Above 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 Madonna Towers Of Rochester during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter was on EBP, with orders and care plan directions for catheter care and high-contact care using gloves and gowns. During observation, an NA wore gloves but did not don a gown while assisting with transfers, adjusting the resident’s legs and linens, and handling the catheter bag. The IP and DON confirmed gowns and gloves were required for direct contact and high-contact care for residents with foley catheters.
Surveyors found that food items in the kitchen refrigerators, such as mushrooms, celery, lettuce, and carrots, were either expired or undated and had not been discarded as required. Staff interviews confirmed that the facility's practice is to label and date opened food and discard it after one week, but this was not consistently followed.
A resident with a history of heart failure and lymphedema experienced ongoing significant swelling in the left upper extremity, but staff failed to consistently assess and document the edema as required by the care plan and facility policy. Despite visible symptoms and staff awareness of the chronic condition, weekly skin checks and medical records did not reflect the resident's edema, preventing evaluation of intervention effectiveness.
Three residents who had previously received PCV13 and PPSV23 were not offered the PCV20 vaccine as recommended by CDC guidelines, and there was no documentation of shared clinical decision-making regarding its administration. Facility records showed missing or incomplete immunization documentation, and staff confirmed that PCV20 had not been offered, despite facility policy requiring adherence to CDC recommendations.
Required nurse staffing information was not updated daily and did not include the facility name, as observed in the main lobby. Staff interviews revealed uncertainty about who was responsible for updating the posting during the staffing coordinator's absence, and it was confirmed that the omission of the facility name had persisted for several months.
The facility failed to respect the toileting preferences of two residents, both cognitively intact and dependent on mechanical lifts for transfers. One resident expressed dissatisfaction with being forced to use a bedpan instead of the toilet, while the other reported discomfort after the ceiling lift used for toileting became unavailable. Staff interviews confirmed that residents' preferences should be honored and reflected in care plans, but this was not done, leading to a deficiency in promoting resident self-determination.
A facility failed to create a comprehensive care plan for a resident with an indwelling urinary catheter and bowel incontinence. Despite the resident's ability to manage bowel movements at home, the care plan lacked specific interventions for catheter care and a toileting schedule. Interviews revealed that the facility did not discuss catheter risks or bowel patterns with the resident, and the DON confirmed the care plan's deficiencies.
A facility failed to reassess the need for an indwelling catheter for a resident who was previously continent, resulting in discomfort and pain. The care plan lacked justification for the catheter and did not include interventions for infection monitoring. Additionally, the facility did not provide services to maintain bowel continence, as the resident preferred using the toilet over a bed pan, but this preference was not consistently honored. The care plan did not reflect the resident's toileting preferences, and there was no assessment of bowel patterns to establish a toileting schedule.
A resident with cognitive impairment and a history of wandering eloped from the facility due to a failure in the alarm system. The door alarm did not sound because it was not reset after a previous incident, and the resident's wander guard was non-functional. Staff were not trained to reset the alarm, leading to the resident's unsupervised exit and subsequent return by police.
The facility failed to conduct regular inspections of bed frames, mattresses, and bedrails, potentially affecting 50 residents. Despite manufacturer guidelines for monthly inspections, the director of maintenance stated beds are inspected yearly, and only one bed is checked. Staff interviews revealed inconsistencies in inspection practices, with the director of nursing not considering the rails as bedrails. This led to a deficiency in ensuring bedrail safety and preventing possible entrapment.
The facility failed to attempt alternative devices before using bedrails for seven residents, who had varying degrees of cognitive impairment and required significant assistance with mobility. The facility did not accurately assess the risk of entrapment or provide ongoing assessments to ensure the bedrail use met the residents' needs.
Failure to Use Required PPE During High-Contact Care
Penalty
Summary
The facility failed to ensure proper PPE was used during high-contact care for a resident with an indwelling urinary catheter who was on enhanced barrier precautions. The resident was cognitively intact, required partial assistance with ADLs, and had diagnoses including neuromuscular dysfunction of the bladder, unsteadiness on feet, muscle weakness, arthritis of the knee, and a history of falling. The resident’s care plan required catheter care per facility protocol, extensive assistance from one staff member for transfers, bed mobility, and ADLs, and enhanced barrier precautions with gloves and gowns for high-contact care activities. During observation, a nursing assistant entered the resident’s room and applied gloves, but did not don a gown before providing care that included removing the catheter bag from the dignity bag, placing it on a towel under the bed, lifting the resident’s legs onto the bed, placing a pillow under the resident’s legs, and covering the resident with a sheet. The nursing assistant then removed gloves and performed hand hygiene. The infection preventionist and DON confirmed that residents with indwelling catheters require enhanced barrier precautions and that staff are expected to wear gowns and gloves during personal contact, transfers, toileting, and care involving the indwelling medical device. The facility policy also identified gowns and gloves as required PPE for high-contact resident care activities.
Failure to Properly Label, Date, and Discard Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items stored in the kitchen refrigerators. During a kitchen tour, several food items, including mushrooms, celery, lettuce, and carrots, were found either expired or undated, with some showing signs of spoilage such as browning and softness. Interviews with the dietary manager, culinary director, and a cook confirmed that the facility's practice is to label opened food with the date and discard it after one week, with the evening shift responsible for removing expired or undated items. However, the observed items had not been discarded as required, contrary to the facility's stated policy and procedures for food storage.
Failure to Monitor and Document Edema Management
Penalty
Summary
The facility failed to comprehensively monitor and assess a resident with a history of heart failure and lymphedema for edema, which prevented the determination of intervention effectiveness and the development of new interventions as needed. The resident's care plan required staff to monitor for adverse reactions to diuretics, apply and assess edema wraps and compression devices, and document skin assessments. However, weekly skin checks over a two-month period consistently indicated no edema, and the medical record lacked further assessment of the resident's left upper extremity edema during this time. Observations and interviews revealed that the resident continued to experience significant swelling in the left upper extremity, with visible puffiness and limited hand movement. Nursing staff acknowledged the chronic nature of the resident's edema but were unable to identify where this was documented in the records. One nurse noted that the edema had persisted at its current level for almost a month without documentation, and another stated that documentation of the edema was expected but not present. The facility's policy required assessments to be documented in the electronic health record, but this was not done for the resident's ongoing edema.
Failure to Offer and Document PCV20 Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three out of five residents reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV)20 as recommended by the Centers for Disease Control (CDC). Documentation revealed that these residents had previously received PCV13 and PPSV23 vaccines, but there was no evidence that PCV20 was offered or that a shared clinical decision-making process occurred between the provider and the resident or their responsible agent regarding the administration of PCV20. The facility's own immunization review forms indicated that pneumococcal vaccinations were not up to date for some residents, and the vaccines were not offered as required. For each of the three residents, medical records and immunization reports confirmed the absence of documentation related to the offer or administration of PCV20. Consent or refusal forms for pneumonia immunizations were present in some cases, but the dates of vaccination were left blank, and there was no record of shared decision-making discussions. The regional nurse consultant and the infection preventionist both confirmed during interviews that PCV20 vaccinations had not been offered to residents, and that documentation of shared decision-making was lacking. The facility's policy on pneumococcal vaccines stated that education and administration of vaccines should be provided according to CDC recommendations, including the use of PCV15 or PCV20 for adults 65 years or older. However, the policy was not followed in practice, as evidenced by the lack of offers and documentation for PCV20 vaccination for the residents in question.
Failure to Post Daily Nurse Staffing Information with Facility Name
Penalty
Summary
The facility failed to ensure that required nurse staffing information was posted daily and that the posting included the facility name, as mandated by policy. On observation, the staffing information displayed in the main lobby was found to be outdated by two days and lacked the facility name. Interviews with the administrator, health unit coordinator, and staffing coordinator revealed confusion regarding responsibility for updating the posting during the staffing coordinator's paid time off. The staffing coordinator also confirmed that the omission of the facility name on the posting had been ongoing since September 2024 and had not been noticed or addressed. The facility's policy required daily posting of nurse staffing information at the beginning of each shift, including the facility name, but this was not followed.
Failure to Honor Resident Choice in Toileting
Penalty
Summary
The facility failed to honor the residents' right to self-determination and choice regarding toileting preferences for two residents. Resident 1, who was cognitively intact and dependent on a mechanical lift for transfers, expressed dissatisfaction with being forced to use a bedpan instead of being assisted to the toilet, which she preferred. She reported feeling a loss of control over her daily activities, including toileting. Her family member also emphasized the importance of dignity in allowing her to use the toilet. Similarly, Resident 2, who was also cognitively intact and required assistance for toileting, reported that the staff had previously used a ceiling lift to help her use the toilet. However, since the lift became unavailable, she was only offered a bedpan, which made her feel uncomfortable. Interviews with facility staff, including the regional director registered nurse and the director of nursing, confirmed that residents' preferences for toileting should be respected and reflected in their care plans. The facility's policy on Activities of Daily Living also supports interventions that align with residents' assessed needs and preferences. Despite this, the facility did not provide the necessary support to allow these residents to use the toilet, as per their requests, leading to a deficiency in promoting and facilitating resident self-determination and choice.
Failure to Develop Comprehensive Care Plan for Catheter and Bowel Management
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter and bowel incontinence. The resident, who was cognitively intact, had a history of diabetes mellitus, a stress fracture of the left tibia, and chronic kidney disease. Despite the resident's admission Minimum Data Set (MDS) indicating the presence of an indwelling urinary catheter and frequent bowel incontinence, the care plan did not include specific interventions for catheter care or a toileting plan for bowel continence. The nursing assistant care guide acknowledged the presence of a catheter but lacked detailed instructions for its care or a toileting schedule. Interviews with the resident and their family member revealed that the resident was able to manage bowel movements independently at home and did not experience incontinence. However, the facility did not discuss the risks associated with the catheter or inquire about the resident's bowel patterns prior to admission. The Director of Nursing confirmed that the comprehensive care plan did not address necessary interventions for catheter care or bowel continence management, which was contrary to the facility's policy on comprehensive assessment and care planning.
Failure to Reassess Catheter Use and Maintain Bowel Continence
Penalty
Summary
The facility failed to comprehensively reassess and justify the continued use of an indwelling catheter for a resident who was previously continent of bowel and bladder. The resident, who had a history of incontinence and reduced mobility due to a fracture, was noted to have an indwelling catheter for skin care management. However, the care plan did not indicate a medical necessity for the catheter, nor were there interventions to monitor for signs and symptoms of infection. The resident experienced discomfort and pain related to the catheter, and there was no documentation of education provided to the resident about the risks and benefits of catheter use. Additionally, the facility did not provide services to maintain bowel continence for the resident, who was previously continent before hospitalization. The care plan lacked person-centered interventions and did not include a toileting plan to maintain bowel continence. The resident expressed difficulty in having bowel movements using a bed pan and preferred to use the toilet, but staff did not consistently honor this preference. The resident's care plan did not reflect her preference for toileting, and there was no assessment of her bowel patterns to determine a toileting schedule. Interviews with staff and family members revealed that the resident's requests to use the toilet were not consistently met, and the facility's policy on bowel assessment was not provided. The facility's failure to reassess the need for the catheter and to provide appropriate bowel continence care resulted in discomfort and unmet care needs for the resident.
Resident Elopement Due to Alarm System Failure
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, resulting in an immediate jeopardy situation. The resident, who had a history of wandering and was cognitively impaired, was able to leave the facility through a fire door without staff knowledge. The incident occurred when the door alarm did not sound, and the resident was found approximately two blocks away by police and returned to the facility. The resident's care plan included a wander guard system, but it was not functioning at the time of the elopement. The deficiency was attributed to the failure to reset the door alarm after the resident had previously triggered it earlier in the day. Staff were unaware that the alarm needed to be reset for it to function properly, leading to the resident's unsupervised exit. Interviews with staff revealed that the maintenance department was not notified to reset the alarm, and nursing assistants were not trained to do so. The resident's wander guard was also found to be non-functional, contributing to the lack of alert when the resident left the facility. The facility's policy on elopement was not effectively implemented, as staff were not adequately trained on the procedures to ensure resident safety. The resident's cognitive impairment and history of wandering behavior were not sufficiently addressed, leading to the elopement incident. The lack of proper alarm system functionality and staff training were key factors in the deficiency, resulting in the resident's temporary absence from the facility.
Removal Plan
- All staff were educated on how to reset all the doors at the facility
- The door alarm company checked all the tags for all the doors
- Equipment was added that allowed the staff to see any door that an alarm had gone off on the televisions
- The facility updated their camera system post motion on the video from the default of 3 seconds to 10 seconds
Inadequate Bedrail Inspection Practices
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bedrails as part of their maintenance program, which could potentially affect 50 residents. The bed manufacturer guidelines require monthly visual inspections for broken welds, cracks, and loose hardware, but the facility did not adhere to this schedule. Instead, the director of maintenance stated that beds are inspected yearly, and only one bed is checked because all beds and bedrails are the same. This discrepancy in inspection frequency and the lack of comprehensive checks for all beds led to a deficiency in ensuring the safety of bedrails and preventing possible entrapment. Interviews with facility staff revealed a lack of clarity and consistency in the inspection process. The regional nurse believed inspections were conducted quarterly, while the nursing department did not inspect bedrails and relied on maintenance to address any concerns. The director of nursing did not consider the rails to be bedrails, viewing them as grab bars, which contributed to the oversight. The facility's policy indicated that siderails and mattresses should be checked for entrapment concerns annually, but this was not aligned with the manufacturer's monthly inspection requirement, leading to a potential risk for residents.
Failure to Attempt Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to attempt alternative devices before using bedrails on residents' beds, affecting seven residents. The facility did not accurately assess the residents for the risk of entrapment by considering their medical diagnoses, size and weight, cognition, communication, mobility, and risk of falling. Additionally, the facility did not provide ongoing assessments to ensure the bedrail use met the residents' needs. This deficiency was identified through observations, interviews, and record reviews. For Resident 1, the facility's documentation indicated the use of side rails, but no alternative devices were attempted. Interviews with staff and family members revealed that Resident 1 was dependent on staff for bed mobility and did not use the bedrails independently. Similarly, Resident 2's records showed the use of siderails and grab bars without any alternative devices being tried. The resident was cognitively impaired and had a history of wandering, yet there was no documentation of attempts to use other methods. Other residents, such as Residents 3, 4, 5, 6, and 7, also had bedrails or grab bars in use without documented attempts of alternative devices. These residents had varying degrees of cognitive impairment and required significant assistance with mobility. Interviews with nursing staff confirmed that alternative devices were not attempted, and there was a lack of consistent assessments to determine the appropriateness and safety of the bedrails for these residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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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) |
|---|---|---|---|---|
| Edenbrook Rochester West | 1.1 mi | ★★★★★ | 26 | 1 |
| Rochester Rehabilitation And Living Center | 1.2 mi | ★★★★★ | 7 | 1 |
| Edenbrook Of Rochester | 1.4 mi | ★★★★★ | 16 | 0 |
| Samaritan Bethany Home On Eighth | 2.7 mi | ★★★★★ | 8 | 0 |
| Charter House Inc | 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.