Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 The Hurlbut during CMS and state inspections, most recent first.
Inconsistent pressure ulcer treatment and monitoring. One resident with a sacral wound had ordered Santyl, Alginate AG, and foam dressing, but nursing notes showed the wound was charted as resolved or intact without provider notification, and an LPN later omitted the ordered Alginate because the wound appeared different. A second resident with a stage 2 left ankle ulcer had missing weekly skin-team/provider assessments, conflicting wound location documentation, and an observed open, bleeding wound with hyper-granulation tissue.
Failure to review and act on monthly pharmacist recommendations. Two residents with depression-related diagnoses and antidepressant use had repeated consultant pharmacist recommendations for GDRs/taper attempts on meds such as duloxetine, trazodone, and mirtazapine, but the facility could not show timely MD/PA/DON review or response for multiple monthly MRRs. Interviews confirmed the pharmacy review process had problems with provider responses and that recommendations were routed through nursing leadership rather than directly documented as acted upon.
A resident with low back pain, glaucoma, and benign prostatic hypoplasia had OTC zinc and vitamin D3 kept at the bedside without a current order for the medication, self-administration, or bedside storage. The resident said they took one tablet daily for their prostate, while an LPN and LPN manager confirmed there was no current order in the EMR and the care plan lacked self-administration goals or interventions. A PA and the administrator stated provider awareness and orders were needed for bedside self-administration.
Food service safety standards were not followed when raw shell eggs were stored above ready-to-eat meats in the walk-in cooler, a dirty section of kitchen flooring was missing tiles under the three-bay sink, and a food service worker handled and served a resident’s sandwich with bare hands during lunch service. The FSD stated the eggs should have been on the bottom shelf and later said sandwiches should be presented with gloved hands and not handled bare-handed once unwrapped.
Infection control failures occurred during wound care and resident care for two residents with pressure ulcers. One resident on EBP had wound care performed by an LPN wearing gloves only and no gown, despite signage on the door. Another resident with a chronic wound had wound care performed by a NP who placed clean and contaminated supplies directly on the bed sheet, did not change gloves, and did not perform hand hygiene during the dressing change; the room also lacked EBP signage and PPE setup, and staff stated the resident was not on EBP because it was not on the care plan.
Inconsistent pressure ulcer treatment and monitoring
Penalty
Summary
The facility did not ensure appropriate pressure ulcer care and monitoring for two residents. One resident had diabetes, blindness, moderately impaired cognition, and a sacral pressure ulcer with an unstageable wound noted on assessment. The resident’s care plan and physician’s order required daily cleansing, Santyl, Alginate AG, and a foam dressing for the sacral area. However, nursing documentation showed multiple days when the wound was charted as resolved, no open area, or skin intact, and the record did not show that a medical provider was notified at those times. During an observation, the wound was still open, and the nurse applied Santyl but did not apply the ordered Alginate because the nurse believed it was only needed for wounds with slough. For that same resident, staff documentation and interviews showed the ordered wound treatment was not consistently followed as written. A late entry note later documented that the coccyx area had closed and the Santyl should be discontinued, but the wound had reopened and the tissue was pink with no slough. Staff interviews confirmed that the wound had changed, that the ordered treatment no longer matched the wound appearance, and that the provider was not notified when the wound was first observed as resolved. The physician assistant stated the nurse should have followed the order and notified medical staff if the treatment was no longer appropriate. A second resident had diabetes mellitus, atrial fibrillation, neuropathy, and a stage 2 pressure ulcer on the left medial ankle. The record showed some wound flow sheet entries with measurements and drainage, but there was a lack of consistent weekly wound assessments by the skin team or a medical provider across multiple time periods. Several provider notes also documented the wound as being on the right lower extremity instead of the left ankle, and one note lacked measurements or staging. During observation, the left ankle wound was open with hyper-granulation tissue and active bleeding, and the nurse practitioner handled contaminated supplies and wound cleanser in a manner observed on the bed sheet while measuring the wound and applying a new dressing. Interviews confirmed that weekly pressure ulcer monitoring should include location, measurements, stage, appearance, and treatment recommendations, and the administrator stated the resident’s pressure ulcer was not monitored weekly.
Failure to Review and Act on Monthly Pharmacist Recommendations
Penalty
Summary
The facility did not ensure that monthly pharmacist drug regimen review irregularities were reviewed by the attending physician and acted upon in a timely manner for residents reviewed during the survey. The facility policy required the consultant pharmacist to complete monthly drug regimen reviews, report irregularities to the attending physician, Medical Director, and DON on a separate written report, and have those reports acted upon. Surveyors found the facility could not provide documentation showing the consultant pharmacist’s recommendations were reviewed by the Medical Director, attending physicians, or their designees for two residents reviewed. One resident had diagnoses including dementia, depression, and adult failure to thrive, with severely impaired cognition and an antidepressant on the medication regimen. The consultant pharmacist repeatedly recommended a gradual dose reduction for duloxetine from 60 mg to 30 mg, noting the last attempt had occurred the prior year, but the facility could not provide evidence that a medical provider received, reviewed, or acted on those recommendations for several months. A later pharmacist review again recommended tapering duloxetine, and a physician assistant responded that the recommendation was disagreed with because the medication was being used for neuropathy and should remain unchanged. Another resident had diagnoses including major depressive disorder, stroke, and insomnia, with mildly impaired cognition and antidepressant therapy. The consultant pharmacist recommended taper attempts for trazodone and later for mirtazapine on multiple monthly reviews, but the facility could not provide documented evidence of physician response for several of those reviews. Some recommendations were not responded to until weeks or months later, and the facility was unable to provide medication regimen reviews for part of the review period. Interviews with the pharmacist, medical director, physician assistant, and administrators confirmed that pharmacy recommendations were being routed through nursing leadership and that there had been problems receiving provider responses since the prior fall, with the DON stating it was unclear what was being done with the recommendations.
Unordered bedside zinc left with resident
Penalty
Summary
The facility did not ensure Resident #52’s environment remained as free of accident hazards as possible when multiple observations found an over-the-counter bottle of zinc left at the resident’s bedside without a current medical order for the medication or for self-administration. Resident #52 had diagnoses including low back pain, glaucoma, and benign prostatic hypoplasia, and the 07/07/2025 MDS documented the resident as cognitively intact. The current comprehensive care plan, last revised 07/17/2025, did not include measurable goals or interventions related to self-administration or bedside storage of medications, and the current physician’s orders reviewed on 07/28/2025 did not include orders for zinc, self-administration, or bedside storage. During observations on 07/24/2025 and 07/28/2025, a bottle of zinc was seen on the bedside table, and on 07/29/2025 a half-full bottle labeled zinc and vitamin D3 tablets was again observed at the bedside. Resident #52 stated they took one tablet daily and had been taking it for 50 years for their prostate, and said nurses should know because they had asked about it before. An LPN stated the resident had an order for medication to be left at the bedside and that the family brought in the vitamin, but the electronic record showed no current order for the zinc and vitamin D3. The LPN manager stated there was no current order for zinc and was not aware the resident was self-administering without an order. A PA stated home medications should be sent to the pharmacy to verify contents and there should be an order to self-administer medications, and the administrator stated a medical provider should be aware and have orders in place for a resident known to self-administer and store medication in the room.
Food Storage, Sanitation, and Bare-Hand Food Handling Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During observation in the main kitchen walk-in cooler, raw shell eggs were stored on the third shelf of a wire rack directly above a pan of plastic-wrapped thin-sliced ready-to-eat meats, including ham and salami. The facility policy on food storage stated cooked foods must be stored above raw foods and raw animal foods should be separated and stored on lower shelves in drip-proof containers. On a later observation, raw shell eggs were again seen stored over the pan of thin-sliced meats, and the Food Service Director stated the eggs should have been stored on the bottom shelf and was not sure who stored them that way. The survey also found a 3 foot by 3 foot section of flooring missing tiles under the right side of the three-bay sink in the main kitchen, and the area was dirty and discolored with food debris. In addition, during lunch service in the main dining area, Food Service Worker #1 used bare hands to hold, cut, and place a sandwich on a plate for a resident. The worker stated they had been trained not to wear gloves while handling food and that the last training was in March 2025. Later, the Food Service Director stated sandwiches should be wrapped in plastic, presented with gloved hands, and not handled with bare hands once unwrapped.
Infection Control Failures During Wound Care and Barrier Precautions
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two residents with pressure ulcers. The facility policy on Enhanced Barrier Precautions stated that gowns and gloves are to be used during high-contact resident care activities, including wound care, for residents with wounds or other risk factors, and that signage should be posted outside the resident’s room. The State Operations Manual guidance also stated that gloves should be changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. One resident had diagnoses including a stage two pressure ulcer to the sacral region, hemiplegia/hemiparesis, and diabetes, and the care plan stated the resident was on enhanced barrier precautions because of a pressure ulcer to the sacral area and right buttock. Although a sign for enhanced barrier precautions was observed on the room door, a LPN performed wound care while wearing gloves only and without a gown. After the procedure, the LPN stated they should have worn a gown but forgot to do so. The Administrator stated staff should wear gowns and gloves when providing care for residents on enhanced barrier precautions and did not know why the gown was not worn. Another resident had diagnoses including diabetes, atrial fibrillation, and neuropathy, and had a stage two pressure ulcer on the left medial ankle with a current wound treatment order. During wound care, a NP wearing gloves only placed clean gauze pads and wound cleanser directly on the resident’s fitted sheet, removed the old dressing and placed it on the sheet, cleansed and dabbed the actively bleeding wound, and continued placing contaminated supplies directly on the sheet. The NP did not change gloves or perform hand hygiene during the dressing change. The resident’s room also lacked enhanced barrier precautions signage and PPE setup during a later observation, and a CNA stated the resident was not on enhanced barrier precautions because it was not on the care plan and there was no signage. The Infection Preventionist stated residents with chronic wounds should be on enhanced barrier precautions and said the resident had been removed from enhanced barrier precautions in April 2025 even though wound care was still being provided.
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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) |
|---|---|---|---|---|
| Monroe Community Hospital | 1.1 mi | ★★★★★ | 3 | 2 |
| Woodside Manor Nursing Home Inc | 1.2 mi | ★★★★★ | 7 | 0 |
| The Highlands At Brighton | 1.4 mi | ★★★★★ | 12 | 0 |
| Jewish Home Of Rochester | 1.9 mi | ★★★★★ | 10 | 0 |
| St. John's Health Care Corporation | 2.3 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.