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 St. Ann's Community during CMS and state inspections, most recent first.
A resident at risk for pressure ulcers developed an open area on the buttocks, but the medical team was not notified for five days, and no treatments were ordered. The care plan was not updated, leading to further deterioration and multiple new skin injuries. Facility staff failed to follow protocols for timely documentation and notification, resulting in actual harm to the resident.
The facility failed to ensure safe medication administration for a resident with cognitive impairment, resulting in multiple doses of calcium carbonate tablets being left unattended at the resident's bedside. The resident accumulated 35 tablets, indicating a lapse in following the facility's policy and proper medication administration procedures.
The facility failed to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident was observed multiple times with their uncovered urinary drainage bag on the floor and once on a dining room table above bladder level. The care plan did not address the resident's behaviors related to the catheter, leading to repeated non-compliance with facility policy.
The facility failed to maintain proper infection control practices during wound care for two residents, as LPNs did not perform hand hygiene or change gloves between treating different wounds and touched various surfaces with soiled gloves.
Failure to Provide Timely Wound Care and Update Care Plan
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident, identified as Resident #3, who was at risk for pressure ulcer development. The resident was found to have an open area on the left buttocks, but the medical team was not notified for five days, and no medical treatments were ordered during this period. The resident's care plan was not updated promptly to address the new skin integrity issues, leading to further deterioration of the pressure ulcer and the development of multiple new skin injuries. The facility's policy on skin care management required timely documentation and notification of new skin issues, as well as adherence to treatment guidelines outlined in the Clinical Practice Quick Reference Guide. However, these protocols were not followed. The resident's baseline care plan included interventions such as nursing treatments per medical orders, preventative skin care products, and regular skin checks, but these were not effectively implemented. The resident's condition worsened, resulting in several facility-acquired pressure injuries, including an unstageable sacral wound and a stage 3 pressure wound on the left ankle. Interviews with facility staff revealed a lack of communication and timely action in addressing the resident's skin issues. Certified Nursing Assistant #1 reported a red area to the team leader, who documented the finding but did not notify the medical team or request immediate treatment. The Clinical Coordinator acknowledged receiving reports of skin issues but did not take further action to expedite wound consultations or update the care plan. As a result, the resident experienced actual harm, though it was not classified as Immediate Jeopardy.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #3: Resident seen by provider and treatments ordered. Care plan reviewed and revised with interventions added. Nurse #3: Nurse was re-educated on the use of the Wound Ulcer Quick Reference Guide, observing the wound, notifying an RN, notifying the provider, getting an order for [REDACTED]. Nurse received disciplinary action. Nurse #4: Nurse did document in the medical record that she notified the medical provider and to leave open to air with no new treatment order. Provider did request wound consult which was ordered. Nurse was re-educated to document the provider's credentials and to add interventions to care plan. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents were assessed for any skin issues to verify any pressure ulcer had a treatment order in place. No issues were found at the time of the audit in (MONTH) and (MONTH) 2024. All elders/patients with a pressure ulcer will be reviewed to ensure there were no other elders/patients found without an assessment, provider notification, or interventions put in place. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? The Wound Ulcer Management Guide has been reviewed and revised to include notification of medical providers. The Wound Ulcer Management Guide was added to the intranet page of the organization home page. Training will be provided to all nurse managers, RN Clinical Coordinator and Senior LPNs, and nursing supervisors regarding wound management guide, notification to medical to obtain treatment orders at time of new open area, use of EMR alerts, and monitoring and tracking in EMR. Policy will be reviewed and revised for skin management. The nursing leader responsible for the unit will review all progress notes, alerts, and orders for wound consults in the last 24 hours Monday – Friday. The day following a weekend or holiday a nursing leader will review all notes since last review and ensure skin management program was followed. New pressure ulcers will be placed on 24 hr. report sheet with location of area. An audit on all residents with pressure ulcers will be done on all to make sure the skin management program has been followed. Nursing administration has coordinated coverage for nursing units when no RN is available on the unit. Will implement a new system to monitor and track wounds through EMR. Will re-educate all Nurse Managers, Clinical Coordinators, Senior LPNs, and supervisors to document any new pressure ulcer and/or interventions on care plan and care card. How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? An audit will be done by Nursing Leaders or designee on every elder/patient with a pressure ulcer to determine if the skin management program has been followed weekly x 8 weeks, monthly x 3, then frequency as determined by QAPI committee. Cynthia Lovetro, RN, CNO responsible for P(NAME)
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for Resident #330, who was moderately impaired cognitively and had diagnoses including narrowing of the esophagus, mild cognitive impairment, and gastroesophageal reflux disease. The facility's policy required medical and nursing staff to determine if a resident is safe to self-administer medications, but there was no documentation in Resident #330's Comprehensive Care Plan regarding their ability to self-administer medications. Despite this, multiple doses of calcium carbonate tablets were left unattended at the resident's bedside without any assessment to ensure safety. The resident accumulated these tablets over several days, indicating that the medication administration process was not properly followed. Observations and interviews revealed that the resident had been storing the tablets in their bedside drawer, with a total of 35 tablets found. Both the Licensed Practical Nurse and the Registered Nurse Manager confirmed that Resident #330 was not authorized to self-administer medications and that the tablets should not have been left in the resident's possession. This oversight in medication administration and lack of adherence to the facility's policy led to the deficiency cited under 10 NYCRR 415.11(c)(3)(i).
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. Specifically, the resident was observed multiple times with their uncovered urinary drainage bag lying directly on the floor and once on a dining room table above the level of their bladder. The facility's policy mandates that the urinary drainage bag should be kept below the level of the bladder and off the floor at all times. However, these guidelines were not followed, and the resident's Comprehensive Care Plan did not include goals or interventions related to behaviors involving their urinary catheter and drainage bag. The resident had diagnoses including neurogenic bladder, benign prostatic hyperplasia, and dementia, with severely impaired cognition. Despite the resident's history of playing with their catheter bag and tubing, the care plan and Resident Care Summary lacked specific instructions to manage these behaviors. Interviews with staff confirmed that the urinary drainage bag should not be on the floor or above the bladder level and should be covered. Staff also acknowledged the resident's behavior of moving and playing with the drainage bag, yet these behaviors were not addressed in the care plan, leading to repeated non-compliance with the facility's policy and procedures.
Infection Control Deficiencies During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by inappropriate hand hygiene and glove use during wound care for two residents. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene before applying gloves, did not change gloves or perform hand hygiene between treating different wounds, and touched various surfaces with soiled gloves. This was observed during wound care for a resident with multiple pressure ulcers and gangrene, where the LPN did not follow proper procedures, leading to potential cross-contamination between wounds and surfaces. Another instance involved an LPN who, while treating a resident with a stage 3 pressure ulcer, failed to change gloves or perform hand hygiene after removing a soiled dressing. The LPN then touched multiple environmental surfaces and the resident's clothing with the same gloves used during the dressing change. Both LPNs acknowledged their failure to follow proper hand hygiene and glove use protocols during interviews. Interviews with the Infection Control Nurse and the Chief Nursing Officer confirmed that the expected protocol was to perform hand hygiene and change gloves between wound sites and after removing soiled dressings. The facility's policies on standard precautions and hand hygiene were not adhered to, leading to deficiencies in infection control practices during wound care for the residents involved.
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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) |
|---|---|---|---|---|
| The Pearl Nursing Center Of Rochester | 0.2 mi | ★★★★★ | 6 | 0 |
| The Brook At High Falls Nursing Home And Rehabilit | 1.7 mi | ★★★★★ | 10 | 0 |
| Lilac Manor Rehabilitation And Nursing Center | 2.7 mi | ★★★★★ | 3 | 0 |
| Kirkhaven | 2.9 mi | ★★★★★ | 10 | 0 |
| Blossom Health Care Center Inc. | 3.6 mi | ★★★★★ | 1 | 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.