Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Latta Road Nursing Home West during CMS and state inspections, most recent first.
A facility was found to have a medication error rate of 7.7%, exceeding the acceptable limit. Errors included administering midodrine against physician's parameters and Vitamin B12 without a prescribed dose. The LPN acknowledged the mistakes, and both the NP and DON confirmed the errors, highlighting a lapse in protocol adherence.
The facility's kitchen had deficiencies in maintenance and equipment functionality. The exhaust hood and filters were dirty, lacking regular cleaning, and the dishwashing machine failed to dispense chlorine sanitizer automatically, requiring manual intervention. The facility used disposable utensils and a three-bay sink for washing until repairs could be made.
A CNA at the facility continued to work with a lapsed certification, violating the requirement for valid certification for direct resident care. The facility's policy required monthly monitoring of CNA recertifications by the DON, but an error in the renewal process led to the CNA working without a valid certification. The Business Office Manager believed there was a 90-day grace period, although this was not confirmed by Prometric.
A resident with impaired cognition and on a mechanically altered diet choked on large pieces of chicken, leading to hospitalization. The facility failed to ensure the correct food consistency was served, as required by the resident's dietary orders. Staff were uncertain if the meal tray was checked for accuracy, and the incident resulted in actual harm to the resident.
A resident with impaired cognition and on a mechanically altered diet choked on a large piece of chicken, leading to hospitalization. The facility failed to thoroughly investigate the incident, lacking documentation and verification of the food consistency provided, as required by their policies. The DON acknowledged the need for dietary order verification in such cases.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
During a recertification survey, it was found that the facility did not maintain a medication error rate of five percent or less, as evidenced by a 7.7 percent error rate. Specifically, for one resident, there were two medication errors out of 26 opportunities. The errors involved the administration of midodrine and Vitamin B12. The midodrine was administered despite the resident's systolic blood pressure being above the parameter set by the physician's order, which indicated the medication should be held if the systolic blood pressure was greater than 90. Additionally, Vitamin B12 was administered without a prescribed dose being included in the physician's order. The resident involved had diagnoses including Parkinson's disease, atrial fibrillation, and type two diabetes, and was cognitively intact. The LPN responsible for administering the medication acknowledged the errors, stating that the midodrine should not have been given and that the Vitamin B12 should not have been administered without a verified dose. The Nurse Practitioner and Director of Nursing confirmed that the medication should have been held and that the order should have been verified before administration. The Director of Nursing also noted that the system should not allow incomplete orders to be saved, indicating a lapse in protocol adherence.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 1. Resident #13. The resident was evaluated by the Medical Provider on 1/16/2025. The Nurse involved was provided counseling and re-education on 1/16/2025. 2. The facility will conduct a review of all current residents’ medication orders to ensure that all components of the order are present and review all current resident medication orders to ensure that all of the residents with parameters in the orders are being followed as written. The Medical Provider will be notified of any residents that were identified with significant findings. Any recommendations and changes in resident orders will be completed as written from the medical providers. Completion date: 2/28/2025 3. The facility will provide all licensed nurses with education on medication orders and reduction risks of medication errors. The facility’s medication administration policy has been reviewed with the Director of Nursing, Administrator, and Medical Director. Completion date: 2/28/2025 4. The facility Director of Nursing will conduct audits on all residents’ new orders to ensure all components, including the dose, are present in the order and all resident orders that have parameters to monitor for parameter compliance. Audits will be conducted weekly for three months and then monthly for three months.
Kitchen Maintenance and Dishwashing Machine Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in accordance with professional standards for food service safety, as observed during the Recertification Survey. The kitchen's exhaust hood and filters were found to have a visible accumulation of grease and dust, indicating a lack of regular cleaning. The Kitchen Supervisor mentioned that a vendor cleans the hood annually in September, and staff are expected to clean it as needed, but there was no documented evidence of regular cleaning on the daily cleaning lists. Additionally, the low temperature dishwashing machine in the main kitchen was not functioning properly. The machine was supposed to wash and rinse at 120 degrees Fahrenheit with chlorine sanitization, but the chlorine sanitizer was not automatically dispensing. The Kitchen Supervisor had to manually activate the dispenser, and there was a leak in the dispensing line, causing erratic sanitizer measurements. The facility resorted to using disposable utensils and plates and washing with a three-bay sink until the dish machine could be repaired.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 1. The dishwasher was fixed by the (NAME) representative on 01/15/2025 confirming that the dish machine was sanitizing pumping between 50-100ppm during the rinse cycle. 2. The exhaust hood and filters were cleaned on 1/15/2025 by the food service manager. 3. Food Service Manager has created a policy for cleaning of the exhaust hood and filters. Exhaust hood and filter will be cleaned on a weekly basis, this will be indicated on a weekly audit form. Audits will be presented to the quality assurance team monthly then quarterly thereafter. 4. The dishwasher will be checked daily for full functionality of the sanitation process. Audits will be reported to the quality assurance team monthly then quarterly thereafter. Responsible party: Dietary manager
Lapsed CNA Certification Leads to Deficiency
Penalty
Summary
The facility failed to ensure that the certification of a Certified Nursing Assistant (CNA) was current during their employment. Specifically, the CNA's certification had lapsed and was not renewed, yet the CNA continued to work in the facility providing direct resident care. The facility's policy required the Director of Nursing to monitor CNA recertifications monthly and initiate the renewal process at the beginning of the month in which the certificate was due to expire. However, the CNA's certification expired, and the renewal process was not completed in a timely manner, resulting in the CNA working without a valid certification. Interviews revealed that the Business Office Manager and the Director of Nursing were responsible for ensuring certifications were up to date. The Business Office Manager stated that there was a perceived grace period of 90 days during which CNAs could work while their certification was being processed, although this was not officially confirmed by Prometric. The delay in processing the renewal was attributed to an error in the employer code and missing information on the renewal form. Despite these issues, the facility allowed the CNA to continue working, which was a violation of the requirement to have a valid certification for direct resident care.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 1. CNA #4 was terminated from the facility effective 10/15/2024. 2. An audit of all CNAs certification at the facility was completed and reviewed. There were no other CNAs that did not have an active C.N.A certificate. Completed: 1/2/2025 3. The facility has reviewed the facility policy on C.N.A renewal and there has been no changes. A spreadsheet is sent to this Director of Nursing and the Administrator that automatically populates notification 45 days prior to the expiration date. 4. All renewed C.N.As will be reported to the Quality assurance team for 3 months then quarterly thereafter to ensure that all Certification renewals are completed timely. Responsible party: Business office
Failure to Provide Correct Food Consistency Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the needs of a resident, as recommended by the speech-language pathologist and physician's orders. Resident #4, who had moderately impaired cognition and was on a mechanically altered diet, experienced a choking incident after being served a meal. The resident was on a ground/soft diet with thin liquids, but during the incident, they choked on large pieces of chicken, which were later removed from their airway at the hospital. The facility's policy required meal trays to be checked for accuracy against the meal tray ticket, but it was unclear if this was done in this case. The incident resulted in actual harm to the resident, who was admitted to the emergency room in acute respiratory distress and required medical intervention to remove the obstruction. Interviews with facility staff revealed uncertainty about whether the correct food consistency was provided, as the resident's tray was removed before the choking incident was fully investigated. The staff member who served the tray was no longer at the facility, and the Director of Nursing at the time of the survey was not in the position when the incident occurred. The facility's failure to ensure the correct food consistency was served led to the resident's choking and subsequent hospitalization.
Plan Of Correction
Plan of Correction: Approved February 11, 2025 1. For resident #4 specifically, the facility has added an order to document when the resident refuses to get out of bed for meals. Resident #4 also worked with SLP upon returning to the facility from a choking incident; dietary order was changed (MONTH) 21, 2024, to reflect speech language pathologist recommendation. 2. All personnel involved in serving residents have been educated on the different consistencies in the facility, completed on (MONTH) 24, 2024. 3. Diet tech and dietician will interchangeably complete weekly meal audits. Findings will be presented to the quality assurance team. Any immediate findings will be corrected accordingly. Date: 3/16/2025 4. Speech Language Pathologist will review all menus and extensions to ensure that we are serving appropriate foods for all consistencies. Date: ongoing 5. The speech language pathologist initiated review of all residents in alignment with the MDS schedule starting (MONTH) 2024 and has continued to do. Completed: (MONTH) 2024. Responsible party: speech language pathologist 6. SLP will communicate any dietary changes to the clinical team utilizing a communication log and the dietary team via email. Nursing will be responsible to make changes in EHR, and the diet tech will reprint the dietary roster. 7. Findings from all audits will be presented to the Quality assurance team monthly for 3 months, then quarterly. Responsible party: dietary
Inadequate Investigation of Choking Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who experienced a choking episode that led to hospitalization. The resident, who had moderately impaired cognition and was on a mechanically altered diet, choked on a large piece of chicken, which was removed at the hospital. The facility's investigation did not include documented evidence such as staff statements or verification of the food consistency provided to the resident, as required by their policies. The investigation summary lacked confirmation that the resident received the correct diet consistency, and staff statements did not provide details about the meal served. The Director of Nursing, who was not in position at the time of the incident, acknowledged that the investigation should have included verification of dietary orders to ensure resident safety. The facility's failure to conduct a thorough investigation violated their policies on incident reporting and aspiration precautions.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 1. The Director of Nursing and Administrator have reviewed the incident and accident policy. The policy has been revised to rule out neglect, abuse and mistreatment within 72 hours of incident. Completed: 1/31/2025 2. All clinical staff will be educated on the incident and accident policy. Date: 2/28/2025 3. The lead investigator will interview all staff whom worked to determine if abuse, neglect, or mistreatment is involved. If determined within 72 hours, the staff will be suspended pending investigation. 4. Review of aspiration protocol was completed by the Administrator, Director of Nursing, Medical Director, and speech pathologist. Reeducation will be held with existing clinical staff on facility aspiration protocol. Completion date: 2/28/2025 5. For resident #4 specifically, the facility has added an order to document when the resident refuses to get out of bed for meals. Resident #4 also worked with SLP upon returning to the facility from choking incident; dietary order was changed (MONTH) 21, 2024 to reflect speech language pathologist recommendation. Completed: 8/21/2024 6. Aspiration precautions: residents will receive tray when C.N.A and/or licensed clinical staff are able to visualize consumption of meal. If the tray or meal ticket are incorrect, the tray will be withheld until staff notify the kitchen immediately for correction and inform supervisor of the error. Completion date: on-going 7. Findings will be reported to the Quality Assurance team on a monthly basis for 3 months, then quarterly. Responsible party: Director of Nursing
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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) |
|---|---|---|---|---|
| Latta Road Nursing Home East | 0 mi | ★★★★★ | 0 | 0 |
| Waterview Heights Rehabilitation And Nursing Cente | 0.3 mi | — | 40 | 2 |
| Edna Tina Wilson Living Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Hamilton Manor Nursing Home | 2.9 mi | ★★★★★ | 1 | 0 |
| Park Ridge Nursing Home | 4.4 mi | ★★★★★ | 1 | 0 |
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