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 Samaritan Bethany Home On Eighth during CMS and state inspections, most recent first.
A resident with depression and insomnia was receiving duloxetine and trazodone, but the chart lacked documentation of informed consent, including discussion of risks, benefits, and alternatives. Staff interviews confirmed the LPN did not complete medication consents, the RN expected verbal consent to be documented in a note, and the DON stated the facility did not do written consents for psychotropic meds; the provider note also did not show that the required discussion occurred.
Failure to ensure safe self-administration of medications: A resident who was cognitively intact and independent with ADLs was observed with oral meds left at bedside on multiple occasions, even though the MAR did not authorize bedside storage. Nursing staff confirmed there was no self-administration assessment or provider order on file, and the facility policy required a licensed nurse evaluation and physician order before a resident could self-administer meds.
Dirty Resident Room and Bathroom: A resident who was cognitively intact and receiving tube feeding had repeated observations of tube feeding residue on an IV pole and stained carpet, dried medication residue on the bathroom sink and in the basin, and Kleenex on the floor. Staff stated rooms are cleaned daily and that spilled tube feeding should be cleaned by nursing or housekeeping, but the same messes remained on multiple observations.
Failure to Monitor Psychotropic Medication Side Effects: A resident with major depressive disorder was receiving duloxetine and trazodone, but the care plan, MAR/TAR, order summary, and progress notes lacked documentation of side effect monitoring or identification of what side effects to monitor. Staff interviews showed uncertainty about whether psychotropic side effect monitoring was being done, and the RN later verified the care plan did not include the required monitoring.
A resident admitted with acute respiratory failure with hypoxia required continuous O2 therapy, but the oxygen tubing was not dated and there was no documentation that it had been changed during the stay. The care plan, order summary, MAR/TAR, task log, and progress notes addressed O2 use and monitoring, but did not identify a tubing-change schedule or responsible staff. Staff interviews showed mixed understanding of weekly tubing changes, and a facility policy stated tubing is replaced weekly on the resident’s bath/skin day.
An LPN was not appropriately trained or competent to care for a resident with a G-tube and to apply a lidocaine patch correctly. The resident had a G-tube for enteral feedings, required aspiration precautions, and had orders for medications and flushes via the tube. During observation, the LPN crushed and administered meds through the G-tube, then applied a lidocaine patch over an existing patch without removing the old one. The LPN stated she had not had recent education on G-tube care, and an RN confirmed the LPN had not received the required education and that the resident’s HOB should have been elevated during tube feeding.
Failure to use EBP PPE for a resident with a PEG tube. An LPN, two RNs, and two NAs entered the resident’s room for medication administration, tube feeding, tube disconnecting, and incontinent care without donning gowns and gloves as required for EBP, and one LPN left without hand hygiene. Staff confirmed the resident required EBP due to the PEG tube, but the care plan and physician orders did not include EBP information.
Nursing daily staffing report was posted behind the reception desk where it was hard to see and read from the desk area. OSs and the ADM stated the report had been posted in that location for years, people in wheelchairs could not see it, and others had to lean over the counter to view it. The ADM also stated the font could be bigger for people to read.
The facility failed to ensure call lights were accessible for two residents, one with cognitive impairment and another with mobility limitations. Both residents were unable to reach their call lights, which were placed out of reach, preventing them from requesting assistance. Staff interviews confirmed that call lights should be within reach, as per facility policy.
The facility failed to adhere to transfer care plans, resulting in falls and injuries for two residents. One resident, with severe cognitive impairment, fell during an unsupervised transfer without the prescribed walker, leading to serious injuries and ICU hospitalization. Another resident, with moderate cognitive impairment, was transferred without using the required walker, causing difficulty in ensuring a safe transfer. The facility's failure to ensure staff followed care plans led to preventable accidents.
A resident with severe cognitive impairment and a history of atrial fibrillation received 14 incorrect doses of aspirin due to a transcription error in the EHR. Despite a physician's order to reduce the dosage from 325 mg to 81 mg due to frequent nosebleeds, the resident continued to receive the higher dose. The error was identified by a family member, and the DON was unaware of the issue, which was not documented or reported as per facility policy.
Lack of Documented Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including discussion of risks, benefits, and alternatives, for psychotropic medications for residents reviewed for unnecessary medications. For R22, the admission MDS dated 3/10/26 indicated intact cognition with no hallucinations, delusions, or rejection of care, and the medical record showed diagnoses including major depressive disorder, acute respiratory failure with hypoxia, acute on chronic congestive heart failure, and type 2 diabetes. The order summary and MAR/TAR showed duloxetine 60 mg daily starting 3/5/26 and trazodone 50 mg at bedtime for insomnia starting 3/4/26, both administered as ordered. Review of R22’s progress notes, hospital discharge summary, EMR, and paper chart found no documentation of education or consent regarding the risks, benefits, or alternatives for duloxetine or trazodone. Staff interviews confirmed that medication consents were not routinely completed for psychotropic medications: an LPN stated she does not complete medication consents and had never talked to a resident or family about risks, benefits, or alternatives of psychotropic medication; the RN care coordinator stated psychotropic consent would be verbal and documented in a note, but no such documentation was found; and the DON stated the facility did not do written consents for psychotropic medications and expected the provider to document the discussion. A provider note referenced R22’s depression, anxiety, insomnia, and treatment with duloxetine and trazodone, but it also lacked evidence of a conversation about risks, benefits, and alternatives.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure safe independent medication administration for 1 resident who was reviewed for self-administration. The resident’s quarterly MDS indicated the resident was cognitively intact, had no delirium or behaviors, had no upper or lower body impairment, and was independent with ADLs and transfers. The resident’s diagnoses included back pain, hypertension, depression, hyperlipidemia, osteoporosis, indigestion, and vitamin D deficiency, and the care plan indicated the resident was independent with ADLs. The MAR showed scheduled morning and noon medications, including atorvastatin, vitamin D, losartan, omeprazole, sertraline, senna-s, acetaminophen, and calcium citrate. The resident’s MAR did not indicate that it was safe to leave medications at bedside, yet during multiple observations the resident was found sitting in a recliner with a plastic medication cup containing oral medications on the table next to the resident. The resident stated the medications were taken after breakfast and that the noon medications were taken slowly. Nursing staff confirmed the resident did not have a self-administration assessment on file, and an RN stated self-administration assessments are based on diagnoses and cognition and require evaluation of the resident’s ability to identify medications, state what they are for, and administer them safely. The RN also confirmed there was no self-administration order on the MAR and that there should have been one. The facility policy required a licensed nurse to complete a self-administration evaluation and obtain a physician’s order before a resident could self-administer medications.
Dirty Resident Room and Bathroom
Penalty
Summary
The facility failed to provide a clean room and bathroom for a resident who was cognitively intact, hard of hearing, able to understand, and had no refusals of care. The resident’s diagnoses included heart failure, high blood pressure, anxiety, and malnutrition requiring feeding through an external tube inserted through the abdominal wall. During observation, the resident’s room had an IV pole with several drops of tube feeding on all four legs extending from the base, and the carpet around the pole was stained with tube feeding residue. The bathroom sink counter had dried brown drops that appeared to be residue from crushed medication, and the sink basin contained dried tan-colored residue. Three pieces of Kleenex were also observed on the floor between the television and the foot of the bed. The resident stated she would prefer the messes to be cleaned up and said she had to rely on facility staff because she could not do it herself. The same conditions remained present on later observations, including the dirty IV pole, stained carpet, medication residue on the bathroom sink, residue in the sink basin, and Kleenex on the floor. Housekeeping staff stated resident rooms are cleaned daily and described routine cleaning of surfaces, floors, bathrooms, and mirrors. Nursing staff also stated rooms are cleaned daily and confirmed that spilled tube feeding liquid should be cleaned by the nurse who spilled it or by housekeeping. An RN confirmed there was tube feeding residue on the floor under the IV pole and on the IV pole. A housekeeping policy was requested but not received.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure appropriate medication side effect monitoring was completed for a resident receiving psychotropic medications. The resident’s admission MDS indicated intact cognition with no hallucinations, delusions, or rejection of care, and the resident was diagnosed with major depressive disorder, acute respiratory failure with hypoxia, acute on chronic congestive heart failure, and type 2 diabetes. The resident’s baseline care plan and later care plan both identified antidepressant use related to depression and set a goal for the resident to be free from adverse reactions, but the only intervention listed was to administer medication as ordered. Neither care plan identified what side effects to monitor for or included any monitoring interventions for the antidepressants. The resident’s order summary showed duloxetine 60 mg daily and trazodone 50 mg at bedtime for insomnia related to major depressive disorder, but there was no documentation or direction to monitor for side effects. The MAR/TAR showed both medications were administered as ordered, yet it lacked evidence of side effect monitoring and did not identify what side effects should be monitored. Progress notes from the review period also lacked documentation of side effect monitoring for either medication. During interviews, an LPN stated they were unsure whether psychotropic side effect monitoring was done and did not know if side effects to monitor would be listed on the care plan, while the RN care coordinator stated staff were always monitoring for side effects and that the baseline care plan should contain the required monitoring; after review, the RN verified the care plan did not contain the side effect monitoring for antidepressant medications and was not being completed.
Oxygen Tubing Not Changed or Documented as Required
Penalty
Summary
The facility failed to ensure oxygen tubing was changed according to standards of care for a resident who required continuous oxygen therapy. R22 was admitted with acute respiratory failure with hypoxia and had additional diagnoses including acute on chronic congestive heart failure, acute eosinophilic pneumonia, and atrial fibrillation. The resident’s MDS indicated intact cognition and continuous oxygen use, and the care plan and order summary addressed oxygen therapy, but neither included an order or direction for how often oxygen tubing should be changed or who was responsible for changing it. During observation, R22 was wearing oxygen and the tubing was not dated. R22 was unsure whether staff had changed the tubing. Review of the MAR/TAR, task log, and progress notes showed oxygen saturations were monitored and oxygen was continued or weaned as tolerated, but there was no documentation that the oxygen tubing had been changed during the resident’s admission. The oxygen tubing on both the portable tank and concentrator was also not labeled when reviewed. Staff interviews showed inconsistent understanding of the tubing-change process. A TMA and an LPN stated oxygen tubing should be changed weekly, but both said it was not documented, and the TMA stated they had not changed oxygen tubing for a long time. An RN stated the tubing should be changed weekly and as needed, and later said it should be changed with the resident’s shower schedule, but also stated it was not documented. A facility policy dated 2/26/26 indicated oxygen tubing is replaced weekly on the resident’s bath/skin day.
LPN Not Competent in G-Tube Care and Lidocaine Patch Application
Penalty
Summary
The facility failed to ensure that 1 of 1 direct-care nursing staff member, an LPN, was appropriately trained and competent to care for a resident with a gastric tube and to apply a lidocaine patch correctly. The resident was admitted with a surgically implanted gastric tube for enteral feedings due to malnutrition and had diagnoses including heart failure, high blood pressure, anxiety, and malnutrition. The resident’s MDS identified the resident as cognitively intact, hard of hearing, able to understand, and with no refusals of care. The resident’s physician orders included Nutren 1.5 tube feedings, water flushes before and after feedings, and multiple medications to be given via the G-tube. The care plan directed staff to assist with management of the gastric tube, provide tube feedings, and follow aspiration precautions, including keeping the resident upright during tube feeding and for 1 hour afterward. During an observation, the LPN administered water, crushed medications, and gave them through the gastric tube, then flushed the tube. The LPN stated she had not had recent education about administering tube feedings via a gastric tube and had not cared for a resident requiring a gastric tube in a long time. During the same observation, the LPN applied a lidocaine patch to the resident’s left shoulder so that it slightly covered an existing patch without removing the old patch. The LPN stated she did not think it would be an issue to overlap the patches. Later, an RN attempted to complete the tube feeding but was not familiar with the pump and could not program it correctly, then turned the pump off and gave the water flush by syringe. The RN stated staff had received education about tube feedings and gastric tubes before the resident arrived, but also confirmed the LPN had not had the required education. The RN further confirmed the resident’s head of bed should have been elevated to 45 degrees during the tube feeding and for up to an hour afterward, and that the LPN had administered the lidocaine patch incorrectly by placing the second patch over the first.
Failure to Use EBP PPE for Resident With PEG Tube
Penalty
Summary
The facility failed to ensure proper use of PPE for a resident who required Enhanced Barrier Precautions (EBP) due to a PEG tube. The resident’s quarterly MDS identified the resident as cognitively intact, hard of hearing, able to understand, and with no refusals of care. The resident’s diagnoses included heart failure, high blood pressure, anxiety, and malnutrition requiring feeding through an external tube inserted through the abdominal wall. The resident had a PEG tube placed due to complete intestinal blockage, and the facility policy identified feeding tubes and other indwelling medical devices as requiring EBP during high-contact care. The resident’s care plan did not include infection prevention information or the need for EBP related to the PEG tube, and the physician’s orders did not include an order for EBP. During observation, an LPN entered the resident’s room to administer medication and start tube feeding without donning an isolation gown or proper PPE, and left without performing hand hygiene. Later, an RN entered to administer medication and complete the tube feed and flush the PEG tube without wearing an isolation gown or proper PPE, and another RN who entered to help disconnect the tube feed line also failed to don an isolation gown or proper PPE. During another observation, two nursing assistants entered the room to assist with changing soiled undergarments without donning an isolation gown or proper PPE. Staff interviews confirmed the resident required EBP because of the PEG tube and that the resident had an EBP sign on the inside of the cabinet door.
Nursing Daily Staffing Report Not Readily Visible
Penalty
Summary
The facility failed to ensure the nursing daily staffing report was posted in a readily available, visible location within the care center. During an observation on 3/24/26 at 4:42 p.m., the report was posted on the wall behind the receptionist desk. Office specialist A stated the report was posted in the morning and, if changes were needed throughout the day, the posted numbers were crossed off and new totals were written in. OS-A also stated that from the reception desk, the report was hard to visualize. During interviews on 3/25/26, OS-B stated the report had been posted behind the reception desk since she started working four years earlier and that she could not read it from the desk. OS-B stated people in wheelchairs could not see it and others would have to lean over the counter to view it and might not be able to read it. The administrator stated the report had always been posted behind the reception desk, that she could not read it without leaning into the desk, and that the font could be bigger for people to read. A facility policy was requested and none was provided.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were accessible. Resident R60, who has cognitive impairment and various diagnoses including Parkinson's and non-Alzheimer's dementia, was observed in a wheelchair with the call light placed out of reach on a nightstand behind him. R60 expressed that he was unable to locate or reach the call light, which hindered his ability to request assistance. His care plan specifically required that the call light be within reach and that he be encouraged to use it for assistance. Similarly, Resident R187, who has limitations in range of motion, requires extensive assistance for mobility, and is on continuous oxygen, was found lying in bed with the call light three feet away on a nightstand, making it inaccessible. R187 stated a preference for having the call light on her body to use it when needed. Interviews with nursing assistants and the director of nursing confirmed that call lights should always be within reach of residents, aligning with the facility's policy. However, both residents were unable to access their call lights, indicating a failure to meet this standard.
Failure to Follow Transfer Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to follow the care plan for transfers, leading to a fall and significant injuries for two residents. One resident, who had severe cognitive impairment and multiple health issues, was at moderate risk for falls. Despite this, the care plan requiring the use of a front-wheeled walker and gait belt with contact guard assist was not followed during a transfer. The resident fell, resulting in serious injuries, including brain hemorrhages and fractures, necessitating an eight-day ICU hospitalization. The incident occurred when a nursing assistant, who was still in orientation and unsupervised, attempted to transfer the resident without using the prescribed walker. The assistant was unaware of the need to lock the brakes on the shower chair and did not realize the care plan required the use of a walker. This lack of adherence to the care plan and inadequate supervision during the transfer process directly contributed to the resident's fall and subsequent injuries. Another resident, with moderate cognitive impairment and a history of dementia, was also transferred without following the care plan. The care plan required the use of a front-wheeled walker and gait belt, but the nursing assistant did not use the walker, leading to difficulty in ensuring the resident's safe transfer. The facility's failure to ensure staff followed individualized care plans for transfers resulted in preventable accidents and injuries.
Medication Transcription Error Leads to Incorrect Aspirin Dosage
Penalty
Summary
The facility failed to accurately transcribe a physician's order into the electronic health record (EHR) for a resident who received 14 incorrect doses of aspirin. The resident, who had severe cognitive impairment and a history of atrial fibrillation, thrombocytopenia, and hypertension, was initially prescribed aspirin 325 mg daily. However, due to frequent nosebleeds, the physician ordered a change to aspirin 81 mg daily. Despite this change, the resident continued to receive the higher dose of 325 mg daily from February 23, 2024, through March 5, 2024. The error was identified during a phone interview with a family member who expressed concern that the dosage change was not implemented. The Director of Nursing (DON) was unaware of the transcription error and explained that medication errors should be documented, assessed, and reported according to facility policy. The facility's policy requires that significant medication errors, which could jeopardize a resident's health or safety, be reported to the medical doctor, the resident or their representative, and documented in the resident's record. However, this process was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Charter House Inc | 0.4 mi | ★★★★★ | 4 | 0 |
| Rochester Restorative Care Center | 1.1 mi | ★★★★★ | 36 | 1 |
| Edenbrook Of Rochester | 1.7 mi | ★★★★★ | 16 | 0 |
| Edenbrook Rochester West | 1.8 mi | ★★★★★ | 26 | 1 |
| Madonna Towers Of Rochester | 2.7 mi | ★★★★★ | 4 | 0 |
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