Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Edna Tina Wilson Living Center
Rochester, NY · 120 certified beds · Last Life Safety survey April 11, 2025
CMS Certification Number 335769 · first certified December 1993
Ownership
Operated by ROCHESTER REGIONAL HEALTH · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
8 citations — more than 20% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 0 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026. This facility’s last Life Safety survey was April 2025. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 8 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 8 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 8 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 17, 2021 | 4 |
| June 16, 2023 | 4 |
| April 11, 2025 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-06-16 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-06-16 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2021-09-17 |
| E-0029 | Develop a communication plan. | 1 | 2023-06-16 |
| K-0222 | 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. | 1 | 2021-09-17 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2021-09-17 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-06-16 |
What the citations cover
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Emergency Preparedness Deficiencies 1
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 16, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (August 25, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 25, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 25, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 25, 2023) |
September 17, 2021 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 12, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.