Cycle 1
Health 2023-12-26 · Fire 2023-12-26
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Rochester, NY
The Friendly Home
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3156 East Avenue, Rochester, NY
(585) 381-1600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
169
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-01-01
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
0.49
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.55
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
4.03
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.21
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
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.88
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,751
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.21
Composite VBP score used to determine payment impact.
Payment multiplier
1.0091
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.57
Baseline 15.44% · Performance 18.39% · Measure score 6.57 · Achievement 6.57 · Improvement 0
Healthcare-associated infections
5.39
Baseline 4.94% · Performance 6.22% · Measure score 5.39 · Achievement 5.39 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.3
Baseline 4.37 hours · Performance 4.30 hours · Measure score 4.3 · Achievement 4.3 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 8.65% · Lower 95% interval 7.47% |
| Discharge to community | 38.04% |
50.57%
12.5 pts worse
|
Worse than the National Rate · Eligible stays 100 · Observed rate 31% · Lower 95% interval 28.9% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 2.08% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 48 |
| Discharge self-care score | 21.95% |
53.69%
31.7 pts worse
|
Numerator 9 · Denominator 41 |
| Discharge mobility score | 31.71% |
50.94%
19.2 pts worse
|
Numerator 13 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 4.17% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 2% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 14.62% |
8.2%
6.4 pts better
|
Numerator 68 · Denominator 465 |
| Staff flu vaccination coverage | 39.93% |
42%
2.1 pts worse
|
Numerator 228 · Denominator 571 |
| Discharge function score | 34.15% |
56.45%
22.3 pts worse
|
Numerator 14 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · 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 | 38.1% |
25.2%
12.9 pts better
|
Numerator 8 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.5 · 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 0.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
91.2%
2.8 pts better
|
93.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 93.0% · Q3 93.0% · Q4 96.9% · 4Q avg 94.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
95.3%
0.6 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.0%
3 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.4% · Q3 7.0% · Q4 7.5% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
18.5%
11.8 pts better
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.0% · Q3 8.0% · Q4 5.5% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
6.1%
2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.6% · Q3 3.1% · Q4 5.1% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
13.5%
1.6 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 12.9% · Q3 11.9% · Q4 14.4% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
14.8%
7.7 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.0% · Q3 9.0% · Q4 7.6% · 4Q avg 7.1% · 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 | 12.1% |
15.1%
3 pts better
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 12.8% · Q3 12.3% · Q4 14.5% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
15.5%
3 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 15.2% · Q3 10.0% · Q4 18.1% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.5% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.4%
1.1 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 5.2% · Q4 3.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
20.8%
10.7 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.6% · Q2 28.5% · Q3 28.8% · Q4 31.2% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.9%
2.2 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.0% · Q3 4.6% · Q4 3.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
76.7%
16.9 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 88.6% · Q3 95.4% · Q4 98.3% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
9.7%
3.6 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.1% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
78.8%
11.2 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.1% |
20.6%
7.5 pts better
|
23.9%
10.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 10.3% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-02 · Fire 2022-03-02
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-09-17 · Fire 2019-09-17
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-12-26
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-12-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-12-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-23
E · Potential for more than minimal harm
2022-03-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-30
E · Potential for more than minimal harm
2022-03-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-19
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.
Not marked corrected
D · Potential for more than minimal harm
2025-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Not marked corrected
E · Potential for more than minimal harm
2023-12-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-12-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-12-26
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 2024-02-23
D · Potential for more than minimal harm
2023-12-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-12-26
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 2024-02-23
D · Potential for more than minimal harm
2023-12-26
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-12-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-23
E · Potential for more than minimal harm
2022-03-02
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 2022-04-12
D · Potential for more than minimal harm
2022-03-02
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2022-04-12
D · Potential for more than minimal harm
2022-03-02
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 2022-04-12
B · Minimal harm
2022-03-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-04-12
D · Potential for more than minimal harm
2019-09-17
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 2019-10-30
D · Potential for more than minimal harm
2019-09-17
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 2019-10-30
D · Potential for more than minimal harm
2019-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-30
Penalties and ownership
What sits behind the stars
Ownership
Baier, Daniel
Corporate Officer · Individual
Brown, Amanda
Corporate Officer · Individual
Brown, Amanda
W-2 Managing Employee · Individual
Cooper, Glen
Corporate Officer · Individual
Johnson, Christine
Corporate Director · Individual
Johnson, Christine
W-2 Managing Employee · Individual
Wilborn, Kimberly
Corporate Officer · Individual
Nearby options
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#3
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5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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