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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D18 | E21 | F1 |
| Minimal | A· | B1 | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jun 9, 2025 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| Jun 9, 2025 | Health | Health Complaint, Health Standard | 14 | Actual harm | — | Open → |
| Dec 13, 2023 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Dec 13, 2023 | Health | Health Complaint, Health Standard | 11 | Actual harm | — | Open → |
| Nov 8, 2021 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Nov 8, 2021 | Health | Health Standard | 5 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jun 9, 2025 | Civil money penalty (fine) | $77,168 | — | 335008|Fine|134823 |
| Dec 13, 2023 | Civil money penalty (fine) | $63,866 | — | 335008|Fine|22109 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D18 | E21 | F1 |
| Minimal | A· | B1 | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jun 9, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Aug 8, 2025 | |
| Jun 9, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Aug 8, 2025 | |
| Jun 9, 2025 | K-0222 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| St Johns Health Care Corporation | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 2, 2007 |
| Robert Boehner | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 25, 2007 |
| Ghinwa Dumyati | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 30, 2021 |
| Helen Halewski | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 30, 2021 |
| Ray Pettine | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 30, 2021 |
| Bridget Shumway | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 25, 2007 |
| William Wallace | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jun 30, 2021 |
| Charles Runyon | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Feb 1, 1993 |
| Charles Runyon | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Feb 1, 1993 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Church Home of the Protestant Episcopal Church 505 Mt. Hope Avenue, Rochester, NY 14620 CCN 335263 | 1.2 km | 182 | Jan 9, 2024 | 20 | — | |
| Monroe Community Hospital 435 East Henrietta Road, Rochester, NY 14620 CCN 335197 | 2 km | 566 | Oct 24, 2025 | 263 IJ1 harm | $95k | |
| The Brightonian, Inc 1919 Elmwood Avenue, Rochester, NY 14620 CCN 335554 | 2.2 km | 54 | Feb 12, 2025 | 22 | — | |
| Woodside Manor Nursing Home Inc 2425 Clinton Avenue South, Rochester, NY 14618 CCN 335366 | 2.3 km | 44 | Aug 29, 2025 | 19 | — | |
| The Highlands at Brighton 5901 Lac De Ville Boulevard, Rochester, NY 14618 CCN 335778 | 2.5 km | 145 | May 7, 2026 | 34 | — | |
| Kirkhaven 254 Alexander Street, Rochester, NY 14607 CCN 335668 | 2.7 km | 147 | Mar 18, 2026 | 441 harm | $8,278 | |
| Unity Living Center 89 Genesee Street, Rochester, NY 14611 CCN 335620 | 2.9 km | 120 | May 15, 2025 | 141 IJ | $13k | |
| Lilac Manor Rehabilitation and Nursing Center 3 Upton Park, Rochester, NY 14607 CCN 335488 | 3.3 km | 200 | Aug 13, 2026 | 431 open | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 335008 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 335008 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| New York DOH Health Facility Information NY | 442 | state_license, licensed_beds, licensee Linked to the CMS record by exact normalized street address and ZIP (the state roster does not publish the CCN). | Inferred | Oct 23, 2026 | Nov 7, 2026 |
| New York DOH Bed Certifications NY | 442 | capacity, bed_certifications | Verified | Nov 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| 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. Egress Deficiencies · Environment & life safety |
| D · Potential harm Isolated |
| Corrected Aug 8, 2025 |
| Jun 9, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 5, 2025 |
| Jun 9, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 5, 2025 |
| Jun 9, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 5, 2025 |
| Jun 9, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Jun 9, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 8, 2025 | Complaint |
| Jun 9, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 8, 2025 | Complaint |
| Jun 9, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 8, 2025 |
| Jun 9, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 5, 2025 |
| Jun 9, 2025 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Sep 22, 2025 |
| Jun 9, 2025 | F-0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Jun 9, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Aug 8, 2025 |
| Jun 9, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Jun 9, 2025 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | B · Minimal Pattern | Corrected Aug 8, 2025 |
| Dec 13, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 11, 2024 |
| Dec 13, 2023 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Feb 11, 2024 | Complaint |
| Dec 13, 2023 | F-0836 | 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. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Feb 11, 2024 | Complaint |
| Nov 8, 2021 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 21, 2022 |
| Nov 8, 2021 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 21, 2022 |
| Nov 8, 2021 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 21, 2022 |
| Nov 8, 2021 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 21, 2022 |
| Nov 8, 2021 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 7, 2022 |
| Nov 8, 2021 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 7, 2022 |
| Nov 8, 2021 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 7, 2022 |
| Nov 8, 2021 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2022 |
| Nov 8, 2021 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 7, 2022 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.66 (case-mix index 1.28).