Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Charter House Inc during CMS and state inspections, most recent first.
The facility failed to ensure accurate medication transcription, lab monitoring, and timely administration for multiple residents. One resident with atrial fibrillation and valve replacement missed INR monitoring and 3 doses of warfarin, another post-knee replacement resident missed 49 doses of aspirin for DVT prophylaxis, a resident with severe constipation had a lactulose increase delayed for 6 days, and another resident missed warfarin doses because of order-processing and medication availability problems. Staff interviews and record review showed gaps in checking faxed orders, tracking pending labs, and maintaining active MAR orders.
A resident with mild cognitive impairment and recent antibiotic use experienced diarrhea, raising suspicion of C-diff. Despite a provider's order for testing, the facility failed to implement transmission-based precautions (TBP) or provide personal protective equipment (PPE) outside the resident's room. Staff interviews confirmed the resident's symptoms and the lack of TBP, contrary to facility policy requiring immediate precautions for suspected infections.
The facility failed to ensure that three residents were appropriately vaccinated against pneumococcal disease according to CDC guidelines. Despite having received previous vaccines, there was no documentation of discussions regarding the PCV-20 vaccine. Interviews revealed that vaccination responsibilities were often deferred to outside providers, and the facility's policy was not followed.
A resident alleged rough care by a nursing assistant, leading to fear and anger. The incident was documented, but the facility failed to report the allegation to the State Agency within the required two-hour timeframe. Staff interviews revealed confusion about reporting procedures, and the facility's policy was not aligned with federal regulations.
A resident with intact cognition reported rough care by a nursing assistant, leading to fear and anger. Despite the allegation, the nursing assistant continued to provide unsupervised care to other residents, contrary to facility policy. Interviews confirmed the failure to remove or supervise the implicated staff, potentially affecting all residents.
The facility's policy for reporting abuse allegations was inconsistent with federal requirements, allowing up to 24 hours for reporting incidents without injury, contrary to the mandate for immediate reporting within two hours. Interviews revealed staff confusion about the correct reporting timeframe, highlighting a need for policy revision.
Medication order transcription and administration failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet residents’ needs because it did not consistently transcribe medication orders, monitor ordered labs, ensure medication availability, or administer medications as ordered for 4 of 4 residents reviewed. The report identified breakdowns involving missed INR monitoring, omitted anticoagulant and antiplatelet therapy, delayed implementation of medication order changes, and medication administration failures. Facility records and staff interviews showed that these problems were tied to order transcription failures, incomplete review of faxed orders, and lack of reliable tracking of pending labs and active medication orders. For one resident with a complex cardiac and thromboembolic history, including heart transplant infection, valve replacement, atrial fibrillation, prior stroke, and chronic heart failure, warfarin management was disrupted when an INR ordered for monitoring was not completed and the corresponding warfarin order was not obtained. The resident missed three doses of warfarin, and the record showed the INR due on the scheduled date was not obtained. Staff interviews confirmed the lab order was missed and that the dashboard settings did not display pending labs for the nurse who was responsible for the task. The resident’s records also showed the warfarin order was not administered during the period when the missed INR should have guided therapy. For another resident following right total knee arthroplasty, aspirin 81 mg twice daily was ordered for DVT prophylaxis, but the order was not properly reactivated after being discontinued in the EHR. Although the facility initially believed only three doses were missed, MAR review showed the resident received aspirin only through the morning dose on one date and then had no active aspirin order for the remainder of the prescribed prophylactic period, resulting in 49 missed doses. The resident’s records also noted redness, mild heat, and drainage at the incision site, and an ultrasound was ordered to rule out DVT. Staff interviews confirmed the prolonged omission and that the restarted aspirin order had not been entered into the EHR. Additional failures involved a resident with vascular dementia, hemiplegia after cerebral infarction, and constipation management needs, whose lactulose order was increased to three times daily but was not transcribed to the MAR for six days. Another resident with atrial fibrillation, prior DVT, stroke history, ESRD on dialysis, and kidney transplant status had warfarin doses missed because of medication availability and order-processing problems; one missed dose was documented as unavailable from the pharmacy, while another missed dose was associated with transcription/order processing issues. The report also stated the facility’s medication error investigations, documentation, and monitoring systems did not consistently identify the full scope of the omissions.
Failure to Implement Transmission-Based Precautions for Suspected C-diff Case
Penalty
Summary
The facility failed to initiate transmission-based precautions (TBP) for a resident suspected of having Clostridioides difficile (C-diff), a highly contagious bacteria. The resident, who had mild cognitive impairment and required substantial assistance with activities of daily living, began experiencing diarrhea a couple of days prior to the survey. Despite the resident's symptoms and a provider's order for a stool sample to rule out C-diff, no TBP or personal protective equipment (PPE) was observed outside the resident's room. Interviews with staff revealed that the resident had been experiencing loose stools for several days and was on antibiotics for a urinary tract infection, which could have contributed to the symptoms. The infection preventionist (IP) confirmed that an order for C-diff testing was received and processed, but the resident was not placed on TBP while awaiting lab results. The IP stated that residents should be placed on TBP when symptoms outside their baseline are suspected, even before lab results are obtained. The director of nursing (DON) also stated that the expectation is for residents to be placed on TBP immediately when testing for gastrointestinal illness is requested. The facility's policy on isolation precautions indicated that modified contact precautions should be used for suspected or confirmed C-diff infections, but this was not followed in the case of the resident.
Failure to Ensure Appropriate Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that three residents were appropriately vaccinated against pneumococcal disease according to current CDC guidelines. Resident 5, who was admitted on a specified date, had previously received PCV-13 and PPSV-23 vaccines but lacked documentation of a discussion with a medical provider regarding the PCV-20 vaccine. Similarly, Resident 9 and Resident 114, both admitted on different dates, had received PCV-13 and PPSV-23 but also lacked documentation of a discussion about the PCV-20 vaccine. The facility's policy required that all residents be assessed for vaccination status prior to admission and that vaccinations be offered annually or as needed, yet this was not adhered to in these cases. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that immunizations were reviewed upon admission, but the responsibility for vaccination was often deferred to the residents' outside primary care providers due to the short-term nature of their stay. The IP confirmed that the residents were eligible for the PCV-20 vaccine, but there was no documentation to show that the vaccine was offered or evaluated for appropriateness. The DON expressed an expectation that vaccines should be offered to eligible residents, indicating a gap between policy and practice.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident to the State Agency. The incident involved a resident who alleged rough care by a nursing assistant during the night shift. The resident, who had intact cognition and was dependent on assistance for certain activities, expressed fear and anger following the incident. The resident's progress notes indicated that the resident had refused care from the nursing assistant and became visibly upset, alleging that the assistant had hurt her. This incident was documented in the progress notes, but the report to the State Agency was delayed. Interviews with staff revealed a lack of clarity and adherence to the reporting procedures. The nursing assistant involved in the incident reported the resident's refusal of care and the allegation to a nurse, who then documented the incident. However, the charge nurse and other staff members were unsure of the timeline and procedures for reporting such allegations. The facility's policy at the time allowed for reporting within 24 hours if no serious injury was involved, which was inconsistent with the federal requirement to report within two hours for allegations involving abuse. The facility's Vulnerable Adult Reporting and Investigation Procedure was not aligned with the federal regulations, which require immediate reporting of abuse allegations to the State Agency. The interim director of nursing acknowledged the discrepancy and indicated that the facility's policy would be revised. The report highlights the failure to adhere to the required reporting timeline, resulting in a deficiency citation for the facility.
Failure to Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to ensure the protection of all residents following an allegation of abuse by a nursing assistant (NA) towards a resident (R1). On the night of the incident, R1, who had intact cognition and no noted behaviors, reported rough care by NA-A, resulting in fear and anger. Despite R1's refusal of care and the subsequent report of the incident to the nurse, NA-A continued to provide care to other residents unsupervised until the end of her shift. This was contrary to the facility's policy, which mandates the immediate removal of implicated personnel from resident contact or their supervision during any direct care activities. Interviews with staff, including the interim director of nursing and the licensed practical nurse on duty, confirmed that NA-A was allowed to work unsupervised with other residents after the allegation. The facility's policy requires that upon receiving any allegations of abuse, the implicated personnel should be either placed under continuous observation, reassigned to a non-resident care role, or placed on temporary administrative leave. The failure to adhere to these procedures potentially affected all residents in the facility at the time of the allegation.
Inadequate Abuse Reporting Policy
Penalty
Summary
The facility failed to have a policy consistent with federal requirements for reporting allegations of abuse to the state agency immediately, but no later than two hours. The facility's existing policy, as outlined in their Vulnerable Adult Reporting and Investigation Procedure dated 3/20/24, required reports to be submitted within twenty-four hours of the incident's discovery, or within two hours only when the alleged maltreatment involved serious bodily injury or death. This discrepancy in the policy had the potential to affect all residents in the facility, as it did not align with the federal mandate that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than two hours if they involve abuse or result in serious bodily injury. During interviews, it was revealed that there was confusion among the staff regarding the correct reporting timeframe. An operations specialist mentioned that in other states, abuse should be reported immediately but no later than two hours, and there was uncertainty about whether the facility's current practice of reporting within 24 hours without injury was correct. The interim director of nursing confirmed that any abuse allegation should be reported immediately but no later than two hours to the state agency, indicating a need for policy revision to meet regulatory requirements.
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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.
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Nursing homes near Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Samaritan Bethany Home On Eighth | 0.4 mi | ★★★★★ | 8 | 0 |
| Rochester Restorative Care Center | 0.8 mi | ★★★★★ | 36 | 1 |
| Edenbrook Of Rochester | 1.8 mi | ★★★★★ | 16 | 0 |
| Edenbrook Rochester West | 2 mi | ★★★★★ | 26 | 1 |
| Madonna Towers Of Rochester | 3 mi | ★★★★★ | 4 | 0 |
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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.