Spencerport, NY

Wedgewood Nursing and Rehabilitation Center

2-star overall rating with 2-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

5 Church Street, Spencerport, NY

(585) 352-4810

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

29

Certified beds

Average residents

27

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1974-01-01

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

0.75

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.17

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.99

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.91

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.60

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.25

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.73

CMS adjusted RN staffing hours

Adjusted total hours

3.93

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

60%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,963

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

14.51

Composite VBP score used to determine payment impact.

Payment multiplier

0.9813

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

0.52

Baseline 59.26% · Performance 61.54% · Measure score 0.52 · Achievement 0.52 · Improvement 0

Adjusted total nurse staffing

2.38

Baseline 4.19 hours · Performance 3.75 hours · Measure score 2.38 · Achievement 2.38 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.42%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 6.51%
Discharge to community	44.08%	50.57% 6.5 pts worse	No Different than the National Rate · Eligible stays 35 · Observed rate 34.29% · Lower 95% interval 30.25%
Medicare spending per beneficiary	1.07	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 73 · Denominator 73
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 73
Discharge self-care score	61.7%	53.69% 8 pts better	Numerator 29 · Denominator 47
Discharge mobility score	59.57%	50.94% 8.6 pts better	Numerator 28 · Denominator 47
Pressure ulcers or injuries, new or worsened	4.11%	2.29% 1.8 pts worse	Numerator 3 · Denominator 73 · Adjusted rate 3.43%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 82 · Denominator 82
Staff flu vaccination coverage	84.44%	42% 42.4 pts better	Numerator 114 · Denominator 135
Discharge function score	65.96%	56.45% 9.5 pts better	Numerator 31 · Denominator 47
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 47 · Denominator 47
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	5.71%	25.2% 19.5 pts worse	Numerator 2 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	86.8%	91.2% 4.4 pts worse	93.4% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 69.6% · Q2 85.0% · 4Q avg 86.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.8%	95.3% 0.5 pts better	95.5% 0.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8%
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	3.0% 1.7 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.9%	18.5% 15.6 pts better	11.4% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · 4Q avg 2.9%
Percentage of long-stay residents who lose too much weight	12.3%	6.1% 6.2 pts worse	5.4% 6.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · 4Q avg 12.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	1.3%	13.5% 12.2 pts better	19.6% 18.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 1.3%
Percentage of long-stay residents who received an antipsychotic medication	2.9%	14.8% 11.9 pts better	16.7% 13.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · 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% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	39.5%	15.1% 24.4 pts worse	16.3% 23.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 39.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.5%	15.5% 5 pts better	14.9% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 20.0% · 4Q avg 10.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.6% 0.6 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.4% 1.4 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.1%	20.8% 2.7 pts better	19.8% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · 4Q avg 18.1%
Percentage of long-stay residents with pressure ulcers	13.0%	6.9% 6.1 pts worse	5.1% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.6% · 4Q avg 13.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	69.8%	76.7% 6.9 pts worse	81.7% 11.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 52.9% · Q2 56.9% · Q3 80.3% · Q4 81.9% · 4Q avg 69.8%
Percentage of short-stay residents who had an outpatient emergency department visit	0.0%	9.7% 9.7 pts better	12.0% 12 pts better	Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	78.8%	78.8% About the same	79.7% 0.9 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 78.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.6%	20.6% 10 pts worse	23.9% 6.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 31.0% · Expected 24.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-03-15 · Fire 2024-03-15

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2022-06-17 · Fire 2022-06-17

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

3 fire-safety deficiencies

Top issue: Electrical (1 deficiency)

Cycle 3 Health 2020-03-04 · Fire 2020-03-04

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-03-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-05-14

D · Potential for more than minimal harm 2024-03-15

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-05-14

D · Potential for more than minimal harm 2024-03-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-05-14

E · Potential for more than minimal harm 2022-06-17

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-08-12

C · Minimal harm 2022-06-17

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2022-08-12

C · Minimal harm 2022-06-17

K901 · Electrical Deficiencies

Fire Safety

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

Corrected 2022-08-12

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-12-04

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 2026-02-04

E · Potential for more than minimal harm 2025-12-04

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 2026-02-04

E · Potential for more than minimal harm 2025-12-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-02-04

D · Potential for more than minimal harm 2025-12-04

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-02-04

E · Potential for more than minimal harm 2024-03-15

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 2024-05-14

E · Potential for more than minimal harm 2024-03-15

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 2024-05-14

D · Potential for more than minimal harm 2024-03-15

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 2024-05-14

E · Potential for more than minimal harm 2023-03-27

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 2023-06-26

E · Potential for more than minimal harm 2023-03-27

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 2023-06-01

E · Potential for more than minimal harm 2022-06-17

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 2022-08-12

B · Minimal harm 2022-06-17

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 2022-08-12

D · Potential for more than minimal harm 2020-03-04

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2020-05-04

D · Potential for more than minimal harm 2020-03-04

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 2020-05-04

D · Potential for more than minimal harm 2020-03-04

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2020-05-04

Penalties and ownership