Rochester, NY

Woodside Manor Nursing Home Inc

4-star overall rating with 4-star inspections with 7 recent health deficiencies

2425 Clinton Avenue South, Rochester, NY

(585) 461-0370

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

44

Certified beds

Average residents

41

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Hurlbut Care

Operator or chain grouping

Approved since

1976-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

13 facilities

Chain averages 4 overall / 4 health / 2 staffing / 3 quality stars

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

0.50

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.00

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.43

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.93

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.50

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.55

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.14

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

4.28

CMS adjusted total nurse staffing hours

Case-mix index

1.26

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

66%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,092

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

Performance score

13.93

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

Baseline 57.45% · Performance 64.15% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.79

Baseline 4.23 hours · Performance 3.87 hours · Measure score 2.79 · Achievement 2.79 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	5.88%	8.2% 2.3 pts worse	Numerator 4 · Denominator 68
Staff flu vaccination coverage	38.46%	42% 3.5 pts worse	Numerator 30 · Denominator 78
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	72.0%	91.2% 19.2 pts worse	93.4% 21.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 83.3% · Q3 67.6% · Q4 63.9% · 4Q avg 72.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.4%	95.3% 2.1 pts better	95.5% 1.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4%
Percentage of long-stay residents experiencing one or more falls with major injury	2.8%	3.0% 0.2 pts better	3.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.8% · Q3 2.9% · Q4 2.8% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	18.5% 18.5 pts better	11.4% 11.4 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 who lose too much weight	6.7%	6.1% 0.6 pts worse	5.4% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.8% · Q3 6.5% · Q4 8.6% · 4Q avg 6.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	3.0%	13.5% 10.5 pts better	19.6% 16.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.2% · Q4 5.7% · 4Q avg 3.0%
Percentage of long-stay residents who received an antipsychotic medication	18.8%	14.8% 4 pts worse	16.7% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.2% · Q3 17.9% · Q4 20.7% · 4Q avg 18.8% · 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	28.8%	15.1% 13.7 pts worse	16.3% 12.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 28.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.6%	15.5% 7.1 pts worse	14.9% 7.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 45.2% · Q3 10.7% · Q4 12.1% · 4Q avg 22.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.6% About the same	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.5%	1.4% 2.1 pts worse	1.7% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.3% · Q3 0.0% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.5%	20.8% 8.7 pts worse	19.8% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 39.9% · Q3 26.0% · Q4 20.8% · 4Q avg 29.5%
Percentage of long-stay residents with pressure ulcers	8.9%	6.9% 2 pts worse	5.1% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 13.4% · Q3 11.9% · Q4 5.5% · 4Q avg 8.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	86.2%	76.7% 9.5 pts better	81.7% 4.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 89.2% · Q3 83.3% · Q4 79.4% · 4Q avg 86.2%
Percentage of short-stay residents who newly received an antipsychotic medication	2.1%	1.2% 0.9 pts worse	1.6% 0.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 4.3% · 4Q avg 2.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	83.8%	78.8% 5 pts better	79.7% 4.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 83.8%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-29 · Fire 2025-08-29

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-03-19 · Fire 2024-03-19

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-07-13 · Fire 2022-07-13

7 health deficiencies

Top issue: Resident Rights (3 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-03-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-17

F · Potential for more than minimal harm 2022-07-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-09-11

E · Potential for more than minimal harm 2022-07-13

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2022-09-11

E · Potential for more than minimal harm 2022-07-13

K321 · Smoke Deficiencies

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 2022-09-11

C · Minimal harm 2022-07-13

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2022-09-11

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-29

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 2025-10-28