Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Edenbrook Of Rochester during CMS and state inspections, most recent first.
A resident’s room had a hole in the wall with two exposed cable cords after a maintenance request was marked complete before the face plate was reattached, and the resident said she had asked staff to cover it but it remained unresolved. The DON was unaware of the issue, while maintenance confirmed the cable work had been done without replacing the face plate. The facility also had dozens of cigarette butts littering the back entrance, driveway, and nearby planter, which a family member found disgusting and the administrator acknowledged was unpleasing to the eye.
Failure to maintain dignity during catheter care and mealtime assistance. Two residents with indwelling catheters were observed with Foley/suprapubic catheter bags and tubing hanging uncovered from wheelchairs, with urine visible draining and the catheter equipment seen by others in the commons area and hallway. In the dining room, an NA stood while assisting four residents to eat, moving from resident to resident without sitting at eye level or communicating with them during the meal.
Failure to follow up on resident council grievances. Residents raised repeated concerns about food during council meetings and said they had not received any response or rationale from staff. The LEC stated grievances were taken to the appropriate dept, but meeting minutes lacked documented responses or rationales, and the admin confirmed there was no proof that follow-through with resident council members had occurred.
A resident's MDS was coded incorrectly when invasive mechanical ventilator use was marked in error instead of CPAP use. The resident's care plan showed CPAP at night, and the MDSC confirmed the error during interview. The DON stated MDS accuracy is important because it affects payment.
Inaccurate Charting of Dialysis Vital Signs and Weights: A resident with ESRD on dialysis had ordered pre- and post-dialysis weights and VS, but staff repeatedly documented them later in the day instead of when obtained. When the resident returned from dialysis, no immediate assessment had been completed, and the RN confirmed the VS and weights had not yet been done. The DON and NP stated charting should reflect the actual time of completion, not end-of-shift entry.
Untrained cook assisted a resident with meals instead of qualified nursing staff. The resident had severe cognitive impairment, dementia, and Alzheimer’s, and the care plan identified ADL self-care and cognitive deficits. During observations, the cook fed the resident briefly and then walked away, and later again gave only a few bites before leaving. The cook confirmed she was not a CNA, while the CD and DON stated only nursing staff or trained staff should assist with feeding.
Failure to Address Clothing Burns During Smoking Safety Assessment: A resident with a right-hand contracture and vascular dementia was assessed as safe to smoke independently, but her smoking care plan lacked clothing protector interventions. During observation, her coat had two burn holes, and she reported difficulty lighting cigarettes with her left hand because of limited movement in her right hand. The NM and DON stated staff were not aware of the burns, and the DON noted residents should be free of burn holes in clothing to smoke independently.
Two residents with indwelling urinary catheters were observed with catheter tubing and bags dragging on the floor, and staff confirmed the equipment should not contact the ground because of infection risk. One resident had a recent UTI and another had a suprapubic catheter. In a separate finding, an LPN exited a resident's room without PPE even though the resident had a dialysis catheter and should have had EBP in place; the DON confirmed the EBP sign and isolation equipment were missing.
Surveyors found that staff repeatedly left medication carts unlocked and unattended, allowing unsupervised access by residents and guests. Multiple medications on the carts were missing required open dates, and expired medications were not removed or destroyed as required. Controlled substances belonging to a deceased resident remained in the cart beyond the expected timeframe for removal. Facility leadership confirmed these practices did not meet policy expectations.
Staff did not clean a mechanical transfer lift after using it with a resident who required substantial assistance, and the same uncleaned equipment was subsequently used with another resident. Staff interviews confirmed knowledge of standard precautions and facility policy requiring cleaning of reusable equipment after each use, but the expectation was not followed in these instances.
A resident with multiple diagnoses was allowed to self-administer prescribed eye drops without a completed self-administration of medication (SAM) assessment or a provider order. An LPN left the medication at the bedside, and staff confirmed that facility policy requires both an assessment and a physician order before permitting self-administration, neither of which were present in this case.
A resident with quadriplegia and dysphagia was observed with dried, chewed food accumulating on his electric wheelchair, which he could not clean himself, and staff were unclear about cleaning responsibilities or frequency. Another resident experienced ongoing discomfort due to a roommate's consistently loud TV, with staff and social services aware of the issue but no effective interventions or policies in place to address sound levels or roommate incompatibility.
Two residents with complex medical needs did not receive care as ordered, including daily weights and application of compression wraps. Staff did not consistently notify providers when residents refused care or when weight thresholds were exceeded, and documentation was lacking. Observations and interviews confirmed that individualized care plans were not followed as required.
The QAPI committee failed to properly identify, investigate, and analyze medication errors, with meeting minutes lacking dates, attendee lists, and specific action plans. Multiple residents experienced missed or incorrectly administered medications, and the facility underreported the true number of errors by not counting each omitted dose. Medication error reports did not include causal analysis or preventive measures, and there was no evidence of staff retraining or accountability.
The facility's assessment did not identify a resident with a liver transplant or address the specific care, monitoring, or staff training required for organ transplant recipients. Interviews with staff, including an LPN, nurse manager, DON, and nurse practitioner, revealed a lack of education and awareness regarding organ rejection monitoring and absence of contact with the resident's transplant team. The facility also could not provide a policy for facility assessment.
A resident with a Foley catheter did not receive care in accordance with enhanced barrier precautions (EBP), as staff failed to use gowns, gloves, and proper hand hygiene during high-contact activities, despite posted signage and policy. The care plan did not clearly specify EBP requirements for catheter care, and the catheter bag was observed on the floor multiple times, with staff handling it without following EBP protocols.
A resident at risk for choking and with a history of aspiration pneumonia was not provided the correct physician-ordered Level 5 minced and moist diet upon returning from the hospital. Instead, the resident received a regular diet due to a failure in the facility's system for updating and communicating dietary orders. The care plan and Kardex were not updated, and the kitchen staff did not receive the new diet orders, leading to the resident receiving the wrong diet for several days.
A resident with a history of diabetes and vascular disease was admitted with bruises that were not properly assessed or documented by the LTC facility. Despite directives to hold aspirin due to a GI bleed, it was administered, potentially worsening the bruising. Staff interviews revealed inconsistencies in procedures for monitoring and documenting bruises, contributing to the deficiency.
A resident with a recent right below-knee amputation experienced a fall that led to wound dehiscence. The facility failed to assess, monitor, and report the wound changes, delaying necessary surgical intervention. Despite the resident's reports of bleeding, the staff did not conduct a comprehensive assessment or notify the physician, resulting in a prolonged healing process and emotional distress for the resident.
Three residents reported being treated without dignity and respect by a nursing assistant (NA-B). One resident, who required maximal assistance due to hemiplegia, felt threatened by rough handling and disrespectful comments. Another resident, dependent on staff for toileting, experienced improper care and derogatory remarks during incontinence episodes. A third resident, needing assistance due to a back fracture, reported dismissive and gruff responses to her needs. Staff interviews confirmed that such behavior violates residents' rights to dignity and respect.
A facility failed to notify physicians of critical incidents involving two residents. One resident fell from a wheelchair, causing a wound dehiscence on a recently healed amputation site, but the surgical team was not informed, leading to delayed treatment. Another resident with elevated potassium levels did not receive prescribed medication due to unavailability, and the physician was not notified, resulting in an emergency room visit. Staff interviews revealed communication gaps and a lack of urgency in addressing these issues.
A resident's privacy was compromised when a facility's video monitoring device captured footage inside their room without consent. The resident, requiring assistance due to hemiplegia, was recorded in a state of undress. The facility's policy prohibited such surveillance, but the camera's placement allowed for this breach, which was unknown to the administrator until the survey.
A resident with diabetes and hemiplegia was not provided routine nail care, despite being dependent on staff for such care. Observations revealed long, soiled fingernails, and interviews with staff confirmed the resident's need for assistance. The care plan required nail care on bath days, but there was no documentation of it being offered or completed.
The facility failed to administer critical medications to three residents, including a resident with hyperkalemia who did not receive Lokelma, a resident with diarrhea who missed Saccharomyces boulardii doses, and a resident with chronic pain who did not receive Pregabalin. The facility did not have a system to identify, record, and report these omissions as medication errors, nor did they notify physicians or follow emergency procedures.
A facility failed to maintain accurate medical records for two residents, leading to care deficiencies. One resident with high potassium levels did not receive critical medication due to poor communication and documentation. Another resident was transferred to the hospital without proper documentation of the transfer. Staff interviews revealed gaps in communication and access to information, impacting care quality.
A resident's privacy was violated during a skin assessment when an LPN conducted a check without permission, exposing the resident in front of a male PT. The resident, who had psychosocial well-being issues, felt embarrassed and moved to another facility.
A resident with severe sleep apnea and heart problems was discharged from an LTC facility to a hotel without a plan for obtaining necessary supplemental oxygen, despite needing it with a Bi-PAP machine. The discharge summary lacked equipment details, and the facility's social service note did not mention a referral for oxygen DME. The DON confirmed the resident was discharged with medications and Bi-PAP supplies but without secured oxygen delivery, contrary to facility policy requiring safe discharge preparation.
Exposed Cable Face Plate and Cigarette Litter at Back Entrance
Penalty
Summary
The facility failed to ensure a cable cord face plate was secured in one resident’s room. The resident had no cognitive impairment per the comprehensive MDS assessment and was dependent on facility staff for bathing and toileting, required substantial assistance for dressing, and was dependent on staff for position changes. During interviews and observation, the resident pointed to a hole in the wall with two cable cords coming out and stated she had asked staff about covering it about a month earlier, but it had not been done. The hole and exposed cords were still present during a later observation, and the resident again stated she wanted the cords covered with an outlet cover. The DON stated she was not aware of the hole in the resident’s wall and acknowledged it could be a safety issue and should be fixed. Maintenance stated he knew the cable in the resident’s room was protruding from the wall and that a maintenance request had been submitted to fix it, but after the cable ends were replaced, the faceplate was not reattached. The maintenance report had been marked completed before the face plate was replaced. The facility also failed to remove discarded cigarette butts from the back entrance area, where dozens of cigarette butts were observed along the wall, driveway toward the smoking area, and in a garden planter. A family member stated she disliked entering through the back door because the area was littered with dirty, old cigarette butts, and the administrator confirmed the cigarette butts were present and unpleasing to the eye.
Failure to Maintain Resident Dignity During Catheter Care and Mealtime Assistance
Penalty
Summary
The facility failed to maintain dignity for two residents who used urinary catheters and for four residents who required assistance with eating in the dining room. One resident had diagnoses including heart failure and renal insufficiency and used an indwelling catheter. During observation, the resident’s Foley catheter bag and tubing were hanging uncovered from the wheelchair while the resident sat in the commons area and later ate breakfast in the dining room. A nurse assistant confirmed the catheter tubing and bag were exposed and stated they should have been covered in a dignity bag so others could not see them, noting that a dignity bag was available on the opposite side of the wheelchair but was not being used. Another resident had diagnoses including coronary artery disease and heart failure and used an indwelling suprapubic catheter. During observation, the resident rolled down the hallway to the room with the catheter bag and tubing hanging uncovered from the wheelchair. Several residents, staff members, and visitors were able to see the catheter tubing, bag, and urine draining through the tube. A nurse assistant confirmed the catheter was exposed and stated all catheter bags and tubing should be placed in a cloth dignity bag so nobody around the resident could see the catheter, tubing, or urine draining. The nurse assistant also stated she had been unable to locate a dignity bag before transporting the residents to breakfast. During a meal observation, a nurse assistant assisted four residents at the same table by standing and moving from one resident to another, giving each resident a bite of food while standing. The nurse assistant did not communicate with the residents while assisting them. She stated she was the only staff member in the dining room and did not want the food to get cold, but also stated that sitting next to one or two residents at eye level would allow conversation and choices and that feeding all four residents in the manner observed would be more of a dignity and respect issue. The nurse manager and DON stated catheter bags and tubing should be covered and that staff should sit when assisting residents with meals, feeding one resident at a time.
Failure to Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to follow up on resident council complaints and grievances after a determination had been made by the facility. During a resident council meeting, five residents voiced concerns about food and stated the issue had been raised at each meeting, but they had not heard back from facility staff or received a rationale for why there was no response. The concerns were documented as recurring complaints related to food. During interviews, the life enrichment director stated that food was a major grievance discussed at resident council meetings and that other items had also been brought up recently. The director said grievances were taken to the appropriate department after the meeting and that follow-up would occur before the next resident council meeting, but notes had not yet been entered into the new form. Review of resident council meeting minutes from 10/25 through 1/26 showed one grievance on 12/17/25 related to canned foods being used too often and artificial sweeteners being used. The minutes did not contain documented responses or rationales for the concerns raised. The administrator stated the resident council spokesperson would bring grievances to the appropriate departments and that the facility handled grievances on a more personal level rather than bringing them back to resident council. A later interview confirmed there was no proof that follow-through with resident council members had occurred regarding the grievances and complaints filed in resident council.
Inaccurate MDS Ventilation Coding
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one resident, R11, whose quarterly MDS dated [DATE] indicated the resident was cognitively intact and listed diagnoses of hypertension and Parkinson's disease. R11 received invasive mechanical ventilator services, but the care plan dated 2/28/25 stated the resident used a CPAP machine at night, which is noninvasive mechanical ventilation. During an interview on 2/10/26 at 2:26 p.m., the MDS coordinator reviewed R11's MDS report from 11/19/25 and confirmed that invasive mechanical ventilator had been marked in error and should have been recorded as CPAP. During an interview on 1/29/26 at 2:33 p.m., the DON stated that MDS accuracy was important because it is part of the facility's payment.
Inaccurate Charting of Dialysis Vital Signs and Weights
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for accurate charting of dialysis assessments, including vital signs and weights, for one resident who required dialysis three times per week for end stage renal disease. The resident’s MDS indicated moderate cognitive impairment and dependence on staff for dressing, hygiene, and mobility. The care plan and active orders required weights and vital signs before dialysis and again upon return from dialysis, and the resident’s dialysis routine included transport to the dialysis center before the scheduled treatment time and return to the facility several hours later. During observation, the resident was being prepared to leave for dialysis, and the NM stated that vital signs and weight are completed before dialysis and again after return to the facility. The dialysis communication sheet for the resident showed a blood pressure documented at 10:50 a.m. with no weight, but that blood pressure was later entered into the chart at 3:17 p.m. rather than at the time it was taken. Review of the TAR from 12/12/25 through 2/9/26 showed multiple instances in which pre-dialysis blood pressures, pre-dialysis weights, post-dialysis blood pressures, and post-dialysis weights were documented later in the day rather than when obtained. When the resident returned from dialysis, the resident was placed in the main living room and no assessment had been completed upon return. The RN stated residents returning from dialysis should be assessed immediately upon return and confirmed she had not completed the resident’s vital signs and weights. The RN also stated staff sometimes chart vital signs at the end of the shift instead of at the time of completion. The DON and NP both stated accurate charting was expected, that vital signs and weights should be entered when collected, and that charted times should reflect the actual time of completion rather than the end of shift. The facility policy on charting and documentation stated the TAR shall record resident care procedures and/or treatments ordered by the physician that are performed and by whom they were performed.
Untrained cook assisted resident with meals
Penalty
Summary
The facility failed to provide care by qualified persons according to the resident’s written plan of care when an appropriately trained staff member did not assist a resident with meals. R24 had an annual MDS assessment indicating severe cognitive impairment, with diagnoses of dementia and Alzheimer’s, and the care plan revised on 8/11/25 identified an ADL self-care performance deficit and a cognitive deficit. During an observation on 2/09/26 at 12:28 p.m., cook C-A was assisting R24 with lunch, gave four bites of food, and then walked away to tend to something else, after which a nurse assistant took over feeding the resident. During another observation on 2/11/26 at 8:16 a.m., C-A approached R24, told the resident they needed to eat, gave two bites of food after several minutes, and then walked away again. C-A later confirmed she assisted R24 with meals on both dates and stated she was not a nurse assistant in Minnesota. The culinary director confirmed C-A was a cook and stated the facility did not use paid feeding assistants and that only nursing staff or trained staff were allowed to assist with feeding residents. The DON stated only clinical staff or someone trained to assist with meals should feed residents and that dietary staff should not assist residents with their meals.
Failure to Address Clothing Burns During Smoking Safety Assessment
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to address clothing burns for a resident reviewed for smoking safety. The resident’s quarterly MDS dated 12/10/25 indicated she was cognitively intact, and her diagnoses included a contracture of the right hand and vascular dementia. Her care plan dated 9/24/25 noted the right-hand contracture and that she required assistance with dressing and undressing, but her smoking care plan did not include interventions for clothing protectors. Smoking assessments dated 5/23/24 through 12/4/25 indicated she was safe to smoke without supervision. During observation on 2/10/26, the resident’s coat had two burn holes on the right forearm. She stated the burn holes occurred after she got her new coat a couple of months earlier and explained that she was right-handed but had difficulty lighting her cigarette with her left hand because of limited movement in her right hand from the contracture. She stated she was upset that her brand-new jacket already had holes in it, though she otherwise felt mostly safe smoking outside alone. The NM stated that if staff observed burn holes in clothing, they would assess the resident for wounds and complete another smoking assessment, but she was not aware of the burn holes in the jacket. The DON stated residents need to be free of burn holes in clothing to smoke independently and that a resident with burns in clothing should be reassessed immediately for safety, but staff did not routinely check clothing for burns.
Catheter Equipment Contacted the Floor and EBP Was Not Implemented
Penalty
Summary
The facility failed to prevent infection risk for two residents with indwelling urinary catheters when catheter tubing and bags were observed in contact with the floor. R30, who had moderate cognitive impairment, heart failure, renal insufficiency, and an indwelling catheter, had a care plan addressing urinary retention and a documented UTI treated with antibiotics. On observation, R30 was seated in a wheelchair in his room with the catheter tubing and bag laying on the floor next to him, with no barrier between the catheter equipment and the floor. Facility staff confirmed that catheter bags and tubing should not come into direct contact with the ground because of infection risk. R2, who had moderate cognitive impairment, coronary artery disease, heart failure, and a suprapubic catheter, was observed rolling down the hallway with the catheter bag and tubing hanging from the wheelchair and dragging along the floor. A nurse assistant confirmed the tubing was dragging and stated she had placed the bag and tubing under the wheelchair after getting the resident up for breakfast. The facility also failed to implement enhanced barrier precautions for R52, who had moderate cognitive impairment, end stage renal disease, and a dialysis catheter. An LPN exited the resident's room without PPE and stated he did not think EBP was needed because there was no sign or isolation equipment on the door. The DON later confirmed the resident should have had an EBP sign and isolation equipment, and the resident did not have them in place.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in medication storage and labeling practices. On several occasions, staff left medication carts unlocked and unattended in hallways, allowing residents and guests to pass by without supervision. Staff members, including those not wearing name badges, repeatedly walked away from the unlocked carts, and even a nurse manager passed by without securing the cart. During medication administration, an LPN also left the cart unlocked while entering a resident's room. These actions left medications accessible and unsecured for extended periods. Further review of the medication carts revealed several medications that were not properly labeled with open dates, including saline nasal gel, Vitamin C, liquid Haloperidol, Prednisolone eye drops, Lantoprost eye drops, Dorzolamide eye drops, Deep-Sea nasal spray, and Flonase nasal spray. An expired bottle of Vitamin C was found, and the LPN acknowledged it should have been removed and destroyed. Additionally, controlled substances belonging to a resident who had expired the previous day were still present in the narcotic box and had not been removed or destroyed as required. The DON confirmed that multi-dose medications should be dated when opened and that medications for expired residents should be removed and destroyed promptly, in accordance with facility policy.
Failure to Clean Mechanical Lift Between Resident Uses
Penalty
Summary
Staff failed to clean a mechanical transfer lift (EZ stand) after use with a resident who was cognitively intact, dependent on staff for toileting, and required substantial assistance with transfers. The EZ stand, which had visible debris, was used by two nursing assistants to transfer the resident from bed to commode. After the transfer, the equipment was placed in the hallway without being cleaned. Later, another nursing assistant used the same EZ stand with a different resident without cleaning it before or after use. Interviews with staff, including a nursing assistant, an LPN, and the DON, confirmed that standard precautions and facility policy require cleaning and disinfecting reusable equipment after each use. Staff acknowledged the expectation to clean equipment and confirmed that infection control training is provided at hire and annually.
Failure to Complete Assessment and Obtain Order for Self-Administration of Medication
Penalty
Summary
A resident with intact cognition and diagnoses including atrial fibrillation, heart failure, respiratory failure, cataracts, and glaucoma was observed to have prescribed eye drop medications left at their bedside for self-administration. The resident's medical record did not contain evidence that a self-administration of medication (SAM) assessment had been completed, nor was there a provider order authorizing the resident to self-administer medications. During medication administration, an LPN left one of the resident's prescribed eye drops on the bedside table and later confirmed that the resident did not have an order to self-administer medications. Interviews with staff, including the DON, confirmed that facility policy requires a SAM assessment and a physician order before residents are permitted to self-administer medications. The DON acknowledged that these steps had not been completed for the resident in question, and that medications should not be left at the bedside without proper assessment and orders. Facility policy also specifies that the ability to self-administer medications must be care planned with interventions specific to the individual resident.
Failure to Maintain Clean Equipment and Address Excessive Noise Levels
Penalty
Summary
The facility failed to maintain resident equipment in a clean and sanitary condition and did not ensure a comfortable environment regarding sound levels for two residents. One resident, who is nonverbal, has quadriplegia, dysphagia, and requires an electric wheelchair for mobility, was observed with a significant accumulation of dried, chewed, and spilled food on various parts of the wheelchair. The resident communicated that he is unable to clean the wheelchair due to his disabilities and does not like the presence of dried food. Staff interviews revealed uncertainty about who is responsible for cleaning wheelchairs and how often this should occur. The director of nursing acknowledged awareness of the issue and confirmed that the wheelchair often appears unsightly after meals, but there were no care plan interventions to protect the wheelchair during meals, and cleaning frequency was not documented. Another resident, who is cognitively intact and requires assistance with mobility and personal care, reported ongoing discomfort due to the loud volume of her roommate's television. The resident stated she had made multiple complaints about the noise, which affected her sleep and comfort, but no effective interventions were implemented. Staff confirmed the roommate's TV is frequently loud, and although they sometimes lower the volume when the roommate is absent, they do not consistently monitor or address the issue. The social services staff was aware of the complaint and had only asked staff to lower the volume when possible, with no further interventions or plans to address the incompatibility or sound levels. The facility lacked clear policies regarding the cleaning frequency of resident equipment and did not have a policy addressing roommate incompatibility or appropriate sound levels in resident rooms. Documentation and staff interviews confirmed that these deficiencies were ongoing and not addressed through care planning or facility policy.
Failure to Implement and Document Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement and follow individualized care plans for two residents with complex medical needs. For one resident with a history of liver transplant, chronic kidney disease, and major depressive disorder, daily weights were ordered to monitor for signs of liver rejection and kidney function changes. However, the resident was not weighed daily as ordered, and when weights were obtained, they were not performed consistently in the same manner or at the same time of day. Documentation showed that the resident refused weights on 17 days, but there was no evidence that the provider or transplant coordinator was notified of these refusals, as required by the care plan and facility policy. Multiple staff interviews confirmed that provider notification was expected after repeated refusals, but this did not occur. For another resident with congestive heart failure (CHF) and atrial fibrillation, the care plan included daily weights and the application of compression garments to manage fluid retention and monitor for CHF exacerbation. The resident's medical record indicated that weights frequently exceeded the threshold requiring provider notification, but there was no documentation that the provider was informed. Observations revealed that compression wraps were not consistently applied in the morning as ordered, and the resident was often seen with swollen feet and without the prescribed wraps. Staff interviews confirmed knowledge of the care plan requirements but acknowledged that time constraints and other factors led to inconsistent implementation. Facility policy required timely provider notification and documentation of significant weight changes or refusals of care. Despite this, both residents' records lacked evidence of appropriate provider notification and consistent implementation of ordered interventions. The deficiency was identified through observation, record review, and staff interviews, all of which demonstrated a failure to follow individualized care plans and provider orders for residents with significant health risks.
Failure to Identify, Analyze, and Respond to Medication Errors in QAPI Process
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to properly identify, investigate, analyze, and respond to medication errors, as evidenced by a review of committee minutes and medication error reports from December 2024 to February 2025. The QAPI meeting minutes were often undated, did not list attendees, and lacked documentation of specific action plans or goals related to medication errors. Medication error reports were inconsistently analyzed, with no causal analysis or preventive measures documented, and the committee did not consistently track each omitted medication dose as a separate error. Multiple medication errors were identified during this period, including missed or incorrectly administered doses for several residents. Examples include a resident receiving Tamiflu at the wrong frequency, another missing multiple doses of Sevelamer Carbonate due to pharmacy and insurance issues, and a resident missing several doses of Muro eye drops because of supply delays. Additional errors involved missed doses of Advair and Erythromycin Ophthalmic ointment following a readmission, and a resident missing multiple doses of Heparin due to a transcription error. In each case, the reports lacked causal analysis, identification of responsible staff, and documentation of retraining or preventive steps. The facility's method of tracking medication errors was inconsistent, as they counted multiple missed doses for a single resident as one error rather than accounting for each omitted dose. This led to significant underreporting of medication errors in QAPI meetings compared to the actual number identified in medication error reports. Interviews with the DON and a nurse practitioner confirmed that the facility did not have an effective process for analyzing medication errors or implementing action plans to prevent recurrence, and that the QAPI committee did not address the full scope of medication errors occurring in the facility.
Facility Assessment Lacked Organ Transplant Recipient Care and Staff Training
Penalty
Summary
The facility failed to ensure its Facility Assessment (FA) included the identification of organ transplant recipients and the specific care or practices necessary to meet their needs. The FA, last revised on 9/18/24, did not document the presence of a resident with a liver transplant and end stage kidney disease, nor did it address the required monitoring for organ rejection or the necessary staff training and competencies for such care. Staff interviews revealed that neither the LPN responsible for the resident's care nor the nurse manager had received education on organ transplant recipient care, and both were unaware of the signs and symptoms of organ rejection. The facility also lacked information and contact with the resident's liver transplant team, and this information was not present in the resident's medical records. Further interviews with the DON, regional nurse manager, and nurse practitioner confirmed that the FA did not address organ transplant recipient care or related education. The liver transplant care coordinator, when contacted, emphasized the importance of monitoring for liver rejection, administering anti-rejection medications, and conducting routine lab and ultrasound monitoring, none of which were documented in the facility's assessment or care practices. Additionally, the facility was unable to provide a policy for facility assessment when requested.
Failure to Implement Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling Foley catheter, as required to reduce the risk of infection transmission. The resident had diagnoses of obstructive and reflux uropathy and required assistance with personal care. The care plan included interventions for catheter care and monitoring for signs of infection but did not specify the need for EBP during catheter-related activities. Although a sign indicating EBP requirements was posted outside the resident's room, the care plan did not clearly identify which care activities necessitated EBP, nor did it link EBP to the Foley catheter. Observations revealed that the resident's catheter bag was repeatedly found lying on the floor, and staff, including an LPN and a nursing assistant, handled the catheter bag without following EBP protocols or proper hand hygiene, despite signage and policy requirements. The LPN was observed entering the room, handling the catheter bag without donning gown and gloves, and failing to wash hands before and after resident contact. The DON confirmed that EBP should have been used for catheter care and that staff were expected to follow posted precautions and hand hygiene protocols. The facility did not provide a requested handwashing policy.
Failure to Provide Correct Textured Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident, who was at risk for choking and had a history of aspiration pneumonia, received the correct physician-ordered textured diet. The resident returned from the hospital with new diet texture orders for a Level 5 minced and moist diet but was instead provided with a regular textured diet from January 3 to January 9. This discrepancy was due to a failure in the facility's system for updating and communicating dietary orders, as the care plan and Kardex were not updated to reflect the new diet requirements. The resident's care plan initially identified a regular liberalized renal diet, but after hospitalization for acute respiratory failure and aspiration pneumonia, the discharge orders specified a Level 5 minced and moist diet. Despite this, the resident continued to receive a regular diet, which was not suitable given their condition and increased risk of aspiration. Interviews with staff revealed that the dietary communication process was flawed, as the kitchen staff did not receive the updated diet orders, and the meal tickets continued to reflect the incorrect diet. Observations and interviews with nursing and dietary staff highlighted a lack of communication and verification processes to ensure diet accuracy. Nursing assistants and nurses relied on meal tickets rather than care plans to verify diet orders, and there was confusion about who was responsible for notifying the kitchen of diet changes. The culinary director confirmed that the meal ticket system was not updated due to a lack of communication from nursing staff, resulting in the resident receiving the wrong diet for several days.
Removal Plan
- Reviewed and revised policies and procedures related to serving resident meals and ensuring residents receive correct textured meals.
- Educated to procedures as appropriate.
- Educated all nursing staff to utilize diet communication form and give to kitchen staff and on updating the care plan for diet orders.
- Educated dietary and all staff who serve resident food to recognize each specific diet type/textured meal.
- Educated dietary staff related to the importance of ensuring the meal ticket is updated.
- Educated all staff who serve resident food items on the importance of checking the diet slip, ensure the resident is getting the correct textured food, and then delivering the correct diet order to the resident.
- Developed and implemented a plan to complete all training before each staff worked their next shift.
Failure to Monitor and Document Bruises
Penalty
Summary
The facility failed to adequately assess and monitor non-pressure related skin injuries, specifically bruises, for a resident identified as R1. Upon admission, R1 was noted to have a hematoma on the forehead and bruising on the upper extremities and abdomen, but the skin assessment lacked details such as bruising color, characteristics, measurements, and pain. Despite R1's intact cognition and medical conditions including diabetes, obesity, and peripheral vascular disease, the care plan did not address the risk of bleeding or bruising, nor did it include interventions to protect R1's skin from further injury. R1 was hospitalized and upon readmission, the bruises were still not properly assessed or documented. The readmission screener and subsequent weekly skin checks continued to lack comprehensive details about the bruises. Furthermore, R1's medication administration record showed that aspirin was administered despite a directive to hold it due to a gastrointestinal bleed, which could have contributed to the bruising. The facility's staff, including nursing assistants and LPNs, failed to document and investigate the bruises adequately, and there was no daily monitoring of the bruises as expected. Interviews with staff revealed a lack of clarity and consistency in the facility's procedures for assessing and documenting bruises. The facility did not have a specific policy for non-pressure skin care, and staff were unsure about when to measure bruises or how to document them properly. The director of nursing and regional nurse manager acknowledged the gaps in the facility's approach to monitoring and documenting bruises, which contributed to the deficiency in providing appropriate care for R1.
Failure to Monitor and Report Surgical Wound Changes
Penalty
Summary
The facility failed to properly assess, monitor, and communicate changes in a surgical wound for a resident who had undergone a right below-knee amputation. The resident, who was admitted with a history of orthopedic aftercare following surgical amputation and type 2 diabetes mellitus, experienced a fall that resulted in the dehiscence of her surgical wound. Despite the presence of bleeding and the resident's report of the incident, the facility did not conduct a comprehensive assessment of the wound or notify the physician, leading to a delay in necessary surgical intervention. The resident's care plan included interventions to monitor and document the status of her surgical wound weekly, but these were not adequately followed. After the fall, the incident report and subsequent assessments failed to document the condition of the wound accurately. The resident's medical records did not reflect a thorough evaluation of the injury, and the surgical team was not informed of the fall and the resulting wound complications. This lack of communication and documentation contributed to the resident's wound dehiscence going unnoticed until a follow-up appointment with a physician, who then arranged for the necessary surgical revision. Interviews with facility staff revealed that there was an awareness of the bleeding from the wound, but the response was insufficient. The staff did not implement a protocol for ongoing monitoring or notify the surgical team, which was a critical oversight. The facility's policies on post-fall monitoring and wound care management were not adhered to, resulting in the resident's prolonged healing process and emotional distress. The deficiency highlights a significant lapse in the facility's duty to provide appropriate care and communication regarding the resident's surgical wound condition.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the experiences of three residents who required assistance with activities of daily living (ADLs). Resident R2, who had diagnoses including hemiplegia following a stroke and required maximal assistance with transfers and bed mobility, reported being handled roughly by a nursing assistant (NA-B). R2 described an incident where the NA changed his sheets without asking, causing him to feel like he was going to fall out of bed, and noted that the NA sometimes hit his legs and spoke to him disrespectfully. Resident R3, who had undergone knee joint prosthesis surgery and was dependent on staff for toileting hygiene, reported that NA-B placed a bedpan incorrectly, leading to an episode of incontinence. R3 stated that the NA responded with frustration and left her to sleep on a soaker pad instead of changing her. R3 also recounted instances where the NA made derogatory comments about her incontinence, making her feel harassed and disrespected. Resident R4, who had a fractured lower back and required assistance with toileting, reported that NA-B responded to her call light with a gruff attitude and made comments about her frequent need to use the restroom. R4 felt that the NA's behavior was dismissive and made her feel like a burden. Interviews with other staff members, including a trained medication aide and another nursing assistant, confirmed that such behavior would make residents feel neglected and disrespected, violating their right to dignity and respect.
Failure to Notify Physicians of Critical Incidents
Penalty
Summary
The facility failed to notify the physician of an injury after a fall for a resident who fell from a wheelchair, landing on a freshly healed below-knee amputation site, causing bleeding and dehiscence. The resident, who had been admitted to the facility with a recent surgical amputation, experienced a fall on 7/9/24. Despite the bleeding and pain reported by the resident, the licensed practical nurse (LPN) only faxed an SBAR report to the primary provider, MD-C, and did not receive a response. The surgical or physical medicine and rehabilitation teams were not notified, which led to a delay in addressing the wound dehiscence. The resident was later admitted to the hospital for revision surgery after the wound was discovered to be open during a follow-up clinic visit. In another incident, the facility failed to notify the physician of the inability to procure and administer an emergent medication for a resident with elevated potassium levels. The resident, who had a history of type 1 diabetes, kidney transplants, and hyperkalemia, was ordered to receive Lokelma to manage high potassium levels. However, the medication was not administered as it was not available, and the facility did not inform the physician of this issue. The resident's potassium levels remained elevated, leading to an emergency room visit for treatment. The lack of communication and failure to obtain the necessary medication in a timely manner contributed to the resident's condition requiring emergency intervention. Interviews with staff revealed a lack of understanding and communication regarding the urgency of the situations. The LPN involved in the fall incident assumed no further action was needed when no response was received from the faxed SBAR report. Similarly, the staff involved in the medication incident did not recognize the importance of the ordered medication and failed to notify the director of nursing (DON) or the physician about the unavailability of Lokelma. These deficiencies highlight significant communication gaps and procedural failures in the facility's handling of critical resident care situations.
Privacy Breach Due to Improper Camera Placement
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident, identified as R2, by having a video monitoring device that captured footage inside the resident's room without their knowledge or consent. R2, who was admitted with diagnoses including hemiplegia following a cerebral infarction, required maximal assistance with personal hygiene and transfers. The facility's electronic health record did not contain a consent form for video surveillance in R2's room. During a review of video footage, it was confirmed that the camera captured R2 in a state of undress while receiving care from a nursing assistant, which was visible from the mid-torso up. The facility administrator acknowledged that the camera, named North Medroom Camera, was positioned in such a way that it could view inside R2's room when the door was open. The administrator was unaware of this issue prior to the survey and confirmed that the camera's view did not protect R2's privacy. The administrator and the environmental services director had access to the footage, which was not displayed on any monitors within the facility. The environmental services director, who installed the cameras, stated that they were intended for monitoring common areas and not resident rooms, as this would violate privacy regulations. Interviews with the social services director and R2 revealed that the resident was informed about the footage and did not express significant concern or distress. The facility's policy on video surveillance explicitly stated that cameras should not allow for viewing inside resident rooms. Despite this policy, the camera's placement allowed for a breach of privacy, as it captured footage of R2 without consent. The facility's failure to adhere to its own policy and ensure the privacy of its residents resulted in this deficiency.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide routine grooming and personal hygiene care, specifically nail care, for a resident who was dependent on staff for such care. The resident, who had intact cognition and required maximal assistance due to conditions including diabetes mellitus and hemiplegia following a stroke, was observed with long fingernails and a brown substance underneath them. Despite the care plan indicating that nail care should be checked and performed on bath days, there was no evidence in the resident's task charting or electronic health record that nail care was offered or completed. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Nursing Assistant (NA), confirmed that the resident needed assistance with hygiene and nail care, particularly because of his diabetes and hemiparesis. The Director of Nursing (DON) acknowledged that nail care should be performed by aides during baths and by nurses for diabetic residents, but there was no documentation of when the resident's nails were last cut. The facility's policy on Activities of Daily Living (ADLs) emphasized the importance of providing care based on the resident's individualized plan and preferences, which was not adhered to in this case.
Failure to Administer Critical Medications and Report Errors
Penalty
Summary
The facility failed to provide and administer medications and lacked a system to identify, record, and report omitted medications as medication errors for three residents. Resident 1, who had a history of type 1 diabetes, kidney transplants, and hyperkalemia, was not administered the prescribed medication Lokelma to lower critically high potassium levels. The medication was not available at the scheduled times, and there was no indication that the pharmacy was contacted or that the physician was notified of the missed doses. Consequently, Resident 1 was sent to the emergency department with elevated potassium levels. Resident 2, diagnosed with hemiplegia, depression, and diarrhea, did not receive the prescribed medication Saccharomyces boulardii for diarrhea from July 1 to July 15, 2024, due to the medication not being available from the pharmacy. There was no documentation of physician notification or a plan to administer the medication, nor was there monitoring for symptoms resulting from the medication not being administered. The facility's medication error reports did not recognize these missed doses as medication errors. Resident 3, who had undergone knee joint prosthesis surgery and suffered from chronic pain, did not receive the prescribed pain medication Pregabalin on two occasions due to the medication not being available at the facility. The facility's emergency medication procedure was not followed, and the pharmacy was not contacted to request the medication STAT. The facility's medication error reports did not identify these missed doses as medication errors, and there was no appropriate follow-up to the errors completed per policy.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care. For the first resident, who had a complex medical history including type 1 diabetes, kidney transplants, and critically high potassium levels, the facility did not document a critical lab value in the electronic health record. The medication Lokelma, prescribed to manage the resident's potassium levels, was not administered as ordered due to a lack of awareness and access to necessary information by the nursing staff. The medication was not available at the scheduled time, and the critical nature of the medication was not communicated effectively among the staff, resulting in the resident being sent to the emergency department for further treatment. The second resident, who had type two diabetes with a foot ulcer and peripheral vascular disease, was transferred to the hospital due to exacerbation of necrosis and pain in the toes. However, the facility failed to document the transfer appropriately in the resident's medical record. There were no progress notes from the time of the transfer, and the record did not include necessary details such as the reason for the transfer, the resident's condition at the time, or notifications made to relevant parties. The lack of documentation did not align with the facility's policy on acute care transfers, which requires detailed records of such events. Interviews with facility staff revealed gaps in communication and documentation processes. Licensed practical nurses reported not having access to lab results or understanding the critical nature of certain medications. The director of nursing acknowledged the absence of required documentation in the second resident's record and expressed expectations for timely and comprehensive progress notes. These deficiencies highlight a failure to adhere to professional standards for maintaining medical records, impacting the quality of care provided to the residents.
Violation of Resident Privacy During Skin Assessment
Penalty
Summary
The facility failed to protect a resident's right to privacy during a routine skin observation, which led to a resident feeling their personal privacy was violated. The incident involved a resident, identified as R2, who was admitted to the facility and had an unplanned discharge to home. During a physical therapy session, an LPN entered the room and conducted a skin check on R2's back and buttocks without asking for permission, exposing R2's bare skin in the presence of a male physical therapist. This action caused R2 to feel embarrassed and violated, as she was not expecting such an examination in front of the therapist. R2's care plan indicated she had potential psychosocial well-being issues related to her recent hospitalization and admission to the skilled nursing facility, including depression, anxiety, and loss of independence. Interviews with R2, the physical therapist, and LPN-A confirmed the sequence of events, with R2 expressing that the experience was shocking and led her to move to a different facility. The facility's policy on resident rights and dignity emphasized the importance of treating residents with respect and ensuring their privacy, which was not upheld in this instance.
Failure to Provide Supplemental Oxygen for Discharged Resident
Penalty
Summary
The facility failed to safely discharge a resident who required supplemental oxygen and a Bi-level Positive Airway Pressure (Bi-PAP) machine for obstructive sleep apnea. The resident, who was cognitively intact and had diagnoses including heart failure, end-stage renal disease, diabetes, obstructive sleep apnea, and morbid obesity, was discharged to a hotel without a plan to obtain the necessary supplemental oxygen. The discharge summary did not list any equipment needed, despite the resident's physician order indicating the need for Bi-PAP with oxygen supplementation for lifetime use. The facility's social service progress note indicated that the resident decided to discharge to a hotel to avoid private pay costs, but it lacked any mention of a referral for oxygen durable medical equipment (DME). The Director of Nursing (DON) confirmed that the resident was discharged with medications and Bi-PAP supplies but without secured oxygen delivery. The facility's policy requires sufficient preparation and orientation for safe discharge, which was not met in this case, as the resident had to independently arrange for oxygen the day after discharge.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 156 citations issued within 25 miles in the last 12 months — including the 3 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
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Rochester West | 0.3 mi | ★★★★★ | 26 | 1 |
| Madonna Towers Of Rochester | 1.4 mi | ★★★★★ | 4 | 0 |
| Samaritan Bethany Home On Eighth | 1.7 mi | ★★★★★ | 8 | 0 |
| Charter House Inc | 1.8 mi | ★★★★★ | 4 | 0 |
| Rochester Rehabilitation And Living Center | 2.6 mi | ★★★★★ | 7 | 1 |
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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.