5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rochester, NY
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1177 East Henrietta Road, Rochester, NY
(585) 424-4770
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
Beds
160
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hurlbut Care
Operator or chain grouping
Approved since
1972-02-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.29
Registered nurse staffing
LPN hours / resident day
1.54
Licensed practical nurse staffing
Aide hours / resident day
2.13
Nurse aide staffing
Weekend hours
3.10
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.3% |
91.2%
5.9 pts worse
|
93.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
95.3%
0.7 pts better
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.0%
0.1 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
18.5%
15.4 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 12.0% |
6.1%
5.9 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.8% |
13.5%
8.7 pts better
|
19.6%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
14.8%
4.7 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.4% |
15.1%
7.3 pts worse
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
15.5%
6.1 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.4%
1.5 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
20.8%
7.6 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
6.9%
4 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.7% |
76.7%
21 pts worse
|
81.7%
26 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.2%
2.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.4% |
78.8%
19.4 pts worse
|
79.7%
20.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Administration (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-14
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-22
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-08
Fire Safety
Develop a communication plan.
Corrected 2022-07-08
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-07-08
Inspection history
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-22
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-22
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-22
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-15
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 2024-04-15
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-04-15
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-15
Health
Post nurse staffing information every day.
Corrected 2024-04-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-08
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-08
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-07-08
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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Rochester, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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