Cycle 1
Health 2025-08-13 · Fire 2025-08-13
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rochester, NY
The Highlands at Brighton
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5901 Lac De Ville Boulevard, Rochester, NY
(585) 442-7960
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
137
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-01-09
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
0.48
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.68
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.01
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.18
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.30
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,550
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.31% · Performance 21.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.14% · Performance 8.93% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.26
Baseline 32.77% · Performance 42.19% · Measure score 5.26 · Achievement 5.26 · Improvement 0
Adjusted total nurse staffing
6.52
Baseline 5.72 hours · Performance 4.93 hours · Measure score 6.52 · Achievement 6.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 9.3% · Lower 95% interval 7.52% |
| Discharge to community | 54.28% |
50.57%
3.7 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 47.87% · Lower 95% interval 44.02% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 57 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 52.27% |
53.69%
1.4 pts worse
|
Numerator 23 · Denominator 44 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 18 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 3 · Denominator 60 · Adjusted rate 5.4% |
| Healthcare-associated infections requiring hospitalization | 8.93% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 12.9% · Lower 95% interval 5.91% |
| Staff COVID-19 vaccination coverage | 6.85% |
8.2%
1.3 pts worse
|
Numerator 25 · Denominator 365 |
| Staff flu vaccination coverage | 35.9% |
42%
6.1 pts worse
|
Numerator 154 · Denominator 429 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 24 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 91.67% |
96.28%
4.6 pts worse
|
Numerator 22 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 41.38% |
25.2%
16.2 pts better
|
Numerator 12 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
91.2%
4.2 pts worse
|
93.4%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.6% · Q2 89.1% · Q3 89.6% · Q4 92.2% · 4Q avg 87.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
95.3%
4 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.0%
0.6 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.9% · Q3 1.6% · Q4 0.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
18.5%
13.2 pts better
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.7% · Q3 7.5% · Q4 3.7% · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.1%
0.6 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.6% · Q3 8.0% · Q4 7.1% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
13.5%
10.5 pts worse
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 26.8% · Q3 18.4% · Q4 22.8% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.9% |
14.8%
18.1 pts worse
|
16.7%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 37.8% · Q3 29.8% · Q4 27.6% · 4Q avg 32.9% · 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 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.4% |
15.1%
4.3 pts worse
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 26.6% · Q3 16.0% · Q4 9.7% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.7% |
15.5%
10.2 pts worse
|
14.9%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 28.0% · Q3 26.3% · Q4 11.0% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.6%
0.4 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.2% · Q3 0.0% · Q4 1.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.4%
0.2 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.3% · Q3 1.6% · Q4 0.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
20.8%
1.3 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 13.5% · Q3 19.6% · Q4 24.4% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 9.6% |
6.9%
2.7 pts worse
|
5.1%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.0% · Q3 9.0% · Q4 8.4% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.5% |
76.7%
8.2 pts worse
|
81.7%
13.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.5% · Q2 71.2% · Q3 68.5% · Q4 69.0% · 4Q avg 68.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
9.7%
4.7 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 6.0% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.2% |
78.8%
2.6 pts worse
|
79.7%
3.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.2% |
| 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 20.0% · Expected 29.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-04 · Fire 2023-10-04
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-12-06 · Fire 2021-12-06
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-08-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-08-13
K909 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum piping is labeled.
Corrected 2025-10-08
F · Potential for more than minimal harm
2023-10-04
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-04
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-08
E · Potential for more than minimal harm
2021-12-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
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 2025-10-08
D · Potential for more than minimal harm
2025-08-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-08-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-08-13
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 2025-10-08
D · Potential for more than minimal harm
2025-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-08-13
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 2025-10-08
B · Minimal harm
2025-08-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-08
D · Potential for more than minimal harm
2023-10-04
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 2023-12-01
D · Potential for more than minimal harm
2023-10-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-04
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 2023-12-01
D · Potential for more than minimal harm
2023-10-04
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 2023-12-01
D · Potential for more than minimal harm
2023-10-04
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 2023-12-01
D · Potential for more than minimal harm
2023-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
B · Minimal harm
2023-10-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-01
E · Potential for more than minimal harm
2021-12-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-06
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 2022-01-31
D · Potential for more than minimal harm
2021-12-06
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 2022-01-31
D · Potential for more than minimal harm
2021-12-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-29
B · Minimal harm
2021-12-06
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 2022-01-31
B · Minimal harm
2021-12-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-01-31
Penalties and ownership
What sits behind the stars
Ownership
Garrett, Elizabeth
Corporate Officer · Individual
Goldstein, Steven
Corporate Officer · Individual
Hall, William
Corporate Officer · Individual
Latella, Robert
Corporate Officer · Individual
Magee, Robbie
Corporate Officer · Individual
Muniak, Jennifer
Operational/Managerial Control · Individual
Riordan, Michael
Corporate Officer · Individual
Vanstrydonck, Gerald
Corporate Officer · Individual
Winiarczyk, Walter
Operational/Managerial Control · Individual
Winiarczyk, Walter
Corporate Director · Individual
Yale, Elizabeth
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Woodside Manor Nursing Home Inc
Rochester, NY
4-star overall rating with 4-star inspections with 7 recent health deficiencies
#2
Jewish Home of Rochester
Rochester, NY
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Brightonian, Inc
Rochester, NY
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
Jump out