Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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.
Unlabeled pre-poured pills were found in six medication cups on a cart, and an LPN said the meds were set aside when residents were not immediately located. The LPN also stated the meds were documented as given before actual administration so the med pass could be completed on time. The DON stated meds should be prepared one resident at a time and documented after they are given.
Untrained staff member fed a resident without approved paid feeding assistant training. A resident with dysphagia, essential tremor, protein-calorie malnutrition, and moderately impaired cognition was observed receiving breakfast assistance from an administrative assistant who had not completed the State-approved paid feeding assistant course. The resident’s care plan included aspiration precautions and adaptive devices, but did not reflect use of a feeding assistant, and the staff member was not listed among the facility’s trained paid feeding assistants.
The facility failed to provide newly admitted residents and/or their representatives with a written summary of a Baseline Care Plan within 48 hours of admission. Nine residents did not receive the necessary documentation, including initial goals, admission orders, dietary, therapy, and social services. Interviews confirmed that the Baseline Care Plans were not provided in a timely manner, as the facility prioritized providing the Comprehensive Care Plan during initial family meetings instead.
A resident with constipation, dehydration, and dementia experienced extended periods without documented bowel movements. Despite having orders for multiple medications, the facility failed to follow its bowel management policy, leading to significant gaps in care and documentation. Staff interviews revealed inconsistencies in monitoring and documenting bowel movements, resulting in inadequate care for the resident.
A resident with Parkinson's disease received an incorrect dose of pramipexole for over a month due to a transcription error by an LPN and a failure to follow proper verification procedures. The resident experienced increased hallucinations and a fall resulting in a head laceration before the error was identified.
Numerous controlled medications, including narcotics and opioids, were found unsecured and not in a double-locked cabinet in one of the medication rooms. The RN Manager and LPN confirmed that the cabinet should always be locked, and the facility's policy mandates double-locking of controlled substances.
Unlabeled Pre-Poured Medications on Cart
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted professional principles on the 3200 Unit medication cart. During observation on 09/09/2025 at 9:10 AM, six unlabeled medication cups containing various pre-poured pills were found on the cart. Licensed Practical Nurse #2 stated the cups contained medications for Residents #3, #23, #33, #48, and #50, and said the medications had been pre-poured and stored in the cart when residents were not immediately located. The nurse also stated that the medications were documented as given in the Medication Administration Record before they were actually administered so the medication pass could be completed on time. Review of the Medication Administration Audit report showed that Residents #3, #23, #33, #48, and #50 were documented as having received their medications between 7:55 AM and 8:31 AM. The facility policy stated medications may not be set up in advance and must be documented after they are taken by the resident. The DON stated nurses should prepare medications one resident at a time and document after administration, and that pre-pouring and documenting as given before actual administration is dangerous because a nurse could give the wrong medications to the wrong resident.
Untrained staff member fed resident without approved paid feeding assistant training
Penalty
Summary
The facility did not ensure that feeding assistants had successfully completed a State-approved training course before providing dining assistance, and a staff member who had not completed that training was observed physically assisting Resident #34 with breakfast. Resident #34 had diagnoses including dysphagia, essential tremor, and protein-calorie malnutrition, and the Minimum Data Set dated 09/01/2025 indicated moderately impaired cognition and the need for set-up assistance with eating. The resident’s comprehensive care plan, reviewed on 09/09/2025, showed aspiration precautions and the use of adaptive devices during meals, but did not reflect the use of a feeding assistant. During the observation, Administrative Assistant #1 was the only staff member in the dining room and was providing feeding assistance to Resident #34. Facility records showed that paid feeding assistant training had been provided in July 2017 and August 2023, and only three staff had completed the approved training; Administrative Assistant #1 was not on that list. In interviews, Administrative Assistant #1 stated that non-CNA and non-licensed staff were assigned to cooking, serving, and cleaning duties and did not identify feeding residents as an assigned task. The Administrator stated that staff who were not CNAs, LPNs, RNs, or trained paid feeding assistants could not feed residents, and later confirmed that Administrative Assistant #1 had received training during the COVID pandemic but had not completed the State-approved training program.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that newly admitted residents and/or their representatives were provided with a written summary of a Baseline Care Plan within 48 hours of admission. This deficiency was identified for nine residents, who did not receive the necessary documentation that included initial goals, admission orders, dietary, therapy, and social services. The facility's policy required that a Baseline Care Plan be initiated and completed within 48 hours of admission, but this was not adhered to, as evidenced by the lack of documentation in the residents' electronic health records and delayed provision of care plans during initial family meetings, which occurred well beyond the 48-hour requirement. For instance, Resident #58, admitted with Alzheimer's disease, depression, and diabetes, had no documented evidence of a Baseline Care Plan being implemented within 48 hours or that a written summary was provided. Similarly, Resident #56, with atrial fibrillation, depression, and a fall with a fracture, did not receive a summary of care until 55 days after admission. Resident #55, admitted with dementia, a pressure ulcer, and diabetes, also did not receive a summary of care until 41 days after admission. Interviews with the Social Worker and the Director of Nursing confirmed that the Baseline Care Plans were not provided in a timely manner, as the facility prioritized providing the Comprehensive Care Plan during initial family meetings instead.
Failure to Manage Bowel Patterns for Resident
Penalty
Summary
The facility did not ensure that Resident #2 received treatment and care in accordance with professional standards of practice. Resident #2, who had diagnoses including constipation, dehydration, and dementia, experienced several extended periods without a documented bowel movement. Despite having physician orders for multiple medications to treat constipation, the resident did not receive appropriate interventions to manage their bowel patterns. The facility's bowel management policy required monitoring and intervention after six shifts without a bowel movement, but this protocol was not followed for Resident #2, leading to significant gaps in bowel movement documentation and care. The comprehensive care plan for Resident #2 did not include measurable goals or interventions to address constipation or bowel management, nor did it address the resident's history of or current refusals of care. The bowel movement report revealed multiple instances where Resident #2 went for extended periods without a documented bowel movement, and the as-needed bowel regimen was not consistently initiated or followed up on. Interviews with staff indicated a lack of adherence to the bowel management policy, with responsibilities for monitoring and documenting bowel movements not being consistently executed. Despite routine medications being administered as ordered, there were no documented results for the as-needed medications, and the resident's refusals of care were not adequately addressed. Staff interviews revealed inconsistencies in running and reviewing the bowel movement report, and there was a failure to add Resident #2 to the bowel movement list for necessary interventions. The Director of Nursing confirmed that the bowel report should be reviewed every shift, but this was not consistently done, leading to the deficiency in care for Resident #2.
Significant Medication Error for Resident with Parkinson's Disease
Penalty
Summary
The facility did not ensure that a resident was free from significant medication errors. Specifically, a resident with Parkinson's disease received an incorrect dose of pramipexole for an extended period. The neurologist recommended stopping pramipexole 1.5 mg three times a day and starting pramipexole extended relief 3 mg once daily. However, a telephone order was incorrectly entered as pramipexole 3 mg three times daily, resulting in the resident receiving a total of 9 mg daily instead of the recommended 3 mg daily. This error persisted for over a month before being identified. The error occurred when a Senior Licensed Practical Nurse (LPN) called a Physician Assistant (PA) to discuss the neurologist's recommendations. The LPN then transcribed the medication order incorrectly, and the order was not read back to the PA for verification. The electronic order was not signed until over a month later by a physician. During this period, the resident experienced increased hallucinations and had a fall resulting in a head laceration. The pharmacy consultant also failed to identify the irregularity during a medication review. Interviews with the Director of Nursing (DON), the Senior LPN, the pharmacist, and the PA revealed that the error was due to human error and a failure to follow proper procedures. The DON confirmed that the order had not been signed until much later, and the pharmacist admitted to missing the alert for the excessive dose due to alert fatigue. The PA could not recall if they had signed the order but acknowledged the process now requires the full consult note before approving and signing an order.
Unsecured Controlled Medications in Medication Room
Penalty
Summary
The facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for one of the two medication rooms reviewed. Specifically, numerous controlled medications, including narcotics and opioids, were observed unsecured and not in a double-locked cabinet as required by regulations. During an observation on the third-floor medication room, the narcotic cabinet double doors were found open and unlocked, leaving the controlled medications unsecured. The Registered Nurse Manager confirmed that the controlled medication cabinet doors should not be unlocked, and the Licensed Practical Nurse admitted to leaving the cabinet unlocked because they were in a hurry. The cabinet contained numerous bags of controlled substances, including pain medications, narcotics, opioids, and anti-anxiety medications. In subsequent interviews, both the Licensed Practical Nurse and the Director of Nursing confirmed that the narcotic medication cabinet doors should always be kept locked. The facility's policy on the storage, distribution, administration, and wasting of controlled substances, dated 4/11/22, documented that controlled substances must be stored, distributed, and administered in a safe, secure manner with total compliance with all legal and regulatory requirements. The policy specifically stated that the narcotics supply is to be kept under two locks at all times and that all controlled substances are to be returned to the medication room narcotic cabinet and double-locked after a medication pass.
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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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Illustrative
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Nursing homes near Webster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maplewood Nursing Home Inc | 1.8 mi | ★★★★★ | 0 | 0 |
| Penfield Place | 5.5 mi | ★★★★★ | 0 | 0 |
| Blossom Health Care Center Inc. | 5.6 mi | ★★★★★ | 1 | 0 |
| St. Ann's Community | 5.8 mi | ★★★★★ | 0 | 0 |
| The Pearl Nursing Center Of Rochester | 5.9 mi | ★★★★★ | 6 | 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.