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St. John's Health Care Corporation Inspection Report, Violations & Safety Grade (Rochester, New York)

150 Highland Avenue, Rochester, New York 14620

Phone: 5857601300

CMS Overall:1/5

Overview & Bed Count

Certified Beds

455

Avg Residents/Day

341.5

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Monroe

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing4/5

Quality4/5

Nurse Staffing Check

Metric	This Facility	New York Avg	Difference
RN Hours per Resident per Day	0.71	0.73	-0.02
Total Nurse Hours per Resident per Day	4.28	3.69	+0.59
CMS Staffing Rating	4/5	2.9/5	-
Nursing Staff Turnover	44.7%	40.3%	-

Health Citation History

30 health citations on record

Date	Category	Description	Severity
2025-06-09	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	G – Actual Harm
2025-06-09	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	G – Actual Harm
2025-06-09	Resident Rights Deficiencies	Allow residents to self-administer drugs if determined clinically appropriate.	E – Moderate Harm Potential
2025-06-09	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	E – Moderate Harm Potential
2025-06-09	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	E – Moderate Harm Potential
2025-06-09	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2025-06-09	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2025-06-09	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-06-09	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2025-06-09	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2025-06-09	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-06-09	Nutrition and Dietary Deficiencies	Provide special eating equipment and utensils for residents who need them and appropriate assistance.	D – Moderate Harm Potential
2025-06-09	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2025-06-09	Resident Rights Deficiencies	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	B – Minimal Harm Potential
2023-12-13	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	G – Actual Harm
2023-12-13	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2023-12-13	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2023-12-13	Administration Deficiencies	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.	E – Moderate Harm Potential
2023-12-13	Resident Rights Deficiencies	Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.	D – Moderate Harm Potential
2023-12-13	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2023-12-13	Resident Assessment and Care Planning Deficiencies	Assure that each resident’s assessment is updated at least once every 3 months.	D – Moderate Harm Potential
2023-12-13	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2023-12-13	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2023-12-13	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2023-12-13	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	D – Moderate Harm Potential
2021-11-08	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	D – Moderate Harm Potential
2021-11-08	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	D – Moderate Harm Potential
2021-11-08	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2021-11-08	Quality of Life and Care Deficiencies	Provide activities to meet all resident's needs.	D – Moderate Harm Potential
2021-11-08	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential

Fire Safety Citation History

14 fire safety citations on record

Date	Category	Description	Severity
2025-06-09	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2025-06-09	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	D – Moderate Harm Potential
2023-12-13	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-12-13	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2023-12-13	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2023-12-13	Services Deficiencies	Install properly constructed and protected linen or trash chutes.	E – Moderate Harm Potential
2023-12-13	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2023-12-13	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential
2023-12-13	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	E – Moderate Harm Potential
2023-12-13	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	E – Moderate Harm Potential
2021-11-08	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2021-11-08	Egress Deficiencies	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	E – Moderate Harm Potential
2021-11-08	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2021-11-08	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential

Total Penalties & Fines

$141,034

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-06-09	Fine	$77,168	-
2023-12-13	Fine	$63,866	-

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