Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 The Grand Rehabilitation And Nursing At Rome during CMS and state inspections, most recent first.
Surveyors found multiple failures in medication security and labeling on three of four medication carts. On one Wing Three cart, an LPN left the cart unlocked and unattended with two unlabeled cups of pre‑poured medications for residents who were not immediately available, and the nurse admitted not knowing what to do with pre‑poured meds when a resident could not be found. On another Wing Three cart, surveyors found an opened, unlabeled lidocaine vial, an undated fluticasone/salmeterol inhaler, expired insulin (Rezvoglar pen and Humulin R vial) still stored in the cart, and additional opened insulin (lispro vial and Lantus pen) that were undated, with the LPN confirming these should have been dated and removed when expired. On a Wing Four cart, opened artificial tears and latanoprost eye drops lacked open dates, and several opened inhalers were undated and unlabeled; the LPN stated they had not been trained that inhalers required dating and believed they did not expire, despite facility policy requiring opened multi‑dose medications to be dated and outdated drugs not to be used.
Surveyors identified multiple failures in food storage, sanitation, and meal service, including a main kitchen reach-in cooler operating above safe temperatures with improperly cooled eggs and other cold foods, and black residue on cooler door gaskets and a walk-in milk cooler ceiling crease in both the main kitchen and a unit pantry. There was no documented kitchen cleaning schedule, no record of gasket or ceiling cleaning, and staff gave conflicting accounts of who was responsible for cleaning refrigerators and gaskets. During meal service, a food service worker attempted to provide a resident with a tray taken from a cart containing dirty and uneaten trays, without a tray ticket, before acknowledging this should not be done and removing the tray.
Failure to Thoroughly Investigate Abuse, Neglect, and Mistreatment Allegations: The facility did not thoroughly investigate multiple allegations involving a resident reporting an LPN withheld pain meds, a CNA calling a resident a liar, and a resident threatening another resident with a broken plate. Records and staff interviews showed the concerns were not fully investigated, involved staff were not properly removed from resident contact during review, and no documented plan was in place to identify or protect the threatened resident.
Two residents receiving hemodialysis had missing pre- and post-dialysis documentation and inconsistent oversight of their access sites. The facility’s LPNs reported completing pre-dialysis forms and post-dialysis checks, but records showed many absent communication sheets and no routine documented assessment of the Tesio catheter or fistula site. One resident also reported returning from dialysis with a clotted catheter and not being assessed or having VS taken.
The facility failed to follow care-planned ADL assistance for two residents who required substantial help with oral hygiene and toileting. One resident with dementia and Parkinson’s disease, care-planned for substantial/maximum assistance with oral care, was repeatedly observed with foul breath, reported that staff did not brush their teeth, and had oral care documented as completed by a CNA who later admitted they had not provided it and had charted anticipated care. Another resident with dementia, dependent for most ADLs and care-planned for regular toileting and brief checks every few hours, was observed sitting in the dining area for extended periods without being toileted or repositioned, was later found with a saturated brief or visibly wet clothing, and had toileting documented at times inconsistent with observations. CNAs and an LPN acknowledged expectations for toileting every 2–3 hours and for staff to brush teeth when substantial assistance was required, but these practices were not carried out or accurately documented.
Surveyors found that the facility failed to maintain accurate and secure controlled substance management on one unit. An LPN and another nurse did not complete required two‑nurse narcotic counts before exchanging keys, and several controlled drug records did not match the actual quantities on hand. For multiple residents receiving Vimpat, gabapentin, hydrocodone‑acetaminophen, and PRN lorazepam, doses were signed out on controlled substance logs with incorrect balances, one PRN lorazepam dose was signed out but not documented as given on the MAR, and a poured dose of liquid Vimpat was left in a cup inside the narcotic compartment instead of being administered or wasted. Staff interviews confirmed that counts were sometimes estimated, done by a single nurse, or pre‑signed, contrary to facility policy requiring real‑time documentation, two‑nurse reconciliation, and immediate wasting of unused controlled doses.
Failure to follow renal diet and fluid restriction orders for a resident with ESRD and dialysis. Staff did not document actual fluid amounts, used percentage-only intake records, and gave extra fluids including chocolate milk beyond the meal allotment. The resident’s chart lacked clear tracking of fluid restriction compliance and related dialysis lab review, while staff interviews showed confusion about renal diet and fluid restriction requirements.
A resident with dementia and bipolar disorder had a care plan that listed only general interventions such as giving meds and asking yes/no questions, without specific person-centered dementia approaches. Staff observed the resident wandering, entering another resident’s room, sleeping in a hallway chair, and loudly vocalizing in the hallway with no staff interaction, while interviews showed staff knew the resident’s preferences but said that information was not included in the care instructions.
Late Ativan Administration: A resident with anxiety and depression received Ativan outside the ordered medication window on multiple occasions. The MAR showed several late doses, and the resident stated the delays increased anxiety and caused shortness of breath. Staff interviews confirmed the doses were late, were not properly documented or reported, and were outside the facility’s medication pass timeframe.
Improper garbage disposal was observed around a dumpster area near the loading dock, where used gloves, empty food containers, and vegetable scraps were found on the ground. The facility policy required dumpsters to be kept clean, secure, and sanitary, but staff interviews showed maintenance was responsible for checking and cleaning the area, which was in poor repair with loose gravel.
Failure to Follow Contact Precautions: Staff did not wear required PPE when entering the rooms of two residents on contact precautions. One resident had quadriplegia, a trach, urinary devices, and ESBL colonization; the other had chronic open leg wounds, skin ulcers, and MDR organism history. Surveyors observed CNAs entering and working in the rooms without gowns or gloves, and one CNA moved an overbed tray table out of a precaution room without disinfecting it.
A resident with diabetes and diabetic wounds was discharged without proper education, supplies, or medication reconciliation, and without confirmation of safe housing or supportive services. The resident, lacking identification and a primary care provider, was sent to the Department of Social Services without prior coordination, resulting in denial of emergency housing and subsequent hospitalization for severe hyperglycemia.
A resident with a history of a brain hemorrhage and dependent on staff for care developed a Stage 2 pressure ulcer due to inadequate incontinence care. The facility's failure to provide consistent toileting hygiene and wound treatment led to the ulcer progressing to an unstageable state with necrotic tissue. Despite care plans and protocols, the resident's condition worsened, resulting in hospitalization.
The facility failed to maintain a safe, clean, and homelike environment across all units, with issues such as sticky floors, damaged walls, and unclean resident chairs. Drain flies were observed, and negative air pressure was lacking in soiled utility rooms. Staff interviews revealed systemic issues in maintenance and housekeeping, with no documented work orders for the deficiencies.
A facility failed to provide adequate hygiene care for residents, including those with dementia and hemiplegia, resulting in untrimmed and soiled fingernails. Staff were unaware of residents' needs for glasses and nail care, and documentation inaccurately reflected care provided.
The facility failed to serve food and drinks at safe and appetizing temperatures, as observed during breakfast and lunch meals. Residents reported dissatisfaction with the food's taste and temperature, with items like scrambled eggs and pureed chicken served below the required 135°F. Cold items, such as diet cola and milk, were also served above the acceptable temperature range. The Food Service Director confirmed that such temperatures could lead to foodborne illnesses.
The facility failed to provide adequate dining facilities for residents on Units 100 and 400, resulting in residents being lined up in hallways during meals. Observations showed that dining areas did not accommodate residents' needs, with many eating in cramped conditions without social interaction. Staff interviews revealed that the main dining room had been closed due to staffing issues, contributing to the lack of space and dignified dining experiences.
Two residents with severe cognitive impairments were treated undignifiedly by staff, who referred to them as 'feeders' and assisted them with eating in a disrespectful manner. This violated the facility's dignity policy, which mandates respectful treatment and avoidance of labels based on care needs.
A facility failed to conduct a Level II PASARR for a resident newly diagnosed with schizoaffective disorder, as required by federal regulations. Despite the diagnosis, no documentation of a referral was found. Interviews revealed that the Director of Social Work did not initiate the screening process for new mental health diagnoses, and the Director of Nursing confirmed that such diagnoses were discussed in meetings but not followed by a new PASARR.
A resident with dysphagia and no teeth was served whole sandwiches instead of the prescribed chopped consistency diet, posing a choking risk. Despite facility policies requiring meal accuracy checks, staff failed to ensure the resident received food prepared to meet their individual needs.
A resident with Alzheimer's and chronic kidney disease did not receive the prescribed fluids and was not offered a suitable substitution when requesting a sandwich. Despite being on a pureed diet, the resident's care plan was not updated to reflect dietary changes, leading to inadequate food intake and dissatisfaction. Staff interviews revealed a lack of follow-through in providing requested food alternatives.
The facility violated CMS regulations by conducting an off-site nurse aide training program despite a prohibition. Observations revealed that nurse aide students were receiving clinical training at the facility, which was not allowed under the CMS letter dated February 2024. The facility's administration was unaware that the prohibition applied to off-site training, leading to the continuation of the program until the survey.
Improper Medication Cart Security and Failure to Label and Remove Outdated Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were securely stored and properly labeled in accordance with facility policy and accepted professional standards. On Wing Three, surveyors observed the front medication cart unlocked and unattended, with the first drawer containing two unlabeled cups of pre‑poured medications. Each cup contained multiple different pills, and the responsible LPN stated they had walked away from the cart to speak with a family member and acknowledged the cart should never be left unlocked and unattended. The LPN also stated that one resident was not available for medication administration and that they were waiting for another resident’s inhaler from the pharmacy, and admitted they were unsure what to do with pre‑poured medications when a resident was unavailable. Further observations on the Wing Three back cart revealed multiple issues with labeling and expiration of medications. Surveyors found an opened, unlabeled, and undated vial of lidocaine in the second drawer, which the assigned LPN stated came with ertapenem and had not been labeled or dated when opened; the LPN was unsure whether it needed to be dated. The third drawer contained an undated fluticasone/salmeterol inhaler, which the LPN acknowledged should probably have been labeled when opened but was not. Another drawer contained a Rezvoglar insulin pen and a Humulin R insulin vial with open dates indicating they were beyond the stated in‑use period; the LPN confirmed they were expired and should be discarded and reordered, and could not explain why expired insulin remained in the cart. The same drawer also contained an opened, undated insulin lispro vial and an opened, undated Lantus insulin pen, which the LPN stated were required to be dated when opened but could not determine when they had been opened or whether they were expired. On Wing Four, surveyors observed additional failures to date and label opened medications. In the first drawer of the back medication cart, artificial tears and latanoprost eye drops were found opened without open dates, despite the assigned LPN stating that eye drops were supposed to be labeled with an open date and an expiration date and that they expired 30 days after opening; the LPN was unsure why these eye drops lacked open dates. In the third drawer, opened, undated inhalers (including umeclidinium/vilanterol and albuterol) were found without labeling to indicate when they were opened. The LPN assigned to this cart stated they had never been trained that inhalers had to be labeled when opened, did not think inhalers expired, and believed they were good until the medication was finished, despite the unit manager later stating that inhalers and eye drops should be dated when opened and were typically good for 30 days. Facility policies in effect required medication storage compartments to be locked when unattended, prohibited use of outdated drugs, and required multi‑dose medications to be dated when opened.
Improper Food Storage, Sanitation, and Meal Tray Handling
Penalty
Summary
The deficiency involves failure to store, clean, and handle food in accordance with professional standards in the main kitchen and a unit pantry. Surveyors observed that the main kitchen cold production reach-in cooler had an internal temperature of 50°F, with stored items including hard‑boiled eggs, cheese slices, poultry cold cuts, liquid supplements, and poured juices; the hard‑boiled eggs measured 43.2°F, above the facility policy requirement that cold food be stored below 41°F. A black substance was observed on the door gasket of this reach‑in cooler, along the ceiling crease of the main kitchen walk‑in milk cooler, and on the door gasket of the Unit 2 snack refrigerator. There was no documented main kitchen cleaning schedule, and the food service maintenance communication log from September 2025 through April 2026 contained no entries for gasket or walk‑in cooler ceiling crease cleaning. Staff interviews revealed conflicting understandings of responsibility for cleaning refrigerators and gaskets, with food service leadership stating maintenance was responsible for gaskets, while maintenance leadership stated kitchen staff were responsible, and nursing staff reporting they cleaned unit refrigerators without a set schedule and did not clean gaskets. The deficiency also includes improper meal service practices. During a lunch observation, a resident who had initially declined lunch later requested it after the food cart had left the wing with dirty and uneaten trays mixed throughout the cart. A food service worker went to the dirty cart in the hallway, pulled several trays out before selecting one they felt looked acceptable, and brought it to the unit without a tray ticket, handing it to a CNA. The worker then acknowledged that trays removed from a dirty food cart should not be served and removed the tray, stating they would obtain a fresh one. The food service director later stated that uneaten meal trays mixed with dirty trays should not be served for infection control reasons and that staff should obtain a new tray from the kitchen.
Failure to Thoroughly Investigate Abuse, Neglect, and Mistreatment Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations involving abuse, neglect, or mistreatment for three residents. The report states that a policy in effect required all reports of resident abuse, neglect, exploitation, or misappropriation to be thoroughly investigated, and that any employee accused of abuse was to be placed on leave with no resident contact until the investigation was complete. However, the documented events showed that allegations involving a CNA calling a resident a liar, an LPN allegedly withholding pain medication from another resident, and a resident threatening another resident with a broken plate were not fully investigated as required. Resident #11 was cognitively intact and had diagnoses including acute osteomyelitis, a brain bleed, and a right leg fracture. The resident’s care plan identified risk for abuse and neglect and included interventions for pain management. The record showed oxycodone orders and medication administration entries by an LPN, including doses documented without a pain level or with pain assessment entries that did not clearly support the resident’s later allegation. The resident stated that the LPN withheld multiple doses of oxycodone and reported this to several staff members, including an LPN, a COTA, and the DON. Staff interviews showed that some staff heard the allegation, but the concern was not reported through the chain of command for investigation, and the DON stated she was not informed of the allegation and therefore no investigation was completed to determine whether neglect or mistreatment occurred. Resident #21 was cognitively intact and independent for most ADLs after set-up. The resident reported having an audio recording of a CNA calling them a liar, and the record included a disciplinary action form showing the CNA violated policy by questioning a resident and calling them a liar. The DON acknowledged the CNA should have been removed from work while the incident was investigated and stated that statements from the involved residents were not obtained. The investigation consisted only of a counseling memo, a statement from the social worker, and a statement from the CNA, with no documented evidence that the allegation was thoroughly investigated to rule out abuse. Resident #37 had paranoid schizophrenia, depression, anxiety disorder, and moderately impaired cognition. Progress notes documented that the resident broke a glass plate, used a piece as a weapon, threatened staff and other residents, and told police they were going to cut another resident’s throat. The record contained no documented evidence that the incident was investigated or that a plan was put in place to protect the other resident. The DON stated there was no investigation completed, that the resident involved should have been identified, and that nothing had been put in place to protect that resident.
Inconsistent dialysis assessments and missing access-site documentation
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for two residents who received hemodialysis at a community dialysis center. Both residents had chronic kidney disease requiring dialysis and diabetes, and both had care plans and physician orders calling for pre- and post-dialysis evaluations, vital signs, weights, monitoring for edema, and assessment of the dialysis access site. The facility policy also described communication with the dialysis center and use of a communication log for residents going to dialysis. For Resident #16, the record showed repeated gaps in the documented pre-dialysis communication sheets and numerous missing post-dialysis communications. The resident’s orders required pre- and post-dialysis evaluations three times weekly and monitoring of the right chest Tesio catheter for bleeding and dressing placement every shift. The resident stated that when they returned early from dialysis because the catheter was clotted, no one checked the catheter site or took vital signs, and that it was rare for staff to look at the catheter site. Staff interviews confirmed that pre-dialysis forms were completed, but post-dialysis documentation was often not completed when the resident returned on a different shift. For Resident #3, the record also showed missing pre-dialysis communication forms on multiple dialysis days, and there was no documented evidence that the dialysis access site was routinely assessed as planned. Staff stated they were responsible for completing pre- and post-dialysis assessments, documenting stability, fistula patency, vitals, and post weights, and sending communication forms with the resident to dialysis, but some forms were not found in the record. The deficiency was based on the lack of consistent on-going assessment and oversight before and after dialysis treatments and the absence of documented routine access-site assessment for both residents.
Failure to Provide Planned Oral Care and Toileting Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically oral hygiene and toileting, as required by residents’ care plans and facility policy. Facility policy stated that residents needing ADL assistance would receive adequate toileting every two to four hours and staff would assist with oral hygiene, with refusals reported to a supervisor. Resident #1, with dementia, anxiety, and Parkinson’s disease, had a care plan and care instructions requiring substantial/maximum assistance with personal hygiene and oral care, meaning staff were to apply toothpaste and brush the resident’s teeth. The Minimum Data Set (MDS) documented moderately impaired cognition, substantial/maximum assistance needed for hygiene and toileting, partial/moderate assistance for oral care, and no rejection of care. Resident #1 was observed on two separate dates with foul breath. Documentation showed that a CNA recorded oral care as completed during the overnight shift, but that CNA later stated they did not perform oral care for the resident and had documented anticipated care at the start of the shift rather than after completion. Another CNA assigned to the resident on day shift stated they did not brush the resident’s teeth because they believed night shift had already done so, and confirmed the resident had never refused care. The resident reported that staff did not brush their teeth and that they liked having their teeth brushed. An LPN and the unit manager both described that substantial/maximum assistance for oral care required staff to brush the resident’s teeth and that refusals should be documented, but the LPN incorrectly stated that the resident was independent with brushing their teeth, contrary to the care plan and MDS. Resident #2, with dementia and dependence for most ADLs, had a care plan documenting dependence on toileting hygiene, supervision or touching assistance for toilet transfers, and interventions including checking and changing briefs every three to four hours and as needed. Continuous observations on two separate days showed the resident seated in the dining area for over four hours each day without being repositioned, taken to the bathroom, or offered toileting, until staff eventually walked the resident to the bathroom or room. On one day, the resident’s brief was observed to be saturated when removed; on the other day, a large wet area was visible on the resident’s pants. Documentation indicated the resident was toileted during the day shift on both days at times inconsistent with the observed lack of toileting. The CNA caring for the resident stated residents were to be toileted or repositioned every two to three hours and that refusals should be reported to a nurse, but admitted that although the resident declined offers to be changed, these declinations were not reported and the resident was not re-approached. An LPN stated residents should be repositioned and toileted every two hours and that the assigned aide was responsible for doing so while the nurse ensured it occurred, and confirmed the resident should not have been sitting for over four hours.
Failure to Accurately Reconcile and Securely Manage Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate records and secure handling of controlled substances on Unit 1, contrary to its own Controlled Substance/Narcotic Management Protocol. Policy required that with each administration, nurses document date, time, prior and post‑administration counts, and sign the controlled substance log; that any dose removed but not given be destroyed in the presence of another nurse; that all narcotics be counted and reconciled at the beginning of every shift by both oncoming and outgoing nurses with both signing; and that discrepancies be reported immediately. On the dates reviewed, the narcotic count sheets, individual controlled substance records, and actual on‑hand quantities did not match, and required two‑nurse shift counts were not consistently performed before narcotic keys were exchanged. For one resident receiving Vimpat (lacosamide) twice daily, the narcotic count record showed 940 mL remaining, while direct observation found only 850 mL on hand (one opened bottle at the 50 mL mark and two unopened 400 mL bottles). The LPN who signed the 8:00 AM administration documented using 20 mL and a remaining balance of 940 mL, and the MAR reflected that the dose was given, but the nurse later stated there were only 850 mL and could not explain why 940 mL was recorded. For another resident on Vimpat 10 mL twice daily, the LPN signed out 10 mL on the controlled substance record, leaving a documented balance of 120 mL, but also documented on the MAR that the morning dose was “poured but not given” because the resident did not wake up. A clear liquid in a 30 mL cup was found spilled in the locked narcotic compartment; the LPN identified it as that resident’s Vimpat, stated they had placed it there when the resident was not awake, and admitted they forgot it and did not discard it as required. For a resident with an as‑needed order for lorazepam 0.5 mg every six hours for anxiety, a blister pack with 26 tablets was observed, while the lorazepam administration record showed that one tablet had been signed out at 8:00 AM with a balance of 25 tablets. The MAR, however, contained no documentation that the resident actually received lorazepam that day. The LPN stated they signed out the lorazepam intending to administer it but did not give it because the resident was not having behaviors, and acknowledged they should not have signed it out on the count sheet. For a resident receiving scheduled gabapentin 300 mg twice daily, there were 55 tablets physically present (a full card of 30 in the medication room and a card of 25 in the cart), but the narcotic count record and controlled substance record documented a balance of 56 tablets after one tablet was signed out at 8:00 AM; the LPN stated they must have counted wrong when documenting the balance. For another resident prescribed hydrocodone‑acetaminophen 5‑325 mg three times daily, there were 66 tablets on hand (two full 30‑tablet cards and one card with six tablets), while the narcotic count record documented a 7:00 AM balance of 68 tablets. The controlled substance administration record showed the LPN signed out one tablet leaving a balance of 66 tablets, which did not reconcile with the earlier count sheet. The LPN reported that narcotics were supposed to be counted by two nurses and that the numbers on the count sheets should match the pills on hand, but stated that when they arrived that morning, the other LPN had already filled out and signed the narcotic count sheet and they then counted alone and co‑signed. The outgoing LPN confirmed that counts were supposed to be done by two nurses at shift change, admitted they had roughly estimated the Vimpat volume without glasses, acknowledged the count sheet should not have shown 940 mL when only about 850 mL were present, and stated they handed over the narcotic keys before completing a joint count because they were busy with a tube feeding. The unit manager and DON both stated that counts should be done by two nurses with both sheets and medications present, keys should not be exchanged until counts are verified, medications should be wasted if not immediately administered, and narcotics should be signed out at the time of actual administration, which did not occur in these instances.
Failure to Monitor and Restrict Fluids and Diet for a Resident on Renal Orders
Penalty
Summary
The facility failed to ensure that a resident with end stage kidney disease, dialysis treatment, a renal diet, and a 1500 milliliter fluid restriction received nutritional and hydration care consistent with the physician’s orders and care plan. The resident’s care plan documented fluid overload related to end stage renal disease and a renal diet with a fluid restriction, and the physician orders specified a renal, no concentrated sweets diet with fluid limits broken down by meal and shift, along with documentation of total fluid consumed each shift. The facility diet manual also stated that the renal diet limited sodium, potassium, and phosphorus, limited milk to 4 ounces daily, and excluded chocolate. Record review showed that the resident’s actual fluid intake was not monitored in a way that captured the amount consumed, and the documentation used by staff did not reflect actual fluid volumes. The medication administration record contained check marks rather than recorded fluid amounts, and the nurse manager stated that this was not how it should have been done. The nurse aide documentation recorded food and fluid intake only in percentage ranges, and staff stated that extra fluid intake would not be captured in the fluid counts. The facility did not complete intake and output records, and the dietitian stated that nursing relied on task documentation and did not calculate actual daily fluid intake. An observation and interview showed the resident received fluids beyond the ordered meal allotment. At lunch, the resident was served cranberry juice and coffee totaling the full 360 milliliter lunch fluid allowance, and later received an additional 8-ounce chocolate milk from a CNA, bringing the lunch fluid total to 600 milliliters. Staff interviews showed that CNAs did not know what a renal diet was, did not know how to identify a fluid restriction from the information they accessed, and acknowledged they should not give extra fluids or chocolate milk without checking with a nurse. The resident’s records also lacked documentation of the prescribed fluid restriction, monthly dialysis laboratory data, and evidence that fluid amounts provided at meals were assessed. Laboratory results showed elevated phosphorus and calcium phosphorus product, and the dialysis center nurse stated the resident was supposed to be on low potassium, low phosphorus, and 1500 milliliter fluid restriction orders, with milk and extra fluids not to be offered.
Lack of Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to ensure a resident with dementia received appropriate treatment and services to maintain the resident’s highest practicable physical, mental, and psychosocial well-being. Resident #47 had diagnoses including dementia and bipolar disorder, and the 07/20/2025 MDS documented severe cognitive impairment, dependence or substantial assistance with most daily living activities, supervision or touch assistance with functional mobility, and use of medications for psychiatric diagnoses. The comprehensive care plan, initiated on 08/06/2024 and revised on 10/10/2025, documented impaired cognition related to dementia, but the only interventions listed were to administer medications and ask yes or no questions. The care plan also addressed risk for mood changes related to bipolar disorder and dementia, with interventions to administer psychotropic medications, monitor mood changes, and provide support and reassurance, but it did not include specific person-centered interventions for dementia. Observations showed the resident walking aimlessly in the hallway, entering another resident’s room, sleeping seated in a hallway chair with the head leaned back, and later sitting in the hallway outside another resident’s room making loud vocalizations for about 30 minutes, with no staff interactions observed during these times. Staff interviews indicated the resident enjoyed walking, juice, music, visits from a male friend with a small dog, and high heeled shoes, but the RN stated the care instructions did not include this information and that the current care plan would not guide an unfamiliar staff member in managing the resident’s behaviors.
Late Ativan Administration
Penalty
Summary
Resident #14 did not receive Ativan within the facility’s prescribed medication administration time frame on multiple occasions, resulting in late administration of a medication ordered for anxiety. The resident had diagnoses including anxiety and depression, intact cognition on the 01/19/2026 MDS, and a care plan that identified psychotropic medication use related to anxiety and depression with interventions to administer medications as ordered and monitor effectiveness and side effects. The physician order documented Ativan 0.5 mg, two tablets daily for anxiety and one tablet at bedtime for anxiety, and the MAR showed the morning dose scheduled for 7:00 AM to 10:00 AM and the bedtime dose scheduled for 7:00 PM to 10:00 PM. The MAR documented several late administrations of Ativan, including doses given at 11:40 PM, 11:11 PM, 12:12 AM, 11:12 AM, and 12:45 PM. During interview, the resident stated the medication was not always given at the appropriate time, which increased anxiety and caused shortness of breath. The resident also stated nursing staff told them the medication could be administered up to eight hours late. During observation, the resident was seen using a nebulizer and stated they were anxious, which caused shortness of breath. Staff interviews confirmed the late administrations were outside the facility’s medication pass window and should have been documented and reported. An LPN stated medications were to be administered within the allowed time window and that late medications should be documented and the provider notified, but acknowledged not signing medications as administered and not knowing why some doses were not clicked in the electronic record. Another LPN stated the evening Ativan dose given at 12:12 AM was late and should have been documented in a progress note with notification to the medical provider. The unit manager also identified the 12:12 AM, 11:12 AM, and 12:45 PM Ativan administrations as late and stated they were not notified of these late doses.
Improper Dumpster Area Sanitation
Penalty
Summary
Garbage and refuse were not disposed of properly for one dumpster area located near the loading dock. During observation, several used gloves, empty food containers, and vegetable scraps were found on the ground around the dumpsters, and the area around the dumpsters was described as mostly loose gravel in poor repair. The facility policy stated dumpsters were to be maintained in a clean, secure, and sanitary condition, cleaned and sanitized routinely, and that waste would not be placed outside dumpsters. During interviews, the Food Service Director stated maintenance was responsible for keeping the area clean, and the Maintenance Director stated maintenance staff checked the dumpster area and were responsible for cleaning it to prevent animals in the area.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents who were on contact precautions. Surveyors observed staff entering and working in the rooms of residents with contact precaution signs posted without wearing the required personal protective equipment. The report states that the facility’s precaution signage required hand hygiene before entering and leaving the room, a mask and eye protection, and gloves before entering the room, with gloves removed before exiting and hand hygiene performed after removal of PPE. One resident had diagnoses including quadriplegia, tracheostomy, and bladder dysfunction, was dependent for all activities of daily living, and had an indwelling urinary catheter, feeding tube, and tracheostomy care. The resident’s care plan documented colonization with ESBL and a suprapubic catheter, with transmission-based precautions and contact precautions ordered. During observation, a CNA was in the resident’s room without PPE despite the contact precautions sign posted at the doorway. An LPN stated that staff entering a precaution room must follow infection control practices and wear the required PPE such as a gown and gloves. The second resident had chronic open wounds of both legs, skin ulcers, nonsurgical dressings, and was receiving an antibiotic. The care plan and physician orders required contact precautions for weeping wounds and a history of multidrug resistant organisms. Surveyors observed a CNA leaving and entering the room without a gown or gloves and bringing an overbed tray table out into the hallway without disinfecting it. The CNA stated they knew PPE should be worn based on the doorway sign and that they should have worn it, while the infection preventionist stated staff should wear a gown and gloves before entering a resident’s room on contact precautions.
Failure to Ensure Safe Discharge and Continuity of Care for Resident with Diabetes
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with diabetes and diabetic wounds, resulting in Immediate Jeopardy. The resident, who was homeless and had no identification, was discharged to the Department of Social Services via family transportation without prior consultation with the Department to confirm the availability of housing or supportive services. The discharge planning process did not include verification that the resident's health and safety needs or preferences were met, and there was no evidence that the resident or their representative received or signed discharge instructions. The resident was discharged without proper education or supplies to manage their diabetes and diabetic wounds. Documentation was lacking regarding the provision of insulin, a glucometer, or wound care supplies, and there was no record of medication reconciliation or teaching for diabetes management. Interviews with facility staff revealed confusion about responsibilities for discharge education and supply provision, and it was confirmed that the resident did not have a primary care provider established at the time of discharge, which prevented the setup of home health or wound care services. After discharge, the resident was denied emergency housing at the Department of Social Services due to a previous unpaid stay and had to rely on their sibling for temporary accommodation and basic needs such as food. The resident subsequently presented to the emergency department with dangerously high blood sugar, having been discharged from the facility without insulin or medications sent to a pharmacy. Interviews with staff and the resident's family confirmed that the resident was not adequately prepared or equipped for self-care post-discharge, and that the facility's discharge process failed to ensure continuity of care or resident safety.
Removal Plan
- The pending discharge was reviewed for verification of post-discharge services, receiving locations, and physician notification.
- Social Services, the Nursing Management team involved in discharges, Director and Assistant Director of Rehabilitation, and the Recreation Director were educated on discharge planning process to include verification of safety and discharge medication.
- A new discharge form was instituted that required medication listed with quantities, medical equipment provided, teaching provided, and discharge location that required both resident/resident representative signature in addition to discharging nurse.
- All discharges in the last 30 days were reviewed for safety and called to ensure they had the necessary services in place.
- All staff identified for education received education, with the exception of staff members who were not available. The individuals who did not receive education will complete education upon their return, prior to the start of their shift.
- Interviews were completed to determine compliance with staff training and education including the Director of Social Services, the Recreation Director, the Assistant Director of Rehabilitation, one Unit Manager, and the Director of Nursing.
Inadequate Pressure Ulcer Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and progression of pressure ulcers for a resident at risk. The resident, who had a history of a non-traumatic subarachnoid hemorrhage and was dependent on staff for all activities of daily living, developed a Stage 2 pressure ulcer on the right buttock due to inadequate incontinence care. The facility's policy required daily skin inspections and timely incontinence care, but documentation revealed that the resident was not consistently provided with toileting hygiene, leading to moisture-associated skin damage and the development of a pressure ulcer. The resident's care plan included interventions such as applying zinc ointment with each incontinence episode, repositioning every 2-3 hours, and using pressure-relieving devices. However, the treatment administration records showed multiple instances where the prescribed treatments were not documented as completed. Interviews with staff indicated that the resident was often found with soaked incontinence briefs and dried feces, suggesting a lack of adherence to the care plan. The wound progressed to an unstageable pressure ulcer with necrotic tissue, indicating a failure to follow physician orders and provide consistent wound care. Despite the facility's protocols and care plans, the resident's condition worsened, leading to hospitalization. Staff interviews revealed inconsistencies in care documentation and a lack of awareness regarding the resident's condition. The facility's failure to provide routine incontinence care and consistent wound treatment contributed to the deterioration of the resident's skin integrity, resulting in a significant deficiency in care.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment across all four units reviewed during the recertification survey. Observations revealed multiple deficiencies, including sticky floors, damaged walls, and unclean resident chairs on Units 100, 200, 300, and 400. Additionally, drain flies were found in the Unit 200 shower room, and there was a lack of negative air pressure in the soiled utility rooms of Units 200, 300, and 400. Specific issues included a call bell out of reach for a resident, a strong odor of urine in a resident's room, and damaged wheelchairs. The facility's housekeeping policy, which mandates routine cleaning and maintenance, was not effectively implemented, as evidenced by the absence of documented work orders for the identified issues. Interviews with facility staff highlighted systemic issues in maintenance and housekeeping responsibilities. Housekeeper #4 noted difficulties in maintaining clean floors due to resident incontinence, while LPN Unit Manager #3 acknowledged that the maintenance department was responsible for painting and repairs, but work orders were not consistently submitted or completed. The Maintenance Director confirmed that work orders could be submitted via computers or a phone application, but there was no evidence of such orders for the observed deficiencies. The facility's goal to maintain a homelike environment was not met, as evidenced by the numerous environmental issues and lack of timely maintenance.
Deficiency in Resident Hygiene and Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #127, who had diagnoses including cerebral infarction and dementia, was observed multiple times with long, untrimmed fingernails and without wearing their glasses, despite being dependent on staff for personal hygiene and requiring corrective lenses. The facility's documentation inaccurately reflected that the resident was wearing glasses, and staff interviews revealed a lack of awareness regarding the resident's need for glasses and nail care. Resident #80, who had right hemiplegia and was dependent on staff for personal hygiene, was observed with long fingernails containing brown debris on several occasions. Despite the resident expressing discomfort and a desire for their nails to be cut, the facility failed to provide the necessary nail care. Interviews with staff indicated a lack of adherence to the facility's nail care policy and a failure to document any refusals of care by the resident. Resident #90, diagnosed with dementia and requiring assistance with personal care, was also observed with long fingernails and brown debris underneath. The resident's care plan indicated dependence on staff for personal hygiene, yet the facility did not ensure proper nail care was provided. Staff interviews highlighted a lack of communication and documentation regarding the resident's hygiene needs, resulting in undignified conditions for the resident.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, attractive, and at safe and appetizing temperatures during the recertification and abbreviated surveys conducted. Specifically, during the breakfast and lunch meals on June 26, 2024, food items were served at temperatures outside the acceptable range. The facility's policy required hot foods to be served at a minimum of 135 degrees Fahrenheit and cold foods to be below 41 degrees Fahrenheit. However, observations revealed that the temperatures of several food items, including cheesy scrambled eggs, pureed barbecue chicken, and pureed macaroni and cheese, were below the required 135 degrees Fahrenheit. Additionally, cold items such as diet cola and honey thickened milk were served at temperatures above the acceptable range. Interviews with residents and the Food Service Director highlighted dissatisfaction with the food's palatability and temperature. Residents reported that the food was bland, lacked taste, and was often served at incorrect temperatures. The Food Service Director acknowledged that food items served at temperatures outside the acceptable range could lead to foodborne illnesses. Despite the facility's policy to test food palatability for two test trays per week, the deficiency in maintaining appropriate food temperatures persisted, affecting the quality of meals served to residents.
Inadequate Dining Facilities for Residents
Penalty
Summary
The facility failed to provide adequately furnished and spacious dining rooms for resident dining and activities on Units 100 and 400. Observations revealed that the dining rooms on these units did not accommodate the social and physical needs of the residents. On Unit 100, the dining area had six square tables, with some tables pushed together, and residents were observed sitting in wheelchairs, reclining chairs, or with assistive devices, leaving no room for ambulatory residents. Many residents were lined up in the hallway during meals, seated with bedside tables, and appeared cramped, with no music or conversation to enhance the dining experience. On Unit 400, there was no designated dining area, and residents were observed eating in the hallway or in their rooms. Interviews with staff revealed that the main dining room had been closed for several months due to staffing issues and had not been used for two years. The CNA stated that residents requiring supervision were lined up in the hallway, while the LPN Supervisor suggested that opening the main dining room could reduce congestion. The Director of Nursing acknowledged that the main dining room had been closed since the COVID-19 outbreak and recognized that dining in the hallway was not a dignified experience for residents. The lack of adequate dining facilities led to residents being lined up in hallways, which did not provide a comfortable or social dining environment.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure a dignified existence for two residents during the recertification and abbreviated surveys. Resident #28, who had severe cognitive impairment and required extensive assistance for eating, was referred to as a 'feeder' by staff. During an observation, a Licensed Practical Nurse (LPN) was assisting Resident #28 with eating when a Certified Nurse Aide Instructor inquired if a student could assist. The LPN responded negatively, labeling the resident as a 'difficult feeder,' a conversation that was audible to others nearby. This labeling was contrary to the facility's policy on dignity, which emphasized treating residents with respect and avoiding labels based on care needs. Similarly, Resident #44, who also had severe cognitive impairment and was dependent on staff for eating, was observed being fed by a Certified Nurse Aide who stood over them, an action acknowledged by the aide as undignified. The aide also referred to the resident as a 'feeder,' indicating a lack of adherence to the facility's dignity policy. Both instances highlight the facility's failure to uphold the residents' rights to dignity and respect, as outlined in their own policies and regulatory requirements.
Failure to Conduct Level II PASARR for Newly Diagnosed Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a newly diagnosed serious mental disorder was referred for a Level II Pre-admission Screening and Resident Review (PASARR), as required by federal regulations. The resident, admitted with diagnoses of anxiety and depression, was later diagnosed with schizoaffective disorder. Despite this new diagnosis, there was no documentation of a Level II PASARR referral, which is necessary to identify the specialized services required by the resident. The New York State Department of Health Instruction Manual mandates that a new SCREEN and Level II referral must be completed within 14 calendar days of a new mental illness diagnosis. Interviews with facility staff revealed a lack of understanding and adherence to the PASARR process. The Director of Social Work admitted to not reviewing PASARRs until after admission and did not initiate a new screening process for newly diagnosed serious mental health conditions. The Director of Nursing confirmed that new mental health diagnoses were discussed in team meetings, but there was no evidence of a new PASARR being conducted. This oversight indicates a gap in the facility's procedures for ensuring appropriate placement and care for residents with serious mental illnesses.
Failure to Provide Appropriate Food Consistency for Resident
Penalty
Summary
The facility failed to ensure that Resident #111 received food prepared in a form designed to meet their individual needs, as required by their physician's order. Resident #111, who had diagnoses including Alzheimer's disease, gastro-esophageal reflux disease, and dysphagia, was ordered a regular diet with chopped consistency due to being edentulous and at risk for malnutrition. However, during a lunch meal observation, the resident was served a whole meatball hoagie and a whole grilled cheese sandwich, which were not chopped as required by their dietary needs. Interviews with various staff members, including a Certified Nurse Aide, Resident Assistant, LPN Unit Manager, Registered Dietitian, Speech Language Pathologist, Food Service Director, and Director of Nursing, revealed a lack of adherence to the facility's policy on food consistencies and definitions. The staff acknowledged that a chopped consistency diet should involve cutting food into smaller pieces, and serving whole sandwiches posed a choking risk for the resident. Despite the facility's policy requiring meals to be checked for accuracy by both the Food and Nutrition staff and service staff, the resident received inappropriate food consistency. The deficiency was further highlighted by the fact that the facility's policy on the accuracy and quality of tray lines was not followed. The Food Service Director admitted that meal tickets should have been checked before trays left the kitchen and upon delivery to the units. The staff's failure to adhere to the prescribed diet consistency for Resident #111, who had no teeth and required chopped food, demonstrated a significant oversight in ensuring the resident's safety and dietary needs were met.
Failure to Accommodate Resident's Dietary Needs and Preferences
Penalty
Summary
The facility failed to provide food that accommodated the dietary needs and preferences of a resident, identified as Resident #59, during a recertification survey. Resident #59, who had diagnoses including Alzheimer's Disease and chronic kidney disease, was on a regular diet with pureed texture and thin liquid consistency due to mild oral phase dysphagia. Despite these dietary requirements, the resident did not receive the ordered fluids on their meal tray and was not offered a suitable substitution when they requested a sandwich. Observations revealed that during a meal, the resident's tray lacked the prescribed Boost and water, and when the resident requested water and a sandwich, they were not provided with appropriate alternatives. The resident expressed dissatisfaction with the food served, stating it left a bad taste in their mouth and that they were often hungry. Interviews with staff indicated a lack of follow-through in providing the resident with requested food alternatives, such as a pureed sandwich, which was within the resident's dietary allowances. The facility's staff, including a Licensed Practical Nurse and a Registered Dietitian, acknowledged the importance of offering alternatives to ensure adequate nourishment. However, there was a failure to update the resident's care plan to reflect changes in dietary needs as recommended by the speech language pathologist. This oversight contributed to the resident's inadequate food intake and dissatisfaction with meal options, highlighting a deficiency in meeting the resident's dietary preferences and needs.
Violation of Nurse Aide Training Prohibition
Penalty
Summary
The facility was found to be in violation of regulations during a recertification survey due to conducting an off-site nurse aide training program despite a prohibition from the Centers for Medicare and Medicaid Services (CMS). The facility had received a letter from CMS dated February 9, 2024, which prohibited the provision of a Nurse Aide Training and Competency Evaluation Program, conducting onsite nurse aide competency exams, or utilizing onsite clinical training by an off-site nurse aide training program, effective through October 2025. However, observations during the survey revealed that the facility was collaborating with a local community college to provide clinical training for nurse aide students within the facility. The facility had a contract with the community college to provide in-agency learning experiences for nurse aide students, which included the college providing the curriculum and instructors, while the facility provided the necessary environment and support. During the survey, it was observed that nurse aide students were present in the facility for training, and the Nurse Aide Instructor confirmed that the students had been training at the facility since January 2024. The facility's Administrator and Corporate Nurse were unaware that the prohibition applied to off-site training programs as well, and upon reviewing the CMS letter, they acknowledged the mistake and stated that the training program would cease immediately.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 123 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rome
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rome Memorial Hospital, Inc - R H C F | 0.7 mi | ★★★★★ | 0 | 0 |
| Colonial Park Rehabilitation And Nursing Center | 0.9 mi | ★★★★★ | 25 | 0 |
| Bethany Gardens Skilled Living Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Betsy Ross Rehabilitation Center, Inc | 1.1 mi | ★★★★★ | 2 | 0 |
| Trustees Of Eastern Star Hall & Home Of The N Y S | 7.5 mi | ★★★★★ | 0 | 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.