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 Penfield Place during CMS and state inspections, most recent first.
A resident with dementia, depression, and diabetes was found with multiple medications left unsupervised on their bedside table without an assessment or care plan for self-administration. Despite being cognitively intact and on high-risk medications, there was no medical order for self-administration. Interviews revealed that medications were left with the resident, who was unaware of all their medications. The DON confirmed the lack of an assessment and care plan, highlighting a protocol lapse.
A facility failed to implement a comprehensive care plan for a resident with respiratory disease and oxygen therapy needs. The resident's care plan lacked information on their condition and oxygen therapy, despite being cognitively intact and having diagnoses like acute respiratory failure. Observations showed the resident receiving oxygen with an empty, unclean humidifier bottle. Staff interviews confirmed the oversight, attributing it to a transition in electronic health records.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer medications. Resident #13, who had diagnoses including dementia with mood disturbance, depression, and diabetes mellitus, was observed with multiple medications left on their bedside table without documented evidence of an assessment or care plan for self-administration. The resident was cognitively intact according to a recent assessment and was taking high-risk medications such as an antidepressant, diuretic, and hypoglycemic. However, the comprehensive care plan did not include goals or interventions for self-administration, and there was no medical order permitting the resident to self-administer medications. During observations and interviews, it was revealed that medications were left unsupervised with the resident, who stated they did not know all the medications they were taking and preferred to take them after eating. Licensed Practical Nurse #1 admitted to leaving pills with the resident, acknowledging the need for evaluation and approval by a medical provider. The Director of Nursing confirmed that an assessment and care plan should have been in place before allowing self-administration. A Physician Assistant noted changes in the resident's cognition and awareness, and the Director of Nursing could not find documentation of an assessment for self-administration, indicating a lapse in the facility's protocol.
Failure to Implement Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with respiratory disease and oxygen therapy requirements. The resident, who was cognitively intact, had diagnoses including acute respiratory failure with hypoxia, pulmonary emboli, wheezing, and anxiety, and was receiving oxygen therapy. Despite these needs, the resident's care plan did not include any information related to their respiratory condition or oxygen therapy, which was a requirement according to the facility's Comprehensive Care Plan Policy. Observations during the survey revealed that the resident was receiving oxygen via nasal cannula, but the humidifier bottle attached to the oxygen concentrator was empty and unclean. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, confirmed that the resident should have been care planned for oxygen therapy, including specific interventions such as filling the humidifier bottle every shift and changing the tubing weekly. The Director of Nursing acknowledged that the resident was not care planned for oxygen therapy, attributing it to an oversight during the transition to a new electronic health records system.
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 155 citations issued within 25 miles in the last 12 months — including the 5 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 Penfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Friendly Home | 2.1 mi | ★★★★★ | 11 | 0 |
| Fairport Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Highlands Living Center | 3.1 mi | ★★★★★ | 2 | 0 |
| St John's Penfield Homes | 3.2 mi | — | 0 | 0 |
| Blossom Health Care Center Inc. | 3.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.