal harm
2023-12-13
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 2024-02-11
E · Potential for more than minimal harm
2023-12-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-11
F · Potential for more than minimal harm
2021-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-21
E · Potential for more than minimal harm
2021-11-08
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-01-21
E · Potential for more than minimal harm
2021-11-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-01-21
E · Potential for more than minimal harm
2021-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-21
Inspection history
Recent health citations
G · Actual harm
2025-06-09
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 2025-08-08
G · Actual harm
2025-06-09
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 2025-08-08
E · Potential for more than minimal harm
2025-06-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-09-05
E · Potential for more than minimal harm
2025-06-09
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 2025-08-08
E · Potential for more than minimal harm
2025-06-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-06-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-06-09
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 2025-09-22
E · Potential for more than minimal harm
2025-06-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-06-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-06-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-06-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-06-09
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
B · Minimal harm
2025-06-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-08
G · Actual harm
2023-12-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
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 2024-02-11
E · Potential for more than minimal harm
2023-12-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-11
E · Potential for more than minimal harm
2023-12-13
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 2024-02-11
D · Potential for more than minimal harm
2023-12-13
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-02-11
D · Potential for more than minimal harm
2023-12-13
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 2024-02-11
D · Potential for more than minimal harm
2023-12-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-02-11
D · Potential for more than minimal harm
2023-12-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-11
D · Potential for more than minimal harm
2023-12-13
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 2024-02-11
D · Potential for more than minimal harm
2023-12-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-11
D · Potential for more than minimal harm
2023-12-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-11
D · Potential for more than minimal harm
2021-11-08
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-08
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 2022-01-07
D · Potential for more than minimal harm
2021-11-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-08
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 2022-01-07
Penalties and ownership
What sits behind the stars
$77,168
2025-06-09
Fine
Fine · fine $77,168
Fine
$63,866
2023-12-13
Fine
Fine · fine $63,866
Fine
Ownership
Boehner, Robert
Corporate Director · Individual
Dumyati, Ghinwa
Corporate Director · Individual
Halewski, Helen
Corporate Director · Individual
Pettine, Ray
Corporate Director · Individual
Runyon, Charles
Corporate Officer · Individual
Runyon, Charles
W-2 Managing Employee · Individual
Shumway, Bridget
Corporate Director · Individual
St Johns Health Care Corporation
Operational/Managerial Control · Organization
Wallace, William
Corporate Director · Individual
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#2
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#3
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