12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Albion, NY
1-star overall rating with 1-star inspections with $71,112 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
14012 Route 31, Albion, NY
(585) 589-5637
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
119
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
RN hours / resident day
0.25
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
8,064
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.93
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
Readmission
5.36
Baseline 22.72% · Performance 19.39% · Measure score 5.36 · Achievement 4.41 · Improvement 5.36
Healthcare-associated infections
2.92
Baseline 7.55% · Performance 6.96% · Measure score 2.92 · Achievement 2.92 · Improvement 1.81
Total nurse turnover
0
Baseline 67.26% · Performance 72.67% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.90
Baseline 3.49 hours · Performance 3.90 hours · Measure score 2.90 · Achievement 2.90 · Improvement 1.30
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 6.82% |
| Discharge to community | 37.1% |
50.57%
13.5 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 25.36% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 45 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 29.63% |
53.69%
24.1 pts worse
|
Numerator 8 · Denominator 27 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 12 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 8.89% |
2.29%
6.6 pts worse
|
Numerator 4 · Denominator 45 · Adjusted rate 8.05% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 8.33% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 22.88% |
8.2%
14.7 pts better
|
Numerator 27 · Denominator 118 |
| Staff flu vaccination coverage | 43.51% |
42%
1.5 pts better
|
Numerator 57 · Denominator 131 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 9 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 69.57% |
25.2%
44.4 pts better
|
Numerator 16 · Denominator 23 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
91.2%
5.5 pts better
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 99.1% · Q3 99.1% · Q4 99.2% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.0%
2.3 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.5% · Q3 6.3% · Q4 5.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
18.5%
17.1 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.4% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
6.1%
0.9 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 10.0% · Q3 8.3% · Q4 4.3% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
13.5%
2.3 pts worse
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 15.2% · Q3 15.3% · Q4 15.1% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.0% |
14.8%
12.2 pts worse
|
16.7%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 26.7% · Q3 25.6% · Q4 30.0% · 4Q avg 27.0% · 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 | 10.9% |
15.1%
4.2 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 11.3% · Q3 10.5% · Q4 12.7% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
15.5%
1.1 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 13.0% · Q3 15.0% · Q4 15.7% · 4Q avg 14.4% · 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 | 1.4% |
1.4%
About the same
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.8% · Q3 1.9% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
20.8%
4.5 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 29.4% · Q3 24.3% · Q4 19.4% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.9%
0.9 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 7.7% · Q3 2.9% · Q4 9.0% · 4Q avg 7.8% · Used in QM five-star |
| 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 · Q1 38.5% · Q2 51.6% · Q3 71.4% · 4Q avg 55.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
9.7%
7.8 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 20.0% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.2%
2.1 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.6% |
78.8%
1.8 pts better
|
79.7%
0.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
20.6%
About the same
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 24.0% · Expected 27.8% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Resident Rights (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Meet other general requirements.
Corrected 2025-03-14
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-14
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-14
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 2025-03-14
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-14
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-03-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-14
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-14
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-14
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-09-08
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-08
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-08
Fire Safety
Install proper backup exit lighting.
Corrected 2023-09-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-08
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 2023-09-08
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-09-08
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-09-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-08
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-08
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-08
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-08
Fire Safety
Meet other general requirements.
Corrected 2021-12-24
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2021-12-24
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 2021-12-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-24
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-24
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-24
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-12-24
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-12-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-24
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-12-24
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-12-24
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
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 2025-03-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
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 2025-03-14
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-03-14
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-14
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-14
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 2025-03-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-14
Health
Post nurse staffing information every day.
Corrected 2025-03-14
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-09
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-02-09
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-16
Health
Have a Compliance and Ethics Program.
Corrected 2023-09-15
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 2023-09-15
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-09-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-08
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-09-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-08
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-08
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 2021-12-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-24
Penalties and ownership
Fine · fine $71,112
Fine
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
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