Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Rochester Restorative Care Center during CMS and state inspections, most recent first.
The facility failed to consistently follow dysphagia-related diet orders and aspiration precautions for two residents, including ensuring correct mechanical soft textures, nectar/mildly thick liquids, supervision during meals, and safe positioning. One resident with a stroke and significant cognitive deficits frequently ate unsupervised in bed despite orders and SLP recommendations for supervision and out-of-bed meals, and was later hospitalized with pneumonitis due to inhalation of food and vomit after a suspected aspiration event. After returning, this resident continued to receive incorrect diet textures and liquid consistencies, with tray tickets, Kardex entries, and dietary production reports not matching physician orders. Another resident on a pureed diet with nectar thick liquids was observed drinking thin hot milk, developed repeated coughing and thick phlegm, and did not receive an immediate respiratory assessment, while hospice was not informed of the incident. Staff interviews and observations showed systemic inconsistencies and confusion between diet orders, Kardex information, and tray tickets, and a lack of reliable processes to ensure appropriate supervision and accurate diet implementation for residents at risk of aspiration.
Improper Food Storage and Labeling in Kitchen: Food in the kitchen refrigerator and freezer was found improperly stored and labeled. A cook was observed with expired sliced ham, undated lettuce that was browning and wilting, a box of food on the freezer floor, and another box touching the freezer fan blade.
Meals were served on plastic trays and left in front of residents in 2 dining rooms, including during lunch, dinner, and breakfast observations. An LPN and a CNA said residents had always been served this way, while residents stated the setup was not home-like and felt like a juvenile setting; one resident also said hot foods were placed next to cold foods on the tray.
A facility failed to safely manage EZ stand transfers and failed to identify fall risk for a resident with repeated falls. Several residents with severe cognitive and mobility impairments were transferred to the toilet with an EZ stand and left attached to the lift while staff left the room, despite the lift manual directing staff to unhook the sling after positioning the resident. In another case, a resident admitted with Parkinson's, weakness, and a new colostomy had no completed fall assessment, no resident-specific fall care plan, and no Kardex, and fell twice within less than 12 hours while trying to reach the urinal and bathroom.
Failure to Dispose of Discontinued, Expired, and Discharged Residents’ Medications: Surveyors found medication cards from discharged residents, discontinued orders, and expired OTC medications left in medication storage areas on multiple floors. An RN, LPN, and another RN each stated they were unsure of the medication destruction process, while the DON described a two-nurse destruction process and the facility pharmacist said he was unfamiliar with the current process.
Failure to assess self-administration of nystatin powder: A resident with DM, ESRD, HF, and morbid obesity was cognitively intact and already self-managed some care, including blood sugar checks and some injections with supervision. However, the resident’s record lacked a SAM assessment for nystatin powder, and the care plan did not include it. The resident kept the powder locked in a bag on the bed, used a preferred bottle, and staff and the resident gave conflicting accounts about whether the resident self-administered it. An LPN and RN confirmed no SAM assessment had been completed for the medication, and the DON stated such assessments are required before a resident may self-administer medications.
A resident with diabetes, kidney disease, heart failure, and a history of refusing care repeatedly refused ordered Nystatin powder, but staff did not timely notify the provider of the ongoing refusals. Staff interviews showed the resident often would not allow the powder to be applied, and the NP stated she had not been informed of the repeated refusals. A second resident with chronic respiratory failure and an order for continuous oxygen was observed without oxygen in use multiple times, and the PCP stated the facility should have sent an SBAR and updated vital signs regarding the ongoing oxygen need.
Failure to complete baseline care plan within 48 hours of admission. A resident with a new colostomy, Parkinson’s, urinary retention, and generalized muscle weakness was admitted needing transfer and ADL assistance, but the EHR showed no baseline care plan initiated within the required timeframe. The PA and DON stated the baseline care plan was expected early in admission to guide basic care, but the nurse had not reviewed the orders or entered the plan.
Care plan not updated after smoking assessment. A resident with CHF, COPD, and osteoarthritis had a smoking assessment showing safe independent smoking and no need for a smoking apron, but the care plan, MAR/TAR, and task list were not updated to match. During observation, the resident retrieved smoking materials from the room and went to the designated smoking area without a smoking apron, and staff were unsure where the smoking information was documented.
Failure to obtain orders and document colostomy care: A resident with a new colostomy, Parkinson’s disease, urinary retention, and generalized muscle weakness had no specific colostomy care orders or care plan directions. Staff assisted with a colostomy bag change after the resident removed the bag, but the treatment was completed without a provider order, no order was requested afterward, and the care was not documented in the chart.
A resident with a new colostomy, Parkinson’s disease, urinary retention, and generalized muscle weakness did not have specific physician orders or a care plan for colostomy care. Staff observed the colostomy bag visible outside the resident’s clothing, and the resident later removed the bag and discarded it in the room while waiting for assistance. The LPN and DON confirmed the admission orders and baseline care plan lacked needed colostomy care details such as appliance type, size, skin products, and change frequency.
Failure to provide ordered oxygen therapy for a resident with chronic respiratory failure and dependence on supplemental O2. The resident was observed multiple times without O2 in use, including while traveling on a scooter and searching for staff because the portable tank was empty. Staff were unsure whether the O2 order was continuous or PRN, and the DON stated she had never seen the resident with O2 in use.
Incomplete Dialysis Assessment Monitoring: A resident with ESRD-related diagnoses, HF, DM2, oxygen dependence, and chronic respiratory failure had ordered pre- and post-dialysis assessments, but the facility documented them only on a few dialysis days. The DON confirmed the forms were not sent consistently, RN-B could not produce the assessment sent with the resident, and the MD stated the facility was expected to complete the assessments and notify the dialysis center of any changes in weight and status.
A resident with CHF, COPD, and osteoarthritis had an order for melatonin 5 mg at bedtime for insomnia, but the MAR and progress notes showed no sleep tracking or monitoring. The RN stated sleep monitoring is usually done but was not in place for the resident, while the DON said sleep would not be tracked because melatonin is OTC. The facility policy defines hypnotics as psychotropic drugs used to induce sleep and treat insomnia.
Failure to use proper EBP PPE occurred during resident care for multiple residents with indwelling devices and dialysis-related needs. CNAs performed peri care and catheter-related care without gowns, and an LPN completed dressing and skin care for a resident on EBP for a dialysis catheter without donning a gown, despite signage indicating gown and glove use. Records showed the residents had PEG tube, suprapubic catheter, and dialysis catheter-related orders and care plans requiring EBP.
Nonfunctioning Shower Room Call Light: The facility failed to ensure a working call light was available in a 3rd floor shower room bathroom area used by seven residents for toileting with an EZ stand. Surveyors observed the call light switch without a cord, later found that the light would turn on but there was no audible alert to staff, and RN and maintenance staff verified the system was not working. The affected residents had severe cognitive and mobility impairments, with care plans directing 2-person assist and EZ stand or sit-to-stand lift transfers.
A facility failed to include the daily census and actual hours worked by nursing staff groups on the daily staffing data document. Observation and record review showed the staffing postings and daily schedule reports lacked this required information, and the scheduler and administrator acknowledged the omission after a template change.
A resident with COPD and asthma, who was oxygen dependent and had moderate cognitive impairment, was self-administering Ventolin and Dulera inhalers without a comprehensive assessment or a physician's order. Staff were aware of the resident's actions for at least two weeks, but no assessment was completed as required by facility policy.
The facility did not maintain accurate and complete medical records for two residents, resulting in discrepancies between physician orders, treatment records, and progress notes for oxygen therapy and antibiotic administration. Staff failed to consistently document changes in orders and care provided, and there was no clear process for integrating outside medical records into the facility's EHR.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not review or update its assessment to specify the minimum number of direct care and licensed staff needed to meet residents' needs, including staffing hours per resident day (PPD) and the division between licensed and direct care staff. Staffing decisions were made daily based on census and acuity, but the assessment lacked a formalized plan, potentially affecting all residents.
The facility failed to maintain a documented plan describing the process for conducting QAPI and QAA activities, as required. Surveyors found no evidence of a structured approach or written procedures for these quality initiatives.
The facility did not set up an ongoing quality assessment and assurance group, resulting in the lack of a formal process to review quality deficiencies and develop corrective plans of action.
The QAA group did not include all required members and failed to meet at least quarterly, as shown by facility records and documentation.
The facility did not allow a resident or the resident's legal representative to access or purchase copies of the resident's records, as required.
A resident was admitted without a plan being created or implemented to address their most immediate needs within 48 hours. The facility did not ensure that a comprehensive assessment and plan were completed in the required timeframe, resulting in the resident's immediate needs not being systematically addressed.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, including improper catheter care and insufficient measures to prevent UTIs.
Annual performance evaluations were not completed for four nursing assistants employed for over a year. Staff interviews indicated a lack of awareness about receiving reviews, and the DON confirmed that these evaluations had not been performed. Requested policies on performance reviews were also not provided.
The facility failed to ensure proper dishwashing sanitization and monitoring, as a dietary aide was observed using a dish machine with incorrect chemical levels. Additionally, expired food was found in a unit refrigerator meant for residents' personal food, despite policies requiring regular cleaning and labeling. The dietary manager and registered dietician confirmed the expectations for sanitization and food storage, which were not met.
The facility failed to ensure proper use of PPE for two residents on enhanced barrier precautions (EBP). A resident with a gastrostomy tube was administered medication without the nurse wearing a gown, and the necessary EBP signage was missing. Another resident with a pressure ulcer received care without the nurse donning a gown, despite EBP signage being present. These lapses indicate non-compliance with the facility's infection prevention protocols.
Two residents were found with medications in their rooms without proper assessment or authorization for self-administration. One resident had Voltaren gel without a physician's order or care plan for self-administration, while another had glucose tablets, aspirin, and iron without a self-administration order. The DON confirmed the lack of necessary orders and assessments, indicating non-compliance with facility policy.
The facility failed to notify resident representatives after two residents experienced falls and were transferred to the hospital. One resident, who was cognitively intact, was not able to have her emergency contact informed despite her request. Another resident with mild cognitive impairment had a similar issue, with the facility failing to make adequate attempts to contact the emergency contact. The facility's policy required immediate notification, but this was not followed, leading to dissatisfaction and concern from the residents' representatives.
A facility failed to complete a baseline care plan for a newly admitted resident requiring post-op orthopedic after-care. The resident's MDS assessment showed moderate impaired cognition and a need for ADL assistance. Neither the resident nor their family received a care plan, and the DON confirmed the required form was incomplete. The facility's policy lacked guidance on baseline care plan development.
A facility failed to develop a comprehensive care plan for a resident with urinary retention and an indwelling urinary catheter. The resident's care plan did not include necessary details about the urinary catheter, leg bag, or drainage bag, despite these being documented needs. The RN responsible for care plans acknowledged the oversight, and the DON confirmed the expectation for these elements to be included in the care plan.
A resident with a history of Alzheimer's and cardiovascular issues did not receive consistent application of prescribed compression wraps for edema management. Observations and interviews revealed that staff were often unaware of the requirement or unsure of their responsibilities, leading to missed applications and increased swelling. The Director of Nursing confirmed the need for daily application, but a policy on edema prevention and treatment was not provided.
Two residents at an LTC facility experienced multiple falls due to inadequate assessment and intervention. One resident, with a history of falls and Alzheimer's, had seven falls over three months, with inconsistent interventions and poor communication among staff. Another resident, admitted for rehabilitation, fell three times in a week, with incomplete incident reports and lack of root cause analysis. The facility's fall prevention policy was not effectively implemented, leading to missed opportunities to prevent future falls.
A resident with urinary retention and an indwelling catheter did not have their leg bag switched to a urinary drainage bag at night, contrary to the facility's catheter care policy. Observations and staff interviews confirmed the oversight, which could lead to urine backflow and potential infection. The facility's policy required the use of a drainage bag at night to ensure proper urine drainage.
The facility failed to maintain the second-floor tub/shower room in good repair and sanitary conditions, affecting 30 residents. Missing tiles exposed wood and plaster, creating an unsanitary environment. The corporate maintenance director and facility maintenance director were unaware of the issue, and a housekeeper could not recall reporting it. A maintenance policy was requested but not provided.
The facility failed to serve meals at a warm and palatable temperature, affecting residents' quality of life and nutritional intake. Observations showed meal trays left unattended, leading to food temperatures below safe levels. Residents reported dissatisfaction with cold meals, and staff acknowledged the issue, citing a broken plate warmer and insufficient staff as contributing factors.
The facility failed to maintain proper food temperatures, leading to resident complaints about cold meals. Observations showed that meal trays were distributed late, and nursing staff did not check temperatures before serving. Dietary management confirmed that recorded temperatures were unacceptable, with some hot foods below the required standards. The facility's policy required food to be served at safe and appetizing temperatures, but practices did not align with these standards.
A resident with chronic respiratory failure did not receive oxygen as per physician orders, leading to a significant drop in oxygen saturation and shortness of breath. The resident's oxygen was set incorrectly, and the nasal cannula was not properly placed. Staff interviews revealed a lack of understanding of oxygen delivery protocols, contributing to the deficiency.
Failure to Follow Dysphagia Diet Orders and Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor known aspiration precautions and prescribed diets for residents with dysphagia, including ensuring correct diet texture, liquid consistency, supervision during meals, and safe positioning. One resident with a history of stroke, dysphagia, and significant cognitive impairment was ordered a mechanical soft diet with mildly thick liquids and required supervision and aspiration precautions. Despite these orders and SLP recommendations for supervision and for the resident to be out of bed for meals, the resident frequently ate in bed, often unsupervised, and the care plan and Kardex did not fully reflect the need for aspiration precautions, supervision level, or specific positioning during meals. Staff reported that the resident often refused to get out of bed, and there was no consistent system to ensure that residents eating in their rooms were supervised or that safe swallowing strategies were followed. On one occasion, the resident was given a dinner tray in bed without staff remaining to assist or supervise. The resident subsequently appeared to choke while eating, with coughing and production of phlegm, and was sent to the hospital. Hospital records documented admission for pneumonitis due to inhalation of food and vomit after a suspected aspiration event while eating at the facility. Prior to and after this event, SLP documentation showed that the resident had thin liquids in the room at times despite an order for mildly thick liquids, and SLP staff had to educate nursing staff about the need to maintain the ordered liquid consistency and to keep the resident out of bed for meals. The resident’s care plan was not updated to include directives for being out of bed for meals or specific safe swallowing strategies, and staff interviews revealed inconsistent awareness of the need for supervision and appropriate positioning. The facility also failed to consistently provide the correct diet texture and liquid consistency after the hospitalization. Observations showed that the resident received regular broccoli instead of chopped broccoli despite being on a dysphagia mechanical soft diet, and the incorrect food remained on the plate long enough for the resident to eat some of it before it was removed. On another day, the resident was served pureed food and honey-thick liquids when the order called for mechanical soft solids and nectar/mildly thick liquids; dietary and nursing staff confirmed that the meal and liquids did not match the physician’s orders. Dietary staff and the dietary manager reported problems with the tray ticket system, including tray tickets not matching diet orders and confusion about how mechanical soft, ground, chopped, and pureed textures were represented and printed. Nursing assistants and other staff relied on Kardexes and tray tickets that did not always reflect current diet orders, and there was no clear, consistently used assessment or process to determine which residents required supervision during meals. A second resident with dementia and dysphagia, on a pureed diet with nectar thick liquids, was observed drinking thin hot milk despite a diet slip indicating nectar thick liquids. The resident began coughing repeatedly and spitting out the liquid, with ongoing coughing and production of thick white phlegm. Staff identified that the liquid in the cup was regular thin milk and removed it to thicken, but the nurse did not perform a respiratory assessment at the time. The resident’s hospice case manager later confirmed that hospice had not been notified of this coughing/aspiration concern. Staff interviews showed that some were unsure of residents’ diet consistencies without checking multiple sources, and that there was inconsistency between diet orders, Kardex entries, and tray tickets regarding thickened liquids. Overall, the facility did not ensure that menus and meal service met residents’ prescribed nutritional and texture needs, that diet orders were accurately communicated and followed by nursing and dietary staff, or that residents with dysphagia received appropriate supervision and monitoring during meals.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Food stored in the refrigerator and freezer was not maintained in accordance with professional standards. During the initial kitchen tour, the cook was observed with sliced ham in the refrigerator that had expired on 3/2/26 and lettuce that had no date and was browning and wilting. In the freezer, a box of food was sitting directly on the freezer floor, and another box was touching the freezer fan blade. On follow-up, the district manager stated the expired ham and undated lettuce had been discarded, confirmed the box on the freezer floor had been placed on a shelf, and confirmed the box touching the fan blade had been moved away from it. The district manager also stated undated items should be thrown out immediately and foods in the refrigerator longer than 3 days should be thrown out.
Meals Served on Plastic Trays in Dining Rooms
Penalty
Summary
The facility failed to provide a home-like dining experience in 2 dining rooms when meals were served on plastic food trays and left in front of residents. During observations in the 3rd floor dining room on 3/9/26, 3/10/26, and 3/11/26, lunch and breakfast trays were brought up in a cart, staff passed out the trays, and food items were left on the plastic trays in front of residents. During an observation in the 2nd floor dining room on 3/9/26, dinner trays were also brought up in a cart and left on plastic trays in front of residents. During interviews, an LPN and a CNA stated the residents had always been served their food on trays and placed in front of them. One resident stated he would like meals served on time and not on trays, and said it was not home. Another resident stated the dining experience felt like being in school in a juvenile setting when food was set in front of residents on trays during mealtime, and added that staff placed hot foods next to cold foods on the tray. A policy titled "Serving a Meal" stated to serve nutritional meals that met residents' needs and to arrange dishes and silverware so residents could reach them easily, and noted it was often helpful to take dishes off the tray.
Unsafe Mechanical Lift Transfers and Incomplete Fall Assessment
Penalty
Summary
The facility failed to comprehensively assess and safely manage transfers with a mechanical lift and failed to ensure supervision during those transfers for 7 residents reviewed for accidents. Residents R6, R36, R2, R8, R51, R60, and R62 each had assessments and care plans identifying significant cognitive impairment, mobility limitations, and transfer needs that included assistance of two staff and use of an EZ stand or sit-to-stand lift. Their care plans also identified fall risk related to dementia, impaired mobility, weakness, poor safety awareness, medications, or prior falls. During observation, R6 was transferred to the toilet with an EZ stand by two nursing assistants and then left attached to the lift while staff left the room. When staff returned several minutes later, there was a large amount of urine on the floor, the EZ stand, and R6. For R2, staff again used the EZ stand in the shower room, left the resident hooked to the lift on the toilet, and one staff member left the room briefly to find assistance. Interviews with NA, RN, PTA, and DON showed that staff commonly left residents connected to the EZ stand while on the toilet, although the lift manual instructed staff to unhook the sling from the lift after positioning the patient on the commode and before removing the sling. The facility also failed to identify fall risk and develop resident-specific fall interventions for R77, who was admitted with intact cognition, Parkinson's, urinary retention, generalized muscle weakness, and a new colostomy. The baseline care plan contained only socialization and activity information and did not include fall risk or fall interventions, and the EMR lacked a fall assessment. R77 fell twice within less than 12 hours, once while reaching for a urinal and once while trying to get to the bathroom. Staff interviews confirmed that R77 did not have a completed Kardex or resident-specific fall care plan, and the DON stated the baseline care plan should have included fall risk information and interventions such as keeping the bed low, using appropriate footwear, and keeping commonly used items within reach.
Failure to Dispose of Discontinued, Expired, and Discharged Residents’ Medications
Penalty
Summary
The facility failed to dispose of discontinued, expired, and discharged residents’ medications in the medication storage areas on the 1st, 2nd, and 3rd floors. On the 1st floor, surveyors observed 23 to 40 medication cards from discharged residents awaiting destruction, along with several bottles of expired over-the-counter medications. RN-B confirmed the medications on the counter were awaiting destruction and stated she was unsure of the medication destruction process, adding that the nurse manager usually handled it and was not currently available. The 1st floor storage area also contained current resident medications awaiting destruction, including medications for residents identified in the report such as Flomax, Inderal LA, Lipitor, Synthroid, Venlafaxine ER, Zyloprim, Methocarbamol, Allegra, and others. On the 2nd floor, LPN-A acknowledged six medication cards from discontinued orders and discharged residents and stated she was unsure of the destruction process and that night shift was responsible. On the 3rd floor, RN-F confirmed medication cards on the counter were from discontinued orders and discharged patients awaiting destruction and was also unsure of the facility’s destruction process and who was responsible. The 3rd floor storage area additionally contained current resident medications awaiting destruction, including multiple prescription cards, an open bottle of OTC acetaminophen, expired OTC aspirin, and an inhaler. The DON stated medication destruction was to be completed by two nurses, with one logging the medications and the other disposing of them in a Stericycle water-activated solution, while the facility pharmacist reported being unfamiliar with the current medication destruction process and referred to the facility policy, which was not provided before the end of the survey.
Failure to assess self-administration of nystatin powder
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of nystatin powder. The resident’s quarterly MDS dated 2/23/26 indicated the resident was cognitively intact, had no upper body impairment, was independent with personal hygiene, and required set-up to supervision for dressing. The resident’s diagnoses included diabetes, end-stage kidney disease, heart failure, and morbid obesity. The resident’s self-administration care plan dated 11/20/25 did not include self-administration of nystatin powder, and the medical record lacked a self-administration assessment for that medication. The provider ordered nystatin powder to be applied to affected areas under the right breast and skin folds twice daily and as needed. During observation and interview, the resident stated the nystatin powder was kept locked in a canvas bag on the bed and that the resident applied it independently twice a day, although the resident could not see the area under the abdomen. The resident also stated the resident preferred a specific bottle and had nursing staff transfer new powder into that bottle when needed. An LPN stated the resident administered own injections, completed blood sugar checks with supervision, and performed own vitals, but also stated the resident refused nystatin powder and that it was kept in the medication cart; the LPN later could not locate it there. When the LPN asked to wash the area and apply the powder, the resident unlocked the bag and handed the powder to the LPN, who then performed the application. The LPN and RN both confirmed no self-administration assessment had been completed for the nystatin powder, and the DON stated self-administration assessments are required to determine whether a resident can safely determine the purpose of medications and store them. The facility policy stated a resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely.
Failure to timely notify provider of repeated medication refusals and oxygen nonuse
Penalty
Summary
The facility failed to timely update the provider about repeated medication refusals for a resident who was readmitted after a 12-day hospital stay for a below-the-knee amputation. The resident’s quarterly MDS indicated she was cognitively intact, had no upper body impairment, and was independent with personal hygiene but needed set-up to supervision for dressing. Her diagnoses included diabetes, end-stage kidney disease, heart failure, and morbid obesity. Her care plan identified her as resistive and noncompliant with treatments and cares related to manipulative behaviors and loss of independence and control. An order dated 11/18/25 directed Nystatin powder to be applied under the right breast and skin folds twice daily and as needed, but the MAR showed frequent refusals from November 2025 through February 2026. Staff interviews confirmed the resident was consistently refusing the Nystatin powder and that the refusals were not promptly communicated to the provider. An LPN stated the resident had not allowed application of the powder, and during an observation the resident only allowed the powder to be applied after a dressing change; the LPN stated the abdominal folds looked a little red and did not appear to have powder on them. The nurse practitioner stated she had not been notified that the resident had consistently refused the Nystatin powder since November 2025 and expected notification so she could speak with the resident and hold an interdisciplinary team meeting. Other nursing staff stated that consistent refusals should be reported to the clinical manager and provider, but one RN stated she was not aware the resident was consistently refusing the powder and guessed the provider had not been notified. The director of nursing stated the provider was notified in February 2026, but the documentation provided only referenced refusal of all medications and treatments on one date and refusal of a surgical wound treatment on another date; neither notification mentioned the ongoing refusal of the Nystatin powder since November 2025. The report also identified a second resident with diagnoses including chronic respiratory failure with hypoxia, oxygen dependence, kidney failure, heart failure, diabetes, pulmonary edema, asthma, and dialysis dependence. That resident had an order for oxygen at 2 liters via nasal cannula continuously, but was observed multiple times without oxygen in use, stated the portable tank was empty, and told the DON, 'I don't need it.' The DON stated she had never seen the resident with oxygen in use and planned to call the provider to get an order to wean her off oxygen, while the resident’s PCP stated the facility should have sent an SBAR and updated vital signs regarding the ongoing need for supplemental oxygen.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident, R77. R77’s admission MDS assessment was not available at the time of survey, and the electronic health record did not show that a baseline care plan had been initiated within 48 hours of admission. A facility document titled Nursing-Admissions/readmission Observation dated 3/5/26 noted that R77 was alert and oriented to person, place, time, and situation, with intact cognition, and required transfer assistance, assistance with ADLs, and assistance managing a new colostomy. R77’s diagnoses included intestinal obstruction requiring a new colostomy, Parkinson’s, urinary retention, and generalized muscle weakness. R77 was admitted to the facility on [DATE] at approximately 2 p.m. During interview, the PA stated it was his expectation that the baseline care plan be created in the first 48 hours after admission and that it was important for basic cares such as hygiene, ambulation, skin concerns, fall interventions, and resident-specific concerns. The DON stated the admission process included transcribing orders, nurse review, loading orders into the MAR and TAR, and entering a baseline care plan based on those orders, but the nurse had not reviewed and uploaded the orders and no baseline care plan was completed. The facility policy stated the baseline care plan would be developed within 48 hours of a resident’s admission.
Care plan not updated after smoking assessment
Penalty
Summary
The facility failed to revise and update the care plan for a resident whose comprehensive assessment showed intact cognition, independence with transfers and wheelchair mobility, and limited assistance with bed mobility. The resident’s diagnoses included chronic systolic and diastolic congestive heart failure, chronic obstructive pulmonary disease, and generalized osteoarthritis. The resident’s care plan dated 11/19/25 stated the resident was allowed to smoke independently in designated smoking areas, needed reminders and assistance to use a smoking apron, and smoking materials were to be secured at the nurses’ station or other designated storage areas. A smoking assessment completed on 2/20/26 indicated the resident was safe to smoke without supervision, demonstrated safe smoking practices, had no indication for smoking apron use, and the facility stored the lighter and cigarettes. However, the care plan was not updated to reflect those changes, and the MAR/TAR dated 3/10/26 lacked smoking assessment recommendations or interventions. The Task Description list dated 3/1/26 also lacked smoking tasks. During observation on 3/9/26, the resident took smoking materials from the room and went to the designated smoking area without using a smoking apron. Staff interviews showed uncertainty about the resident’s smoking status and where smoking-related information was documented, and the DON stated nursing was responsible for updating the care plan after the smoking assessment was completed.
Failure to Obtain Orders and Document Colostomy Care
Penalty
Summary
The facility failed to provide professional standards of practice when staff completed colostomy-related treatment for a resident without a provider order, did not request an order after the treatment was performed, and did not document the treatment in the resident’s chart. The resident, who was alert and oriented with intact cognition, required assistance with transfers, ADLs, and management of a new colostomy. His diagnoses included intestinal obstruction requiring a new colostomy, Parkinson’s disease, urinary retention, and generalized muscle weakness. His admission MDS was not available at the time of survey, and his care plan lacked direction or interventions for colostomy care. The admission orders included emptying the bag every shift and recording the amount, but did not include specific appliance change instructions such as bag type, bag size, skin protectants, skin barriers, or bag removal. During observation, the resident removed his colostomy bag while waiting for staff assistance, and staff then assisted him with changing his clothing and applying a new colostomy bag. Interviews with an LPN, the DON, and a PA confirmed that the resident did not have colostomy care orders or a colostomy care plan, that the last bag change was not documented appropriately, that no progress note was completed, and that staff did not request a provider order after the treatment was completed. The DON and PA stated that admission orders and the baseline care plan should have been entered immediately so staff would know how to care for the resident’s colostomy, and the RN job description stated RNs provide professional nursing care in accordance with physician orders and facility policies.
Missing Colostomy Care Orders and Care Plan
Penalty
Summary
The facility failed to ensure physician orders were in place to provide treatment and monitoring for a resident’s new colostomy. The resident was admitted with diagnoses including intestinal obstruction requiring a new colostomy, Parkinson’s disease, urinary retention, and generalized muscle weakness. Admission documentation noted the resident was alert and oriented, cognitively intact, and required transfer assistance, help with ADLs, and assistance managing the colostomy. However, the resident’s care plan lacked direction or interventions for colostomy care, and the admission orders only directed staff to empty the bag every shift and record the amount, without specific instructions for appliance changes, bag type or size, skin protectants, skin barriers, or bag removal. During observation, the resident’s colostomy bag was visible because the shirt was not covering it, and the resident stated he did not like it being visible and adjusted his clothing to cover it. In a later observation, while waiting for staff assistance, the resident removed the colostomy bag and threw it into the garbage can in his room; staff then assisted with changing his clothing and applying a new colostomy bag. An LPN stated the colostomy care information should have been in the admission orders and/or baseline care plan and confirmed it was not present. The DON stated the resident should have had colostomy care admission orders and a baseline care plan, and confirmed both were incomplete and lacked specific colostomy care information.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for one resident who was reviewed for respiratory care. The resident had diagnoses including chronic respiratory failure with hypoxia, dependence on supplemental oxygen, chronic pulmonary edema, moderate persistent asthma, and dependence on renal dialysis. The admission MDS dated 2/20/26 indicated intact cognition and that the resident required partial to moderate assistance with toileting hygiene. The resident’s admission orders included oxygen at 2 liters via nasal cannula continuously. During observations, the resident was seen on the oxygen concentrator at 3 liters, but later was observed in the hallway on a motorized scooter with no oxygen in use while searching for staff because the portable oxygen tank was empty. The DON filled the portable tank, but the resident was then observed returning to her room with no oxygen in use, and later the oxygen tank was again not in use. Staff interviews reflected uncertainty about whether the oxygen order was continuous or as needed, and the DON stated she had never seen the resident with oxygen in use. The MD stated the facility was expected to send an SBAR and updated vitals for ongoing need for supplemental oxygen. The facility policy stated staff shall document ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.
Incomplete Dialysis Pre- and Post-Assessment Documentation
Penalty
Summary
The facility failed to complete ongoing assessment of a resident's condition and to monitor for complications before and after dialysis treatments received at a certified dialysis facility for one resident. The resident's admission MDS dated 2/20/26 indicated intact cognition and partial/moderate assistance with toileting hygiene. The resident's diagnoses included acute kidney failure, dependence on renal dialysis, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, pulmonary edema, moderate persistent asthma, dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. The resident was admitted on 02/5/26, and orders dated 2/19/25 directed dialysis pre- and post-assessment every Tuesday, Thursday, and Saturday, with the assessment to be printed and sent with the resident to dialysis and returned paperwork placed in the manager box. Review of the MAR/TAR dated 2/5/26 to 2/28/26 and 3/1/26 to 3/10/26 showed pre- and post-dialysis assessments were completed only on 2/24/26, 2/27/26, and 3/3/26, with no documentation for the other scheduled dialysis days. The DON verified on 3/9/26 that the dialysis pre-assessment form had not been sent consistently and was unable to provide completed pre- or post-assessment forms when requested. RN-B stated on 3/10/26 that the dialysis pre-assessment would be completed and sent with the resident to the dialysis center, but later was unable to provide a copy of the form. The MD stated on 03/12/26 that the facility was expected to complete the pre- and post-dialysis assessments and notify the dialysis center of any changes in the resident's weight and status.
Failure to Monitor Sleep Effectiveness for Melatonin Use
Penalty
Summary
The facility failed to monitor the effectiveness of a medication prescribed for sleep for one resident. The resident’s MDS assessment dated 12/3/25 indicated intact cognition, independence with transfers and wheelchair mobility, and limited assistance with bed mobility. The resident’s diagnoses included chronic systolic and diastolic congestive heart failure, chronic obstructive pulmonary disease, and generalized osteoarthritis. The resident had an order for Melatonin 5 mg by mouth at bedtime, starting 12/01/25 for insomnia. A review of the resident’s MAR from 02/1/26 to 3/11/26 showed no sleep tracking or monitoring, and the resident’s progress notes from 02/1/25 to 3/11/26 contained no reference to sleep monitoring. During interview, the RN stated that the resident was taking melatonin and that sleep monitoring is usually done, but there was no sleep monitoring in place for that resident and she did not know why. The DON stated that sleep would not be tracked with melatonin use because melatonin is an over-the-counter medication. The facility policy titled Gradual Dose Reduction of Psychotropic Drugs defines psychotropic drugs to include hypnotics used to induce sleep and treat insomnia.
Failure to Use EBP PPE During Resident Care
Penalty
Summary
The facility failed to ensure proper PPE use for residents on Enhanced Barrier Precautions (EBP) who received tube feeding, dialysis-related care, or care for indwelling devices. R6 had severe cognitive impairment, Parkinson’s disease, dementia, and a PEG tube for enteral nutrition and medication administration, with physician orders and a care plan identifying EBP for tube feeding. R14 had severely impaired cognition, non-traumatic brain dysfunction, renal insufficiency, and Alzheimer’s disease, with orders and a care plan identifying EBP for a suprapubic catheter and infection risk related to the indwelling device. During observation, CNA-G and CNA-F performed peri care and toileting in the shower room for R6 while there was a large amount of urine on the floor, and neither staff member was wearing proper EBP while cleaning the floor, EZ stand, and the resident. On another observation, CNA-K attempted to reattach R14’s leg bag after it had been hanging out of the resident’s pants and dragging on the floor; CNA-K emptied the urine and reattached the bag while not wearing proper EBP. Staff interviews showed differing understanding of EBP, with one CNA stating it was only used for COVID and another stating it was only needed when manipulating catheters, feeding tubes, or wounds. R4’s records showed dialysis care, a surgical wound, and an order for EBP due to a dialysis catheter. During observation, an LPN performed a dressing change and other care to R4 without donning a gown, despite the EBP sign outside the room indicating gown and glove use. The LPN stated staff were only required to wear PPE if they were providing care for the reason the resident was on precautions, and later confirmed R4 was on EBP due to having a dialysis catheter. The DON stated gown and gloves were required for all high-contact cares, and the facility policy identified EBP for residents with indwelling medical devices and high-contact care activities.
Nonfunctioning Shower Room Call Light
Penalty
Summary
The facility failed to ensure a working call light was available in the 3rd floor shower room bathroom area. During observation, the shower room had a call light switch on the back wall by the toilet, but no cord was seen. Later, a RN found a cord and tied it around the switch so it could be pulled, and the light then turned on outside the door. At another observation, the call light was not lit in the hallway or ringing at the nurse’s station for the shower room, and later RN-E and RN-F verified that the call light was not working because the red light came on but there was no sound to alert staff. The shower room was used by seven residents who were brought there for toileting with an EZ stand: R6, R36, R2, R8, R51, R60, and R62. Each of these residents had significant cognitive impairment and mobility limitations documented in their MDS assessments and care plans. Their records identified diagnoses such as dementia, Parkinson’s disease, hemiplegia, seizure disorder, congestive heart failure, diabetes, and other conditions, and their care plans directed transfers with assistance of two staff and use of an EZ stand or sit-to-stand lift. Staff interviews confirmed the problem was known during the survey observations. A CNA stated that if the shower room call light was not working, staff would hear a resident yelling or banging for assistance. The DON stated it was the first time he had been told there was a problem with the call light, and maintenance later verified that the call light was not working. The facility’s policy stated that call lights must be available at each resident’s toilet and bathing facility and that problems with the call light system should be reported immediately.
Missing Daily Staffing Data Information
Penalty
Summary
The facility failed to include the daily census and actual hours worked by nursing staff groups on the daily staffing data document. During observation on 3/9/26 at 11:30 a.m., the staff posting for 03/09/26 did not show the daily census and actual hours worked by nursing staff groups. During document review on 3/10/26, daily schedule reports for 3/9/26 through 3/13/26 also lacked the daily census and actual hours worked by nursing staff groups. During interviews on 03/12/26, the scheduler stated there had been a change in template in September and that the daily census and actual hours worked by nursing staff groups had been missing from the daily staffing data document, and the facility administrator acknowledged that the information was not shown on the facility daily staffing data document.
Failure to Assess Resident for Self-Administration of Inhalers
Penalty
Summary
The facility failed to complete a comprehensive assessment for self-administration of medications for a resident with chronic obstructive pulmonary disease (COPD) and asthma, who was oxygen dependent and had moderately impaired cognition. The resident's care plan included interventions for respiratory impairment, and physician orders specified the use of Ventolin and Dulera inhalers. Despite these orders, the resident was found to be self-administering both inhalers, keeping them in her pocket, and had not received a comprehensive assessment to determine her ability to safely self-administer these medications. There was also no physician order authorizing self-administration, as required by facility policy. Multiple staff members, including RNs, were aware that the resident had been self-administering her inhalers for at least two weeks, but no assessment had been completed. The resident reported keeping the inhalers on her person for quick access and had informed staff of her desire to self-administer, but was told the inhalers should be kept in the medication cart. The DON confirmed that no self-administration assessment had been completed, and the facility's policy required both a prescriber's order and an interdisciplinary team determination of safety before allowing self-administration of medications.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For one resident with chronic obstructive pulmonary disease and asthma, there were discrepancies between physician orders, treatment administration records (TAR), and progress notes regarding oxygen therapy. The physician ordered a change from 3 liters per minute (L/min) to 2 L/min of oxygen, but this change was not transcribed into the official physician orders. The TAR continued to reflect administration of 3 L/min, while progress notes documented administration of 2 L/min on several occasions. Additionally, refusals of oxygen therapy were not consistently documented, and notifications to the physician were based on verbal reports rather than written documentation. Nursing staff and the director of nursing acknowledged that the medical record was inaccurate due to these inconsistencies. For another resident with chronic kidney disease, cellulitis, diabetes, and heart failure, there was a lack of documentation regarding the discontinuation of an antibiotic prescribed after a hospital visit. The hospital after visit summary included an order for Augmentin, but the facility's electronic health record (EHR) showed a verbal order for the medication with a start and stop date, without any corresponding written order or physician note explaining the discontinuation. Staff interviews revealed uncertainty about the process for retrieving and incorporating outside medical records into the facility's EHR, and the director of nursing confirmed that the record did not address the discontinuation of the antibiotic. The facility's medical record policy required documentation according to the resident's level of care and for any unusual activity, event, or change in assistance. However, the lack of accurate transcription of physician orders, inconsistent documentation of care provided, and unclear processes for integrating external medical records led to incomplete and inaccurate records for the residents involved.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Identify and Document Minimum Staffing Requirements in Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to identify the minimum or baseline number of direct care and licensed staff required to meet residents' needs during both routine operations and emergencies. The assessment did not specify staffing hours per resident day (PPD) goals or the breakdown between licensed and direct care staff necessary to provide care based on residents' diagnoses, assessed needs, and comprehensive care plans. The assessment process described was fluid and based on daily evaluations by the nursing department and interdisciplinary team, but lacked concrete staffing numbers or ratios. The special memory care unit was noted to require special staffing considerations, but no specific minimums were documented. Interviews with staff revealed that daily staffing decisions were made based on the DON's direction and current census, with a general target of 3.3 to 3.4 PPD, but without a formalized or documented staffing plan in the facility assessment. The scheduler and DON both confirmed that the assessment did not identify the number or type of staff needed for each shift. Additionally, the facility assessment policy was requested but not provided. This deficiency had the potential to affect all 51 residents in the facility.
Lack of QAPI and QAA Process Plan
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or evidence outlining the procedures or steps the facility uses to carry out these required quality activities.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no formal mechanism in place to ensure that quality deficiencies were consistently identified or that appropriate corrective actions were developed and implemented.
QAA Group Lacked Required Members and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) group was composed of the required members and that meetings were held at least quarterly. This deficiency was identified through review of facility records and documentation, which showed that the QAA group did not consistently meet the mandated membership requirements and did not convene at the required frequency.
Failure to Provide Access to Resident Records
Penalty
Summary
The facility failed to ensure that each resident or the resident's legal representative was able to access or purchase copies of all the resident's records. This deficiency was identified based on the facility's actions or inactions that did not provide residents or their legal representatives with the required access to their records as mandated.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address the resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency occurred due to the facility's failure to ensure that a comprehensive assessment and plan were developed and put into place promptly after the resident's admission. The lack of timely planning resulted in the resident's immediate needs not being systematically identified or addressed within the required timeframe.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These findings indicate that the facility did not meet the required standards for ensuring proper continence management, catheter maintenance, and infection prevention for its residents.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five nursing assistants who had been employed for over one year. Staff records for these nursing assistants showed hire dates ranging from 1996 to 2024, but no annual performance evaluations were provided upon request. Interviews with the nursing assistants revealed that they did not recall receiving annual performance reviews, and the DON confirmed that she was responsible for conducting these evaluations but had not completed them for the identified staff. Additionally, the facility was unable to provide policies regarding performance reviews when requested.
Dishwashing and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper dishwashing sanitization levels and monitoring during the dishwashing process. During a kitchen tour, a dietary aide was observed placing dishes through a dish machine, with the wash dial indicating a temperature of 130 degrees Fahrenheit and the rinse dial at 140 degrees Fahrenheit. The dietary aide stated that the dish machine sanitized dishes with hot water and used test strips to check chemical levels after dishwashing. However, the test strips did not change color, indicating a failure in the sanitization process. The dietary manager confirmed that the dish machine used chemical sanitization, not temperature, and acknowledged ongoing issues with the dish machine. Additionally, the facility failed to ensure expired food was identified and removed from a unit refrigerator storing residents' personal food. A refrigerator on the second floor was observed with a sign indicating it was cleaned weekly, and all items must be labeled with the resident's name and date. However, the refrigerator contained several expired food items, including a plastic container with red sauce and pasta, an ice-cream sandwich, miracle whip, yogurt, cantaloupe, a piece of lemon pie, and pizza. The registered nurse confirmed the presence of expired food and removed it from the refrigerator. The facility's policies on ware washing and food storage were not adhered to, as evidenced by the failure to maintain proper dishwashing sanitization levels and the presence of expired food in the refrigerator. The dietary manager and registered dietician confirmed the expectations for checking chemical levels during dishwashing and ensuring expired food was not present in unit refrigerators. The director of nursing and district dietary manager also acknowledged the deficiencies in cleaning and monitoring the refrigerator.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for two residents, R54 and R23, who were on enhanced barrier precautions (EBP). R54, who had severe cognitive impairment and a gastrostomy tube, was observed during a medication administration without the registered nurse (RN-A) donning a gown as required. The nurse confirmed that R54 was on EBP due to the g-tube, but the necessary signage indicating EBP was missing from the resident's door. Additionally, the trained medication aide (TMA-A) was unaware of R54's EBP status, indicating a lack of communication and adherence to protocols. R23, who had a stage 2 pressure ulcer and was on EBP, was assisted by RN-E without wearing a gown during peri care. Although the EBP sign was present on R23's door, RN-E admitted to forgetting to wear the gown during the care process. The infection preventionist (RN-B) confirmed that R23 was on EBP due to skin alterations and reiterated the expectation for staff to wear gowns and gloves during high-contact care activities. The facility's policy on enhanced barrier precautions, dated 8/8/24, requires signage on resident doors and the availability of PPE outside rooms for residents with wounds or indwelling medical devices. The policy also mandates that staff be aware of which residents require EBP before providing care. However, the observations and interviews revealed lapses in adherence to these protocols, leading to deficiencies in infection prevention and control measures.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, who were observed to have medications in their rooms, were appropriately assessed and deemed safe to self-administer medications. Resident 6, diagnosed with rheumatoid arthritis and dementia, had a tube of Voltaren gel in her room without a physician's order for self-administration or an assessment for safe self-administration documented in her electronic medical record (EMR). During an interview, Resident 6 mentioned that she did not apply the medication herself, indicating a lack of self-administration. The care plan for Resident 6 did not include self-administration of medication. Resident 49, with a history of stroke, type 1 diabetes, and dementia, was found with several medications in his room, including glucose tablets, aspirin, and iron, without a self-administration order or assessment in the EMR. Although Resident 49 stated he brought the medications from home and did not use them anymore, the presence of these medications in his room was not in compliance with the facility's policy. The Director of Nursing confirmed the absence of self-administration orders for both residents and acknowledged that the medications should not have been in their rooms without proper authorization and assessment.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to notify resident representatives following falls and subsequent hospital transfers for two residents. Resident R20, who had a history of falls and was cognitively intact, experienced a fall resulting in a femur fracture. Despite R20's request to notify her emergency contact, FM-A, the facility did not make the notification. FM-A only learned of the incident when R20 contacted her from the emergency department. The administrator and director of nursing were aware of the policy to notify resident representatives but did not follow through, citing R20's ability to make her own decisions, despite her being in considerable pain and unable to contact FM-A herself. Resident R164, who had mild cognitive impairment and a history of falls, was also not properly notified. After a fall that led to a hospital transfer, FM-B, R164's emergency contact, was not informed by the facility. The facility's documentation indicated an attempt to contact FM-B, but no follow-up was made when there was no answer. The director of nursing acknowledged that staff should have made additional attempts to contact FM-B or informed the next shift to try again. The facility's policy required immediate notification of resident representatives in the event of an accident involving injury or a significant change in condition. However, in both cases, the facility failed to adhere to this policy, resulting in a lack of communication with the residents' emergency contacts during critical situations. This oversight led to dissatisfaction and concern from the residents' representatives, who were not able to provide support during the hospital transfers.
Failure to Complete Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to complete a baseline care plan for a newly admitted resident, identified as R164, who had been admitted for post-operative orthopedic after-care following neck surgery. The resident's admission Minimum Data Set (MDS) assessment indicated moderate impaired cognition, clear speech, and a need for assistance with activities of daily living (ADLs), as the resident did not walk independently. Despite these needs, neither the resident nor their family member received a copy of a baseline care plan after admission. Upon review of the resident's electronic medical record and paper chart, it was found that a baseline care plan was not documented. A carbonless form titled Baseline Care Plan Summary was found in the paper chart with only the resident's name and room number filled in, leaving the rest of the form blank. The Director of Nursing (DON) confirmed that this form was intended for documenting the baseline care plan and acknowledged that it had not been completed. Additionally, the facility's Comprehensive Care Plan policy did not include language about developing a baseline care plan and providing a summary to residents or their representatives.
Failure to Develop Comprehensive Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R163) who was reviewed for urinary catheter use. The resident's facesheet indicated a diagnosis of urinary retention, and the Minimum Data Set (MDS) assessment showed dependency on staff for most activities of daily living and the presence of an indwelling urinary catheter. Despite these documented needs, the care plan dated 1/27/25 did not include the resident's urinary retention, the use of an indwelling Foley catheter, leg bag, or urinary drainage bag. During interviews, the registered nurse (RN-C) responsible for updating care plans acknowledged the omission, stating it was a mistake and that she would correct it immediately. The Director of Nursing (DON) also confirmed that the urinary retention and catheter use should have been included in the care plan to ensure staff were aware of the necessary care interventions. The facility's policy requires a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Apply Compression Wraps for Edema Management
Penalty
Summary
The facility failed to comprehensively assess and provide ongoing treatment for a resident (R5) who required leg wraps to prevent and treat edema. R5 had a history of multiple medical conditions, including Alzheimer's disease and impaired cardiovascular status, and was prescribed low stretch compression wraps for both legs. However, the facility's records indicated that the compression wraps were not applied consistently, with several instances of missed applications due to the resident sleeping or other undocumented reasons. Additionally, R5 refused the wraps multiple times, but there were no documented reattempts to apply them. Observations and interviews revealed that R5 was often found without the prescribed compression wraps, and staff members were either unaware of the requirement or unsure of their responsibilities regarding the application of the wraps. Family members expressed concerns about the lack of care, noting increased swelling in R5's legs and the absence of necessary interventions such as massaging and moisturizing before applying the wraps. Staff interviews highlighted a lack of communication and understanding of roles, with some staff believing that only nurses could apply the wraps, while others thought nursing assistants could do so. The Director of Nursing confirmed the presence of an order for bilateral leg wraps and stated that staff should apply them daily and remove them at bedtime. The DON also mentioned that residents who refuse care should be approached a minimum of three times. Despite these expectations, the facility's policy on edema prevention and treatment was not provided, indicating a possible gap in procedural guidance. The deficiency was further compounded by the lack of consistent documentation and follow-up on R5's care needs.
Inadequate Fall Prevention and Intervention for Residents
Penalty
Summary
The facility failed to adequately assess and implement interventions to prevent falls for two residents, R5 and R164, who were at risk for accidents. R5, who had a history of falls and multiple medical conditions including Alzheimer's disease and impaired mobility, experienced seven falls over a period of three months. Despite these incidents, the facility's interventions were inconsistent and not effectively communicated to staff. Observations revealed that R5's room lacked a 'call don't fall' sign, and necessary items were not within reach, contributing to the resident's attempts to self-transfer and subsequent falls. R164, admitted for short-term rehabilitation following neck surgery, also experienced multiple falls within a week of admission. The facility's response to these falls was inadequate, as incident reports were incomplete, and the interdisciplinary team (IDT) failed to conduct thorough root cause analyses or implement new interventions. The lack of communication and follow-up on fall incidents resulted in missed opportunities to address the underlying causes and prevent future falls. The facility's fall prevention and management policy was not effectively implemented, as evidenced by the failure to conduct timely fall risk assessments and update care plans with appropriate interventions. The director of nursing acknowledged the shortcomings in the facility's response to falls, highlighting a need for improved communication and adherence to established protocols to ensure resident safety.
Failure to Switch Catheter Leg Bag to Drainage Bag at Night
Penalty
Summary
The facility failed to provide appropriate management of an indwelling catheter for a resident diagnosed with urinary retention. The resident, who was dependent on staff for most activities of daily living, had an indwelling urinary catheter. Observations revealed that the resident's leg bag was not switched to a urinary drainage bag at night, as required by the facility's catheter care policy. This oversight was noted during multiple observations, where the resident was found with a leg bag in place, which was not changed to a urinary drainage bag at night. Interviews with staff, including an LPN and a nursing assistant, confirmed that the catheter should have been connected to a urinary drainage bag at night to ensure proper urine drainage and prevent backflow, which could lead to a urinary tract infection. The Director of Nursing also acknowledged the importance of switching to a urinary drainage bag at night to prevent urine backflow. The facility's catheter care policy, revised in March 2023, clearly stated that leg bags should be removed and replaced with a bedside drainage bag at night, which was not adhered to in this case.
Deficiency in Tub/Shower Room Maintenance
Penalty
Summary
The facility failed to maintain the second-floor tub/shower room in good repair and sanitary conditions for the 30 residents who could potentially use the area. During an observation, it was noted that a wall partially enclosing the shower area was missing six tiles, exposing wood and plaster. The corporate maintenance director was unaware of the missing tiles and acknowledged the unsanitary and non-homelike environment. A housekeeper was aware of the issue but could not recall to whom it was reported. The facility maintenance director, new to the position, was also unaware of the missing tiles and was dealing with a backlog of repairs. A policy on building maintenance was requested but not provided.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a warm and palatable temperature, affecting the quality of life and nutritional intake for residents on the second floor. Three residents, each with specific dietary needs and cognitive impairments, reported that their meals were consistently served cold. Observations confirmed that meal trays were left unattended on the second floor for extended periods, leading to food temperatures significantly below the recommended safe levels. The dietary manager acknowledged that the food should be served at temperatures closer to 135 degrees Fahrenheit, but the facility's plate warmer had been out of service for two weeks, contributing to the issue. Interviews with residents and staff revealed that the lack of sufficient staff to deliver meal trays promptly was a contributing factor. Residents expressed dissatisfaction with the temperature of their meals, and the registered dietician confirmed concerns about food safety and palatability due to the low temperatures. The facility's policy stated that food should be prepared and served at safe and appetizing temperatures, but this was not adhered to, as evidenced by the observations and resident feedback.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food was maintained at proper temperatures, resulting in complaints from six residents about receiving cold meals. Observations and interviews revealed that residents consistently received meals that were lukewarm or cold, regardless of whether they dined in their rooms or the dining room. Specific instances included a resident receiving lunch at 2:00 p.m. with food that was not as ordered and often cold, and another resident who found the food cold but did not request reheating. During observations, it was noted that meal trays were distributed late, and nursing staff did not check food temperatures before serving. A Licensed Practical Nurse (LPN) mentioned that trays sometimes arrived late, and dietary staff did not pass out trays, leaving this task to nursing staff. The LPN also noted that hot plates were rarely used, and food was often reheated in microwaves before serving. Temperature checks conducted by dietary staff showed that food items were below the required temperature standards, with some hot foods measuring significantly below the minimum 135 degrees Fahrenheit. Interviews with dietary management confirmed that the temperatures recorded were unacceptable. The dietary account manager stated that food was taken from the oven to the steam table, but space limitations affected temperature maintenance. Observations showed that food was plated without lids, and cold items were placed on warm plates. The facility's policy required food to be served at safe and appetizing temperatures, but the practices observed did not align with these standards, leading to dissatisfaction among residents.
Failure to Deliver Oxygen According to Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen was delivered according to physician orders for a resident with chronic respiratory failure and other related conditions. The resident was supposed to receive continuous oxygen at 1 liter per minute (LPM) via nasal cannula, as per physician orders. However, during an observation, the resident was found with the oxygen concentrator set at 2 LPM, and the nasal cannula was not properly placed in the resident's nose. Additionally, the resident's head of bed was not elevated as required by the care plan. When the resident was transferred to a wheelchair, the oxygen saturation dropped significantly, and the resident experienced shortness of breath, prompting staff to increase the oxygen to 3 LPM, which was not in accordance with the physician's order. Interviews with staff revealed a lack of understanding and adherence to the oxygen delivery protocol. Nursing assistants were not aware of the importance of continuous oxygen delivery and were not trained to titrate oxygen levels, although they were involved in tasks that required temporary removal of oxygen. The facility's oxygen policy emphasized the necessity of oxygen for survival, yet the staff's actions did not align with this policy, leading to a deficiency in providing safe and appropriate respiratory care for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 136 citations issued within 25 miles in the last 12 months — including the 2 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) |
|---|---|---|---|---|
| Charter House Inc | 0.8 mi | ★★★★★ | 4 | 0 |
| Samaritan Bethany Home On Eighth | 1.1 mi | ★★★★★ | 8 | 0 |
| Edenbrook Of Rochester | 2.6 mi | ★★★★★ | 16 | 0 |
| Edenbrook Rochester West | 2.8 mi | ★★★★★ | 26 | 1 |
| Madonna Towers Of Rochester | 3.8 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.