Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pomeroy Living Rochester Skilled Rehabilitation during CMS and state inspections, most recent first.
Food service sanitation and storage practices were not maintained. Staff observed soil buildup in dry storage, condensate dripping onto packaged single-service items in a reach-in cooler, food thickener stored in the handwash area, a leaking ice machine with standing water, mold-like buildup, damaged floor tiles, and drain flies. Juice machine nozzles were soiled, damaged spatulas were in use, wet plate covers and improperly stored utensils were observed, and preset silverware was left uncovered on dining tables used for resident activities.
Medications and skin products were found unsecured and improperly stored in multiple areas of the facility. An LPN observed Nystatin Powder on a resident’s sink counter, loose pills were found in a medication cart drawer without packaging or identifiers, a barrier ointment was left on a resident’s bedside tray table without MAR documentation, skin protectants and Vitamin A&D ointment were stored in shower rooms, and an unlocked med cart was left unattended.
Failure to Operate an Effective Antibiotic Stewardship Program: The facility did not consistently ensure infection criteria were met before antibiotics were used for multiple residents. Record review showed several antibiotic starts for UTI, pneumonia, cellulitis, and CAUTI with missing or conflicting documentation for symptoms, diagnostics, cultures, and McGeer’s Criteria, including cases where hospice declined testing or urine studies were negative. Interviews with the interim infection preventionist and acting DON confirmed ongoing problems with antibiotic stewardship documentation and oversight.
Central shower rooms serving two unit areas were observed with broken and missing tiles, rusted thresholds, standing water, black mold-like buildup on tiles and caulking, and soiled shower equipment including mats, beds, and a shower chair. Staff also stored brushes, wheelchairs-cleaning tools, and multiple resident care items and personal products in the shower rooms and closets, while the DON/NHA described wheelchair cleaning in the shower area without a related policy provided. Records reviewed did not address wheelchair cleaning procedures, equipment storage, or disinfectant contact time.
A resident admitted after a femur fracture had hospital discharge paperwork that included staple removal instructions and an order for Lovenox 30 mg BID for 21 days, but the facility failed to transcribe the anticoagulant into the MAR. The WCC reported the staples were not removed because the PCP wanted the surgeon to remove them, and the conversation about that decision was not documented.
Failure to Complete Annual PASARR Evaluation: A resident admitted with schizophrenia, dementia, bi-polar disease, and PTSD did not have the required annual OBRA Level I PASARR evaluation completed to determine whether a Level II eval or exemption was needed. The record contained a PAS/ARR document noting dementia and recent psychotropic use, but no other PASARR documentation was found. The SW Director stated residents should be screened annually and/or with a significant change, and no PASARR policy was provided.
A facility failed to follow physician-ordered treatment for a resident with CHF and chronic leg swelling when ace wraps were not in place even though they were documented as completed, and the resident reported they had not been wrapped for days. The facility also failed to follow medication administration standards for a newly admitted resident with COPD when an LPN entered a contact isolation room without PPE, set up and started a nebulizer treatment, and left the resident without a completed self-administration assessment.
A resident with CHF was observed sleeping in bed with 3 L of oxygen via NC on two occasions, but the chart had no physician order for the oxygen. The care plan directed oxygen use at 2 L/min as ordered, and an LPN confirmed there was no order for the oxygen administration.
A resident with dementia was maintained on prophylactic Nitrofurantoin for recurrent UTI history, but the record lacked documentation of the benefit or appropriateness of the antibiotic. The resident also received Bactrim DS for a UTI while already on the prophylactic antibiotic, and staff stated the family requested the prophylaxis, but no physician documentation supporting the rationale was available.
Failure to use PPE for a resident in contact isolation: an LPN and a CNA entered a resident’s room without PPE, despite the resident being on contact isolation and receiving a breathing treatment. The resident had COPD, C. difficile enterocolitis, and sleep apnea. The acting IP acknowledged staff should have worn PPE, and camera review later showed staff entering the room without PPE.
Surveyors found that appropriate care was not provided for residents regarding continence management, catheter care, and UTI prevention. The report notes lapses in these areas but does not specify the actions or omissions or provide details about the residents involved.
A resident with dementia and a change in condition did not have ordered CBC and CMP labs completed, and abnormal urinalysis and culture results indicating E. Coli were not promptly reported to the practitioner or acted upon. There were significant delays in both laboratory processing and facility notification, and the facility lacked a policy for ordering and reporting lab results.
The facility failed to maintain sanitary conditions in the kitchen, with observations of soiled equipment, mold-like substances, and pest presence. Additionally, staff did not sanitize thermometer probes when measuring food temperatures, potentially risking foodborne illness among residents.
The facility's assessment was not reviewed and revised per regulatory requirements, affecting 117 residents. The assessment lacked involvement from the Medical Director, direct care staff, and input from residents and families. The Administrator acknowledged the oversight and scheduling conflicts prevented attending resident council meetings.
The facility failed to implement and maintain enhanced barrier precautions (EBP) for three residents, potentially affecting all 117 residents. The infection prevention program lacked consistent documentation, and staff did not follow proper hand hygiene or EBP protocols. Residents with catheters and wounds lacked necessary signage and PPE, and linen carts were improperly maintained with non-linen items stored among clean linens.
A facility failed to properly store and label medications, as observed during a survey. A resident had a tube of ointment on their bedside table without documentation for self-administration. Multiple medication carts had issues such as unlocked drawers, unlabeled insulin pens, and improper storage of food items with medications. Loose pills were also found in a medication drawer without identification.
A facility failed to provide water within reach for a resident, despite clear instructions and care plan interventions. Observations showed the resident's water was consistently placed out of reach, and the issue was acknowledged by the Assistant DON. A policy on accommodation of needs was requested but not provided.
A resident's request to change their code status to DNR was not honored due to the facility's policy requiring a physician's signature, despite the resident's clear wishes and signing of a DNR form. The facility continued to list the resident as a full code, and staff confirmed that CPR would be initiated if necessary, highlighting a delay in updating the resident's medical records.
The facility failed to follow professional standards in medication administration for two residents. One resident's blood sugar level was not documented as required, and another resident's blood pressure medications were administered late. The responsible nurses admitted to these oversights, and the ADON confirmed the facility's protocols were not followed.
A resident requiring assistance for all ADLs, including oral care, did not receive necessary help with brushing their teeth. The resident's daughter expressed concerns, and the resident confirmed the lack of assistance. The CNA assumed oral care was completed by the previous shift, which was not the case. The ADON acknowledged the oversight, but no further documentation was provided.
The facility failed to timely implement treatments for a fungal rash and edema for two residents and did not obtain a physician-ordered blood sugar level for another resident. A resident's prescribed ointment for a fungal rash was not applied upon admission, worsening the condition. Another resident did not receive prescribed ACE wraps for edema due to a shortage, leading to extended dialysis. Additionally, a resident's blood sugar was not checked as scheduled, affecting insulin administration.
A resident experienced a 22.94% weight loss over a period, and the facility failed to conduct timely nutritional assessments or interventions. Despite the resident's medical history of moderate protein-calorie malnutrition and chronic kidney disease, no dietary assessments were conducted during the critical period of weight loss. The facility's policy required monitoring of significant weight changes, which was not adhered to, leading to the deficiency.
A facility experienced a 10.34% medication error rate during a survey. Errors included a nurse withholding a blood pressure medication without proper parameters and administering the wrong allergy medication. Another nurse gave a nighttime cholesterol medication in the morning and misrepresented it as a vitamin to a resident. These issues were acknowledged by the facility's ADON and Administrator.
The facility failed to implement an effective antibiotic stewardship program, leading to inconsistent antibiotic use for three residents. One resident lacked documentation for antibiotic necessity and had an incomplete treatment for clostridium difficile. Another resident was prescribed an antibiotic without a start date, missing the first dose. A third resident experienced a delay in starting their antibiotic treatment. The facility's infection control preventionist acknowledged these lapses.
The facility failed to serve meals at desirable temperatures, leading to resident dissatisfaction. Multiple complaints were made about cold food, particularly breakfast. Observations confirmed that some food items were served cold, and the Registered Dietician acknowledged challenges in maintaining food temperature due to staffing issues. The facility's administrator was informed of these concerns, but the policy on food palatability was not provided to the survey team.
The facility failed to administer medications and treatments as prescribed for three residents, leading to deficiencies in care. One resident did not receive a STAT x-ray or Zofran before leaving AMA. Another experienced delays in medication and skin treatment applications. A third resident did not receive their weekly pain patch as ordered. The DON acknowledged these failures, highlighting issues with adherence to physician orders and timely administration.
The facility failed to provide oxygen services per physician orders for two residents, leading to significant health issues. One resident was sent to a medical appointment with an empty oxygen tank, resulting in hospitalization due to low oxygen saturation. Another resident experienced breathing difficulties due to conflicting oxygen orders, with no clarification on which order to follow. The facility's lack of communication and verification of oxygen levels contributed to these deficiencies.
A resident with Parkinson's Disease and severely impaired cognition, under hospice care, experienced inadequate pressure ulcer care due to inconsistent skin assessments and documentation. The facility's wound care coordinator admitted to not entering weekly assessments into the clinical record, and the last documented assessment was incomplete. The Director of Nursing confirmed that required weekly assessments had not been completed, leading to the deficiency.
Food Service Area Sanitation and Storage Deficiencies
Penalty
Summary
The facility failed to maintain food service areas and equipment in accordance with professional standards. During the kitchen and dietary services tour, the dry storage area was observed with debris along the floor/wall juncture and soil buildup on storage shelving. The Dietary Manager acknowledged the areas needed cleaning attention. In an upright reach-in cooler, a towel full of water was placed in the bottom of the unit to absorb condensate dripping from the top interior onto packaged single-service food items, and the Dietary Manager stated this had been occurring since they had been there. In the [NAME] Terrace dining area, a pump container of food thickener was observed stored at the handwash sink behind the faucet and near the hand soap dispenser, and the item was later observed in the handwash area again during lunch service in the main dining room. In the dining area, the ice machine was leaking with standing water pooled on the floor under and behind it, the floor tiles were soiled with a black mold-like substance, several tiles were loose, damaged, or missing, and the drain lines were soiled with black buildup. The ice bin drain line terminated below the flood rim of the floor drain without the required air gap, and several small flying insects were observed in the area. The Dietary Manager stated the concern would be shared with maintenance staff. Additional observations included juice machine nozzles and the surrounding area soiled with a dark mold-like substance, with the Corporate Chef indicating the area would be detail cleaned. Clean stored rubber spatulas were observed with torn or damaged edges, stacked domed plate covers were stored wet with food-contact surfaces exposed, and clean utensils were stored with eating portions exposed rather than handles. Pre-set silverware was also observed uncovered on napkins and on dining room tables, including in a room used for resident activities throughout the day. The Corporate Chef reported there was no related policy for dining room table set up.
Medications Found Unsecured and Improperly Stored
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in locked compartments, including separately locked compartments for controlled drugs. During an observation of medication administration with an LPN for one resident, three bottles of Nystatin Powder were found stored on the resident’s sink counter, and the LPN stated they should not have been there and removed them. At the same time, Medication Cart #1 was observed with a loose white oval pill and a loose round orange pill in the residential storage drawer, with no packaging or resident identifiers. Additional observations found a brown and silver tube labeled Clear Zinc Barrier Ointment on another resident’s bedside tray table, although the MAR did not document the medication as ordered or to remain at the bedside. In the unit shower rooms, two packages of skin protectant were lying among used shampoo and body products, and a shower caddy in the closet contained multiple single-use packages of Vitamin A&D ointment. A separate medication cart on the subacute rehabilitation wing was observed unlocked with no nursing staff present, and the Unit Manager acknowledged the cart should not have been unlocked.
Failure to Operate an Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to operationalize an effective antibiotic stewardship program to ensure appropriate infection criteria were met for residents who were prescribed antibiotics. Review of the January, February, and March 2026 antibiotic surveillance records showed multiple residents with antibiotic orders and infection investigations that did not consistently align with documented signs, symptoms, diagnostics, or McGeer’s Criteria. Examples included a resident with a UTI line listing showing no signs or symptoms and no testing indicated, yet Keflex was ordered; a resident with pneumonia where diagnostics were marked not applicable and no x-ray date was documented; a resident with a UTI line listing noting change in urine and stating the resident did not meet McGeer’s Criteria, yet Keflex was ordered; and a resident with cellulitis whose infection investigation documented no onset date, no symptoms, and no testing, while cephalexin and doxycycline were ordered. Additional records showed a resident with CAUTI whose infection investigation documented hospice declined the urine culture and that the original antibiotic was changed from Bactrim to Macrobid, and another resident with UTI whose investigation documented facility-acquired infection, a urine culture date, and a negative result, while the attached nursing note documented negative nitrites, moderate leukocytes, clear urine without sediment or odor, no pain, and no fever. During interview, the interim infection preventionist stated she had only taken over the program three weeks earlier and that the prior infection preventionist had been retrained on McGeer’s Criteria and antibiotic stewardship but quit. The acting DON stated multiple people had tried to retrain the prior infection preventionist on antibiotic stewardship, but it did not seem to make any difference.
Central shower rooms were unclean, damaged, and improperly used for equipment storage and wheelchair cleaning
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the central shower rooms used by the [NAME] Unit and [NAME] Unit. During a tour with the Housekeeping Director, broken and missing tiles were observed around shower drains and wall corners, rusted and deteriorating storage room door thresholds, debris on the floor of multiple storage rooms, and black mold-like substance on tiles, grout, and caulking around the showering areas. In one shower area, the vinyl floor was stained, cracking, and separated from adjacent tile, creating a gap where water could collect, and standing water was observed not draining to the floor drain in an adjacent storage room. The shower rooms also contained equipment and supplies stored in an unclean and disorganized manner. A long-handled utility brush was stored in the resident showering area, a scouring utility brush used by nursing staff to clean resident wheelchairs was observed in the shower room, and a HealthWeight chair stored in the shared hall area was soiled around the base. Shower beds, shower mats, and a shower chair were observed soiled with black substance, and several light bulbs were burned out at the hand sink lighting. In the [NAME] Unit shower rooms, multiple bottles of half-used shampoo and body wash, shaving cream, razors, hairbrushes with visible hair, a candy bar, loofah, artificial sweetener packets, gloves, hangers, a trach receptacle with garbage, and wheelchair footrests were observed stored in the shower rooms and closets. The record review showed a Capital Project Approval Request for replacement of sheet vinyl in the spa bathroom due to cracking and aged/dirty appearance. Facility staff stated that nursing staff uses the central shower area to clean resident wheelchairs on midnight shifts and that showers are then cleaned before resident use, but no policy was provided for this practice at the time of interview. The Infection Prevention and Control manuals reviewed addressed cleaning and disinfecting bathing tubs and showers, but did not address cleaning wheelchairs, storage of cleaning equipment away from residents, shared shower area use for wheelchair cleaning, or required disinfectant contact time. Maintenance staff acknowledged that broken tile pieces on the floor should not have been left there.
Failure to Transcribe Hospital Discharge Medication and Document Staple Removal Communication
Penalty
Summary
The facility failed to transcribe a hospital-ordered medication for a resident admitted with a displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, muscle weakness, and other lack of coordination. The hospital discharge paperwork included orders for staples to be removed and for Lovenox 30 mg twice daily for 21 days to prevent blood clots, but the facility's transcribed orders did not include the Lovenox medication in the resident's regimen. During interview, the resident stated the facility was okay but said the staples needed to be removed so discharge back to the community could occur. The Wound Care Coordinator reported the staples were not removed because the resident's primary care physician did not want facility staff to remove them and wanted the surgeon to remove them instead. The Wound Care Coordinator also stated the nurse who spoke with the physician did not document that conversation, and was unable to locate the Lovenox order, reporting that the admitting nurse was responsible for entering orders and that the IDT reviews hospital paperwork again to ensure everything is added, but was unsure how the medication was missed.
Failure to Complete Annual PASARR Evaluation
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident reviewed. The resident was admitted with diagnoses including schizophrenia, dementia, bi-polar disease, and PTSD, and the most recent MDS showed a BIMS score of 15/15, indicating the resident was cognitively intact. The clinical record contained a PAS/Annual Review document dated 2/25/25 that noted a hospital exemption discharge, identified the resident as having dementia and receiving treatment for dementia, and stated the resident had routinely received one or more prescribed antipsychotic or medications within the last 14 days, with an explanation referencing Ativan for anxiety. No other PASARR documentation was found in the resident's record. During interview, the SW Director stated that residents should be screened annually and/or when a significant change is found, and a request for the facility's PASARR policy was made, but no policy was provided by the end of the survey.
Failure to Provide Ordered Treatment and Proper Medication Administration
Penalty
Summary
The facility failed to provide treatment and services according to professional standards of practice when it did not implement physician-ordered treatment for a resident with chronic lower extremity swelling and CHF. R110, a long-term resident with a BIMS score of 13/15, reported that their legs were supposed to be wrapped daily at 9:00 AM and removed at bedtime, but the ace wraps were not in place during observation and the resident stated the legs had last been wrapped two days earlier. The treatment order required bilateral ace bandage wraps to the feet and legs once daily at 9:00 AM and removal at 9:00 PM or bedtime, yet the treatment record showed the wraps were documented as completed even when they were not observed on the resident. The resident’s bilateral knee-high nylon stockings were also observed rolled and leaving an indentation around the calves, and the left leg was noted to be more swollen than the right. The facility also failed to ensure appropriate medication administration practices for a newly admitted resident receiving a nebulizer treatment. R135 was admitted with diagnoses including COPD, Enterocolitis due to C. difficile, and obstructive sleep apnea. During observation, an LPN entered the resident’s contact isolation room without PPE, set up the respiratory breathing treatment, applied the mask to the resident, started the nebulizer machine, and left the room while telling the resident they would return to stop the treatment when it was complete. Record review showed no self-administration assessment had been completed for the resident, and the facility policy stated residents may self-administer medications only when specifically authorized by the attending physician and in accordance with self-administration guidelines.
Oxygen Administered Without Physician Order
Penalty
Summary
The facility failed to ensure a physician order was implemented for oxygen administration for one resident reviewed for respiratory care. The resident was admitted with diagnoses including systolic and diastolic congestive heart failure. During observation, the resident was seen sleeping in bed with 3 liters of oxygen administered via nasal cannula on two separate occasions. Review of the medical record showed no physician order implemented for the oxygen administration, even though the care plan directed oxygen use at 2 L/min via nasal cannula as ordered and to observe oxygen precautions. When the assigned nurse was asked to review the orders, the LPN confirmed there were no orders for the resident’s oxygen administration and stated they would follow up with the physician. The facility policy stated that a resident will receive oxygen per physician’s orders and facility protocol.
Unnecessary prophylactic antibiotic use without documented rationale
Penalty
Summary
The facility failed to prevent the use of an unnecessary antibiotic for one resident who was reviewed for unnecessary medications. The resident was admitted with dementia and had a physician order for Nitrofurantoin Macrocrystal 50 mg once daily for lower urinary tract calculus. The transferring medication list also documented Nitrofurantoin 50 mg daily for prophylactic UTI prevention, and multiple clinician notes referenced the medication as UTI prophylaxis. The record did not contain documentation describing the benefits of the antibiotic or why it was appropriate for the resident to receive it. The record also showed that in March 2026 the resident was started on Bactrim DS every 12 hours for 5 days after a urine collection, while the resident was already receiving the prophylactic Nitrofurantoin. The March 2026 MAR documented administration of the Bactrim for a UTI in addition to the ongoing Nitrofurantoin. During interviews, the interim IP and an RN stated the family requested prophylactic antibiotic use because of a history of frequent UTIs, and the physician kept the resident on the medication after discussing it with the family, but no physician documentation supporting the rationale was provided.
Failure to Use PPE for Resident in Contact Isolation
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not don PPE for a resident in contact isolation. On 4/19/26 at 9:39 AM, an LPN was observed entering R135’s room without any PPE, accompanied by a CNA who was also not wearing PPE. The LPN set up a respiratory breathing treatment, applied it to the resident’s face via mask, started the nebulizer machine, and then walked out of the room while the resident remained in contact isolation. Record review on 4/20/26 showed that R135 had been admitted with chronic obstructive pulmonary disease, enterocolitis due to Clostridium difficile, and obstructive sleep apnea. During an interview that same day, the acting infection control preventionist stated they had just taken over the program after the previous IP quit three weeks earlier and acknowledged that staff should have been wearing PPE when entering the room. The facility policy for transmission precautions for contact isolation stated that clean, non-sterile gowns should be worn upon entering the resident’s room under specified conditions, including when the resident has diarrhea. On 4/21/26, the DON and Administrator reviewed camera footage and observed staff members entering the room without PPE.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Order, Obtain, and Report Laboratory Results as Directed
Penalty
Summary
The facility failed to order and obtain laboratory tests as directed by the physician or nurse practitioner, ensure timely laboratory services, and promptly notify the ordering practitioner of abnormal results for one resident with a change in condition. The resident, who had dementia and required total assistance with activities of daily living, exhibited symptoms including cloudy and discolored urine, increased confusion, and back pain. A nurse practitioner ordered a urine dip and, if positive, further testing, as well as a CBC and CMP. While the urine dip was performed and urine was sent for further analysis, the CBC and CMP were never ordered or resulted. The urinalysis and urine culture, collected on the same day, revealed an abnormal result with a significant presence of E. Coli, but there was no documentation that these abnormal findings were communicated to the physician or nurse practitioner, nor was any treatment initiated for the infection. There was a six-day delay in the laboratory reporting the abnormal urinalysis to the facility, and an additional delay in the facility reporting these results to the physician or nurse practitioner. The abnormal results were only sent to the practitioner the day after they were received by the facility. The facility also lacked a policy or procedure for ordering laboratory tests and reporting abnormal values to the physician. Interviews with the administrator and DON confirmed the absence of such a policy and described inconsistent processes for handling lab orders and results, as well as issues with the contracted laboratory's timeliness.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of unsanitary conditions in the kitchen. During an inspection, dried milk was found on the floor of the walk-in cooler, and the bottom shelf of the Victory freezer was soiled with food spills and debris. The ceiling vent near the ice machine was coated with dust, and the floor beneath the ice machine had a heavy buildup of trash debris and a black, mold-like substance. Additionally, the hand sink next to the Southbend skillet had a hose dripping water onto the floor, which was wet and had a black mold-like substance on the tiles. The flooring under the three-compartment sink was also wet with a similar mold-like substance, and there was a buildup of food debris on the floor in the dry storage room. The trash can for the hand sink was heavily soiled, and numerous small drain flies were observed at the floor drain under the dish machine's soiled drainboard. Furthermore, the facility's staff did not follow proper procedures for measuring food temperatures. Dietary Staff Z was observed using a thermometer to measure the internal temperatures of food items on the steam table without sanitizing the thermometer probe before or between uses. Chef X confirmed that the thermometer should have been cleaned with a probe wipe initially and between each food item. These deficiencies in food safety practices have the potential to result in foodborne illness among residents consuming food from the kitchen.
Facility Assessment Lacks Required Involvement and Input
Penalty
Summary
The facility failed to ensure that the facility-wide assessment was reviewed and revised in accordance with current regulatory requirements, potentially affecting all 117 residents. The assessment, last updated on January 10, 2025, did not include active involvement from the Medical Director, direct care staff, or input from residents, resident representatives, and family members, as required by the revised Facility Assessment requirements effective August 8, 2024. The documentation only included participation from the Administrator, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Social Services Director, Dietary Manager, Housekeeping/Laundry Manager, and Maintenance Director. During an interview, the Administrator acknowledged the lack of resident and family input and was uncertain about the requirements effective from August 8, 2024, as they had started their role around that time. The Administrator also admitted to not attending resident council meetings due to scheduling conflicts. An updated facility assessment provided by the Administrator still failed to address the concerns of lacking involvement from the Medical Director, direct care staff, and resident input.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) for three residents, which could potentially affect all 117 residents. The infection prevention and control program lacked consistent documentation of signs, symptoms, and laboratory data for infections in January and February 2025. The Infection Control Preventionist (ICP) admitted responsibility for ensuring surveillance completion but relied on floor nurses' documentation, which was insufficient. Resident 53 was observed without EBP signage on their room door, and staff entered the room without sanitizing their hands. The resident had a catheter bag dragging on the floor, and their comprehensive care plan indicated a need for EBP to reduce urinary tract infection risk. The ICP confirmed that EBP signage should have been present, and staff should have sanitized their hands before entering the room. Resident 48 had a urinary catheter and wounds but lacked EBP signage and personal protective equipment (PPE) availability. Staff entered and exited the room without cleaning their hands. The Unit Manager confirmed the resident should have been on EBP but could not explain the lack of implementation. Resident 78 had EBP signage, but the cart outside the room lacked necessary supplies like gloves and hand sanitizer. Staff entered the room without cleaning their hands, and the linen carts throughout the facility were improperly maintained, with non-linen items stored among clean linens.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. A resident was found with a tube of Triad ointment on their bedside table, without any documentation or assessment indicating they were capable of self-administering the medication. The Assistant Director of Nursing confirmed that the resident was unable to apply the ointment themselves and that it should have been stored in the treatment cart. Additionally, multiple medication carts were found with deficiencies. Some carts had drawers that could be opened without unlocking, and insulin pens were found without proper labeling or dating. Food items were improperly stored with medications, and loose pills were found in a medication drawer without identification. The Assistant Director of Nursing acknowledged these issues, noting that medication carts should be reviewed to ensure proper maintenance.
Failure to Provide Water Within Reach for a Resident
Penalty
Summary
The facility failed to ensure that water was provided and kept within reach for a resident, identified as R33, who was reviewed for accommodation of needs. Observations on multiple occasions revealed that R33 was in bed without water within reach, despite a typed note on the bedside table instructing staff to place the tray table above the resident's abdomen for easy access to water. Additionally, a chalkboard message on the bathroom door requested that water be kept within the resident's limited reach of the right hand. The care plan for R33 indicated a decreased ability to self-care and included interventions to keep personal items within reach and encourage the use of the call light for assistance. The Assistant Director of Nursing acknowledged the concern when the issue was shared with them. A policy regarding accommodation of needs was requested but not provided by the end of the survey.
Failure to Honor Resident's DNR Request
Penalty
Summary
The facility failed to honor the end-of-life wishes of a resident, identified as R417, who expressed a desire to change their code status to Do Not Resuscitate (DNR). Despite R417's clear communication of their wishes to not receive Cardiopulmonary Resuscitation (CPR) and their signing of a DNR form, the facility continued to list them as a full code in their medical records. This discrepancy was confirmed during an interview with Nurse N, who stated that CPR would be initiated if R417 became unresponsive, as the resident was still documented as a full code. The delay in updating R417's code status was attributed to the facility's policy, which required a physician's signature to effectuate the change, a process that could take several hours. The Social Work Director and Social Services staff explained that verbal orders were not typically used for advance directives, although the Director of Clinical Services confirmed that nurses could take verbal orders. The facility's Advance Directive Policy indicated that a DNR becomes effective upon signature, yet the policy did not accommodate immediate changes through verbal orders, leading to a failure in promptly updating R417's code status as per their wishes.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for two residents. For one resident with type 2 diabetes mellitus and diabetic neuropathy, the facility did not document the blood sugar level as required by the physician's orders. The nurse responsible for this resident admitted to obtaining the blood sugar reading but failed to document it on the Medication Administration Record (MAR) at the time it was obtained, as per the facility's protocol. The Assistant Director of Nursing (ADON) confirmed that the blood sugar should have been documented immediately upon obtaining it. For another resident concerned about their blood pressure, the facility did not administer blood pressure medications at the scheduled time. The resident expressed concern about not having their vital signs taken or receiving their blood pressure medications on time. The nurse responsible for this resident admitted to being late in administering the medications, which were scheduled for 9:00 AM but were documented as administered at 10:32 AM. The ADON stated that the facility's protocol allows for medication administration within an hour before or after the prescribed time, and if running late, the nurse should have informed the doctor and management.
Failure to Assist Resident with Oral Care
Penalty
Summary
The facility failed to consistently provide necessary assistance for oral care to a dependent resident, identified as R58, who was unable to perform this activity independently. Observations and interviews revealed that R58, who required staff assistance for all activities of daily living (ADLs) due to conditions such as traumatic subdural hemorrhage, muscle weakness, and dysphagia, was not receiving the needed help with brushing their teeth. R58's daughter expressed concerns about the lack of assistance, noting that R58 could brush their teeth if staff set up the toothbrush and toothpaste. However, staff were not ensuring this assistance was provided, as confirmed by R58 who stated they had not received help with oral care on the mornings observed. Further investigation showed that on one occasion, the Certified Nursing Assistant (CNA) assigned to R58 assumed that the midnight CNA had already assisted R58 with oral care, which was not the case. The Assistant Director of Nursing (ADON) acknowledged that oral care should have been completed when R58 was assisted with getting out of bed and dressed. Despite these acknowledgments, no further explanation or documentation was provided by the facility by the end of the survey, indicating a lapse in the coordination and execution of care responsibilities for R58's oral hygiene needs.
Failure to Implement Timely Treatments and Monitoring
Penalty
Summary
The facility failed to timely implement a prescribed treatment for a fungal rash for a resident, identified as R372. Upon admission, the resident's discharge paperwork from the hospital included a prescription for miconazole nitrate ointment to be applied twice daily to the affected area. However, the facility did not implement this treatment upon admission, and there was no documentation or clarification in the medical record explaining the omission. The ointment was only ordered three days after admission, following a complaint from the resident's husband to the surveyor. Observations confirmed the rash had worsened and spread, indicating a lack of timely care. Another resident, R85, experienced a delay in the implementation of treatment for edema. The resident, who had diagnoses including chronic kidney disease and congestive heart failure, was observed with swollen legs and reported that staff had not been applying the prescribed ACE wraps. The medical record indicated that the wraps were to be applied daily, but documentation showed they were not applied on several occasions. The resident had to undergo extended dialysis to remove excess fluid, and it was revealed that the facility had a shortage of ACE wraps, affecting the resident's care. Additionally, the facility failed to obtain a physician-ordered blood sugar level for resident R48. The resident, who had diabetes and required insulin administration based on blood sugar levels, did not have their blood sugar checked as scheduled. The nurse assigned to the resident was not informed of the resident's request for a blood sugar check, and the task was delayed due to meal tray distribution. The Medication Administration Record lacked documentation of blood sugar results and insulin administration for several days, indicating a lapse in the resident's diabetes management.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for a resident, identified as R23, who experienced a 22.94% weight loss over a period from late October to early December 2024. R23, who was observed to be thin and confirmed their weight loss, had a medical history including moderate protein-calorie malnutrition and chronic kidney disease. Despite these conditions, the facility did not conduct timely nutritional assessments or interventions during the period of significant weight loss. R23's medical records indicated a series of weight measurements showing a drastic decline from 148 lbs on October 30, 2024, to 114.05 lbs by December 2, 2024. The resident was on a minced and moist diet and had a variable appetite, consuming between 25% to 100% of meals. Despite being at nutritional risk due to moderate protein-calorie malnutrition and other factors, there were no dietary assessments or reviews addressing the significant weight loss in November 2024. The facility's registered dietician, RD F, acknowledged the lack of dietary assessments during the critical period in November 2024, attributing it to a transition in dieticians. The facility's policy required monitoring of significant weight changes and assessments by a registered dietician, which were not adhered to in this case. The deficiency was identified during a survey, highlighting the facility's failure to implement timely nutritional interventions for R23's significant weight loss.
Medication Administration Errors Result in 10.34% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate during a medication pass observation. Two residents were affected by these errors. For one resident, Nurse 'U' incorrectly held a 5 mg midorine tablet due to a misunderstanding of blood pressure parameters, despite the resident's blood pressure being recorded as 115/58, which did not meet any specified criteria for withholding the medication. Additionally, Nurse 'U' administered 10 mg of cetrizine, an allergy medication, instead of the prescribed loratidine 10 mg, due to a mix-up in the medication orders. Another resident received a nighttime medication, Atorvastatin 40 mg, in the morning instead of at bedtime as ordered. Nurse E administered the medication in the morning, claiming the order was incorrect and intended to contact the physician for clarification. Furthermore, Nurse E misrepresented the medication as a vitamin to the resident, following a family member's request to prevent medication refusal. These errors were acknowledged by the facility's Assistant Director of Nursing and Administrator during the survey.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inconsistent application of protocols for appropriate antibiotic use for three residents. For one resident, there was no documentation of signs and symptoms justifying the need for an antibiotic or the associated lab tests. This resident was also on contact precautions for clostridium difficile, but the antibiotic order was not transcribed correctly upon admission, leading to incomplete treatment. Another resident was prescribed an antibiotic without a start date, and the first dose was not administered. Additionally, a third resident experienced a delay in starting their prescribed antibiotic treatment. During an interview, the facility's infection control preventionist and the Director of Clinical Services acknowledged the lapses in protocol. They confirmed that the necessary labs were not conducted for the first resident, and the antibiotic order for clostridium difficile was incorrectly entered. For the second resident, they recognized the need for a stop date and acknowledged the missed first dose. The infection control preventionist was unsure why the third resident's medication was restarted. These findings indicate a lack of adherence to established protocols for antibiotic use within the facility.
Failure to Serve Meals at Desirable Temperatures
Penalty
Summary
The facility failed to ensure meals were served at a desirable temperature, leading to dissatisfaction among residents. Multiple complaints were submitted to the State Agency regarding the palatability of the facility's food. Observations and interviews revealed that residents frequently received meals that were cold, particularly breakfast. For instance, one resident reported that breakfast was always ice cold, prompting their family to bring food from outside. Another resident expressed concerns about cold food during lunch and dinner, and noted that meat was often overcooked and tough. During the survey, a dietary aide was observed delivering food trays, and a test tray review confirmed that some items, such as pancakes and sausage, were ice cold. The Registered Dietician (RD) acknowledged that most residents ate breakfast in their rooms, and trays were prepared in the kitchen before being sent to each unit. However, the RD admitted that staffing challenges sometimes led to the use of carts for delivering meals, which could affect the temperature of the food. The facility's resident council minutes also documented concerns about cold meals, particularly breakfast. The facility's administrator was informed of the concerns regarding cold food and the serving process for residents who preferred to eat in their rooms. Despite requests, the survey team did not receive the facility's policy on food palatability before the survey exit. The report highlights the facility's failure to maintain appetizing temperatures for meals, as evidenced by resident complaints and direct observations of cold food items.
Medication and Treatment Administration Failures
Penalty
Summary
The facility failed to ensure medications and treatments were administered as prescribed, leading to deficiencies in care for three residents. One resident, admitted with a diagnosis including aftercare following surgery and absence of the left leg below the knee, experienced a change in condition with vomiting. Despite receiving a verbal order for a STAT abdominal x-ray and Zofran, the x-ray was not completed, and the Zofran was not administered before the resident left the facility against medical advice. The Director of Nursing (DON) acknowledged the failure to implement the Zofran order and the lack of documentation for the standing order. Another resident, with diagnoses including chronic respiratory failure and COPD, did not receive timely administration of medications and skin treatments. Medication administration audits revealed significant delays, with medications scheduled for 9:00 PM being administered at 2:56 AM, and multiple medications scheduled for 9:00 AM being given at 11:45 AM. Additionally, skin treatments were not applied on several nights as ordered. The DON confirmed that medications should be administered within an hour of the scheduled time and acknowledged the failure to apply skin treatments as ordered. A third resident, with diagnoses including rheumatoid arthritis and depressive disorder, did not receive their physician-ordered pain patch weekly. The resident's clinical record indicated an order for a weekly buprenorphine patch, but the Medication Administration Record showed the patch was only applied once in May. The DON mistakenly believed the order was for a monthly application and could not provide documentation to support this belief. These deficiencies highlight the facility's failure to adhere to physician orders and ensure timely and accurate medication and treatment administration.
Failure to Provide Proper Oxygen Services
Penalty
Summary
The facility failed to provide oxygen services per physician orders for two residents, resulting in significant health issues. One resident was sent to a pulmonologist appointment with an empty oxygen tank, causing their oxygen saturation levels to drop to 80%, which required immediate hospitalization. The resident had a history of rheumatoid arthritis, depressive disorder, and obstructive sleep apnea, and was supposed to receive oxygen continuously at 2 liters per minute. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the incident, noting that the nurse responsible should have ensured the tank was full before the resident left for the appointment. Another resident experienced difficulty breathing due to conflicting supplemental oxygen orders. The resident had chronic respiratory failure, chronic obstructive pulmonary disease, and obstructive sleep apnea. The facility had two oxygen orders in place: one for continuous oxygen at 4 liters per minute and another for CPAP with 3 liters of supplemental oxygen during sleep. The facility's records showed that both orders were signed off as being administered simultaneously, but there was no documentation clarifying which order should have been followed during sleeping hours. The DON and ADON admitted that the orders were not clarified with the physician or coordinated with the respiratory therapist. The facility's failure to ensure proper oxygen administration and coordination of care led to these deficiencies. The lack of communication and verification of oxygen levels before appointments and the failure to resolve conflicting medical orders contributed to the residents' adverse health outcomes. The facility's policy on oxygen administration was not adequately followed, resulting in these critical incidents.
Inconsistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to consistently complete skin assessments and thoroughly document the assessments of existing pressure ulcers for a resident, identified as R702, who was under hospice care. R702 was admitted with diagnoses including Parkinson's Disease and had severely impaired cognition, requiring full assistance for daily activities. The resident had a documented stage 1 pressure ulcer upon admission, but subsequent assessments were not consistently documented in the clinical record. Observations and interviews revealed that R702 was often left in the same position for extended periods, potentially exacerbating pressure ulcer development. The facility's wound care coordinator, RN 'A', admitted to assessing the resident's wounds weekly but had not entered these assessments into the electronic clinical record. The last documented assessment by the former wound care nurse was incomplete, and there was a lack of consistent documentation of the resident's multiple pressure ulcers, which included stage 2 and stage 3 ulcers, as well as a deep tissue injury. The Director of Nursing confirmed that weekly head-to-toe skin assessments were required but had not been completed since early June. Facility policies required that all assessments be entered into the clinical record at the time of assessment, which was not adhered to in this case. The lack of consistent and thorough documentation and assessment of pressure ulcers led to the deficiency noted in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,095 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rochester Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Troy | 2.6 mi | ★★★★★ | 16 | 0 |
| Optalis Health & Rehabilitation Of Bloomfield Hill | 3.1 mi | ★★★★★ | 29 | 0 |
| Woodward Hills Health And Rehabilitation Center | 3.5 mi | ★★★★★ | 19 | 0 |
| Oakland Manor Nursing And Rehabilitation Center Ll | 4 mi | ★★★★★ | 14 | 0 |
| Bellbrook | 4.1 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.