Below 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 Livingston County Center For Nursing And Rehabilit during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide and document needed grooming and shaving assistance for several residents who required help with ADLs. One resident with severe cognitive impairment and another with visual impairment, both care-planned for staff assistance with shaving, were repeatedly observed with overgrown facial hair and reported disliking facial hair or being unable to shave independently, while records lacked evidence that grooming was offered, provided, or refused. A third cognitively intact resident with Parkinson’s disease and other comorbidities, also care-planned for assistance with trimming facial hair, had a long beard and mustache for months despite requesting help, with no documentation of grooming or refusals. Staff and the DON stated that facial hair care was expected, usually on shower days, but acknowledged there was no consistent place or practice for documenting grooming services or refusals.
Two residents were not treated with respect and dignity when one cognitively intact resident with diabetes, cerebral palsy, and anxiety disorder repeatedly experienced significant delays in meal service, waiting up to 45 minutes or more while watching others eat despite having a completed meal ticket, and another resident with paraplegia, traumatic brain injury, severe cognitive impairment, and a feeding tube was repeatedly left unclothed or in only an incontinence brief with stool present, visible from the hallway due to an open door and lack of a privacy curtain, while staff attempted partial coverage and door positioning that did not fully prevent hallway visibility.
An LPN prepared medications for two residents simultaneously and left one resident's medications unattended at another resident's bedside. The resident, who had a history of hypertension, atrial fibrillation, and heart failure, ingested the wrong medications, resulting in severe bradycardia, hypotension, and acute kidney injury. Facility policy prohibits leaving medications unattended, and staff interviews confirmed awareness of this requirement, but the error occurred when the LPN became distracted during the medication pass.
Surveyors found that two residents were left with unsupervised medications at their bedsides without documented assessment or physician orders for self-administration, resulting in one resident accidentally taking another's medication. Additionally, an LPN left a medication cart unlocked and unattended in a hallway. Facility leadership acknowledged that staff had been educated on these policies, but lapses continued to occur.
Failure to Provide and Document Required Grooming and Shaving Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary grooming and personal hygiene services, specifically shaving and facial hair care, for multiple residents who required assistance with activities of daily living. Facility policies required shaving male residents daily and women as needed, and indicated that licensed nurses and CNAs were responsible for implementing shaving procedures to improve appearance and morale. The DON stated facial hair was expected to be groomed at least on shower days, yet also acknowledged there was no designated area in the record to document grooming assistance and that refusals were expected to be documented in progress notes. One resident with Alzheimer’s disease, dementia, and depression had severe cognitive impairment and required maximum assistance with personal hygiene, including shaving per the care plan and CNA Kardex. Over a review period of several months, the electronic medical record contained no documentation that staff offered, provided, or recorded refusals of shaving or grooming, despite observations on multiple days showing long, patchy facial stubble and an overgrown mustache curling into the mouth. The resident’s family member reported that staff were expected to assist with shaving and that the resident did not like facial hair. A CNA and an RN manager both stated residents were shaved on shower days and acknowledged the resident required assistance and could be resistive at times, but there were no documented refusals. Another resident with a history of stroke, diabetes, and hypertensive heart disease was cognitively intact, visually impaired, and required substantial assistance with personal hygiene, including hair combing and shaving. The care plan and Kardex directed staff to assist with grooming, and ADL sheets showed grooming after set-up assistance with no refusals documented. This resident was repeatedly observed with long chin hair and facial hair on the upper lip and reported disliking facial hair, being unable to remove it independently due to impaired vision, and not refusing grooming care; the resident also stated staff had not offered assistance. A nurse manager confirmed the resident did not refuse care and that staff were expected to offer grooming assistance. A third resident with Parkinson’s disease, diabetes, and anxiety, cognitively intact and requiring moderate assistance with personal hygiene, had a care plan and Kardex directing staff to assist with shaving and trimming facial hair. Over several months, there was no documentation of grooming assistance or refusals, while observations showed a beard several inches long and a mustache curling into the mouth. This resident stated they wanted help trimming facial hair and that it had been months since grooming was last completed, while staff interviews revealed grooming was usually tied to shower days, often undocumented, and dependent on resident requests, despite the resident’s stated preferences.
Failure to Ensure Timely Meal Service and Privacy, Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity and that their quality of life was maintained or enhanced. One resident with diabetes, cerebral palsy, anxiety disorder, and intact cognition, who required set-up assistance with meals, experienced repeated and significant delays in meal service compared to other residents. During a dining observation, this resident remained the only person in the dining room without a meal for more than 45 minutes after trays began being passed, watching others eat while being told by an LPN that the meal would arrive shortly. The resident eventually left the dining room without having been served and later received the meal in their room, after the LPN acknowledged the meal ticket had been completed that morning and that the meal should have arrived with the others. Interviews and record review showed that this resident routinely received meals later than others, with delays sometimes lasting 30 minutes to an hour, and that the resident reported feeling bad and frustrated while waiting and watching others eat. A CNA stated they frequently contacted the kitchen about this resident’s meal and were often told it would take additional time, even when other residents had already been served. The RN Manager confirmed it was problematic that the resident did not receive their meal for more than 45 minutes after others and that the meal ticket had been reviewed by the dining services supervisor, who could not explain why the meal was not placed on the cart. The dining services supervisor acknowledged that residents seated together were not always served together and attributed this to lack of attentiveness to seating sheets, while the DON confirmed awareness of dining concerns and that other residents had reported long wait times. A second deficiency involved another resident with paraplegia, traumatic brain injury, severe cognitive impairment, and a feeding tube, whose care plan and CNA Kardex documented a preference not to wear clothing in bed and a requirement that the privacy curtain remain drawn at least halfway. Observations showed this resident lying in bed unclothed with the room door open and genitals exposed, visible from the hallway, and on another occasion lying in bed wearing only an incontinence brief with stool present between the legs, again visible from the hallway. Staff interviews revealed that the room lacked a privacy curtain, and staff sometimes left the bathroom door open or covered the resident with a top sheet in an attempt to conceal the resident while honoring the preference to be unclothed. The RN Manager stated staff attempted to preserve the resident’s dignity by covering them but was unaware the resident was frequently visible from the hallway, and the DON acknowledged it was not dignified for the resident to be visible from the hallway while unclothed.
Significant Medication Error Due to Unattended Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by an incident involving two residents. An LPN prepared medications for two residents at the same time, labeling both medication cups, and left one resident's medications unattended at the bedside of another resident. The resident, who was cognitively intact and had a history of hypertension, atrial fibrillation, and heart failure, ingested the medications intended for their roommate. Facility policy specifically prohibits preparing medications in advance or leaving them for self-administration outside of a nurse's supervision, and there was no documented order or assessment for the resident to self-administer medications. Following the ingestion of the wrong medications, the resident received an overdose of blood pressure and heart medications, including metoprolol and lisinopril, in addition to their prescribed regimen. This resulted in severe bradycardia and significant hypotension, with blood pressure readings dropping as low as 62/36. The resident experienced symptoms such as nausea, vomiting, lethargy, and episodes of diarrhea, and ultimately developed acute kidney injury due to hypotension and acute tubular necrosis. The resident required continuous monitoring, frequent reassessments, and was eventually transported to the hospital for further treatment and monitoring in the intensive care unit. Interviews with facility staff, including the LPN involved, the DON, and the administrator, confirmed that medications should not be left unattended in resident rooms and that staff are educated on this policy. Despite this, the LPN became distracted during the medication pass and left the medications at the bedside, leading to the error. The medical director confirmed that the incident constituted a significant medication error and emphasized that medications should be administered to one resident at a time under direct observation.
Unsupervised Medications and Unattended Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two of three residents reviewed. Specifically, medications were left unsupervised at the bedsides of two residents, and there was no evidence that these residents had medical orders or had been assessed for their ability to safely and competently self-administer medications. In one instance, a resident with diagnoses including hypertension, atrial fibrillation, and heart failure, who was cognitively intact, accidentally ingested another resident's medications after a nurse left a medication cup at the bedside and left the room. The resident's care plan did not include goals or interventions related to self-administration, and there was no documentation of assessment or physician order for self-administration. In another case, a cognitively intact resident with osteoarthritis, rheumatoid arthritis, and chronic pain was observed with an unmarked medication cup containing topical cream left unattended on their tray table. The nurse confirmed that the resident applied the cream independently, but there was no care plan or assessment for self-administration in place. Additionally, an unlocked and unattended medication cart was observed in a common hallway. A nurse admitted to leaving the cart unlocked while attending to another room, acknowledging this was against facility policy. Interviews with facility leadership confirmed that staff are educated not to leave medications in resident rooms or leave medication carts unattended, but these practices continued to occur. The Director of Nursing noted that leaving medications unsupervised is a safety concern, especially given the presence of residents with mild dementia on the unit where these incidents occurred.
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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.
Illustrative
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Illustrative
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Nursing homes near Mount Morris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Conesus Lake Nursing Home, Llc | 11.9 mi | ★★★★★ | 0 | 0 |
| East Side Nursing Home | 12.6 mi | ★★★★★ | 2 | 1 |
| Wyoming County Community Hospitals Snf | 12.9 mi | ★★★★★ | 0 | 0 |
| Avon Nursing Home L L C | 14.3 mi | ★★★★★ | 0 | 0 |
| Leroy Village Green Residential Health C F, Inc | 17.7 mi | ★★★★★ | 0 | 0 |
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