Below 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 The Pearl Nursing Center Of Rochester during CMS and state inspections, most recent first.
The facility failed to maintain a safe, comfortable, and homelike environment when boiler and heating system problems were documented, multiple resident rooms and common areas measured below the required temperature range, and several PTAC units were damaged or not working. Staff reported the heat had been problematic for weeks, the third floor heat had not worked for a while, and residents said it was freezing and always cold; one resident was observed wrapped in blankets in bed. The main entrance automatic door opening feature also did not work, and staff and a vendor struggled to move a wheelchair and a medical cart through the doors.
A resident with a PICC line, sepsis, diabetes with a foot ulcer, and CKD had ordered PICC assessments, dressing and cap changes, saline flushes, and VS monitoring that were repeatedly not documented in the MAR/TAR. The records showed numerous missing nursing signatures, and staff including the DON confirmed that if the tasks were not signed for, there was no way to verify they were completed.
Surveyors found that food and beverages were served at sub-optimal temperatures, with hot items such as potatoes, ham, and asparagus delivered below recommended standards. The Food Services Director acknowledged the issue, and a resident reported that hot food was sometimes served cold.
A resident with significant risk factors for pressure ulcers did not have individualized prevention interventions included in their care plan or Kardex, leading to the development of a pressure ulcer. After the wound was first identified, there was a three-day delay before treatment orders were implemented. Staff interviews revealed inconsistent application and documentation of pressure ulcer prevention protocols.
A resident bathroom was found with mold, water damage, missing and stained ceiling tiles, exposed wall damage, loose floor tiles, and a strong urine odor. Multiple work orders for plumbing issues were documented, but maintenance staff were unaware of ongoing leaks. These conditions demonstrated a failure to provide necessary housekeeping and maintenance services.
The facility failed to maintain an adequate number of CPR-certified staff and lacked documentation of staff training, as required by their policy. This deficiency was evident during an incident involving a resident with severe cognitive impairment, where the facility could only verify the CPR certification of two nurses present. Interviews revealed staff were unaware of certification requirements, and documentation of emergency preparedness training was absent.
The facility failed to maintain a system to monitor staff CPR certifications, as required by its policy. During a survey, it was found that the Registered Nurse Manager was unaware of the number of CPR-certified staff needed per shift, and the Corporate Infection Control RN could only verify the certification of two nurses. The facility had experienced turnover in its educator/trainer role, contributing to this deficiency.
The facility failed to maintain a safe and clean environment, with non-functional exhaust ventilation, plumbing issues, and structural damages across resident-use floors and the basement. Maintenance and housekeeping services were inadequate, leading to an accumulation of bugs, improper storage of care items, and safety hazards like exposed wires in the kitchen. A resident reported theft due to unsecured storage, and staff interviews revealed delays in addressing these issues.
Two residents did not receive wound care as ordered, with missing documentation and confusion over treatment orders. One resident with chronic ulcers did not have an ace wrap applied as prescribed, while another with a surgical wound had incomplete documentation of care. Staff interviews revealed confusion over orders and a lack of communication with medical providers.
The facility failed to maintain a safe environment, with significant lint buildup in the laundry room posing a fire hazard and water temperatures in resident rooms exceeding safe levels. A resident known to vape was not properly assessed or monitored, despite the facility's tobacco-free policy. Staff interviews revealed inconsistent documentation and monitoring of the resident's vaping activities.
The facility failed to ensure accurate reconciliation of controlled substances on two residential care units. Narcotic count logs were not consistently signed by two nurses to verify the completion and accuracy of the narcotic count at the end of each shift, as required by facility policy. Despite staff awareness of the procedure, numerous missing signatures were found on the logs, indicating a systemic failure in maintaining accurate narcotic counts.
The facility did not maintain essential laundry equipment in safe working condition, with one dryer and one washing machine found non-functional. A staff member confirmed that all laundry is done in-house, and having all machines operational would be beneficial.
The facility did not provide lab services as ordered for two residents. One resident, with dysphagia and diabetes, required a Basic Metabolic Panel due to Lasix use, but it was not completed. Another resident, with diabetes and chronic kidney disease, had orders for a hemoglobin A1C and lipid panel, which were also not completed. Staff interviews confirmed the oversight, with no documentation of refusals or reasons for the missed lab work.
A resident with paranoid schizophrenia did not receive their prescribed clozapine on multiple occasions due to a lack of documented physician orders and incomplete blood work. Facility staff interviews revealed confusion and lack of responsibility regarding medication management and required lab work, contributing to the medication errors.
The facility failed to properly dispose of garbage and refuse, with surveyors observing an uncovered dumpster and trash scattered around, including a medication blister pack with a resident's information. The Acting DON acknowledged the blister pack should have been shredded. Additionally, two dumpsters were left open, indicating ongoing issues with waste containment.
The facility was non-compliant with the 2015 IFC and NFPA 720 standards, as it failed to provide documentation of carbon monoxide detector locations and monthly testing. Observations showed detectors in the basement kitchen and second-floor corridors, but no records of maintenance were available.
The facility failed to provide Baseline Care Plan summaries to residents and/or their representatives within 48 hours of admission, as required by policy. This deficiency was identified during a survey of eight residents with various medical conditions. Despite developing written summaries, the facility did not provide these to the residents or their representatives. Interviews revealed a lack of clarity regarding responsibility for the Baseline Care Plans, with the Director of Social Work only recently being made aware of their role. The Acting DON acknowledged the broken system and the need for improvement.
The facility did not maintain the confidentiality of resident-identifiable information, as empty medication blister packets with resident details were found in unsecured areas accessible to staff, residents, and visitors. Despite the facility's policy requiring such information to be shredded, observations revealed these packets in open bins on two residential care units and outside near garbage dumpsters. Interviews with staff, including the acting DON and LPNs, confirmed the mishandling of these packets, which should have been placed in designated shredding bins.
Unsafe temperatures and nonfunctional entrance doors
Penalty
Summary
The facility did not provide maintenance services necessary to maintain a safe, comfortable, and homelike environment for residents on all three sleeping floors. Record review showed the facility policy required residents to be provided with a safe, clean, comfortable, and homelike environment, including comfortable safe temperatures between 71 F and 81 F. A vendor service report dated 09/25/2025 and signed by the facility on 10/17/2025 identified multiple boiler and heating system problems, including a burned-out main controller for the boilers and pumps loop control system, a leaking boiler exhaust, dirty burners and heat exchangers, a failed supply water temperature sensor, leaks in drain and exhaust lines, corroded valves and fittings, a grinding pump bearing assembly, and a starter contactor issue. The report also noted taped-off gas line spots due to signs of past leaks, and no documentation was provided at that time showing the repairs had been made or scheduled. Survey observations showed the main entrance automatic door opening feature was not functional. On 11/07/2025, a staff member struggled to pull a resident in a wheelchair through the double doors, and the blue push buttons marked "push to open" did not work when pressed. Later that same day, a vendor was also struggling to bring a mobile medical cart and screen through the entrance because the automatic door opening feature was still not operational. The Administrator stated the doors had not worked since they started, and later stated they were not aware of any heating problems and had recently signed off for some boiler repairs. Temperatures measured in resident rooms and common areas on the second and third floors were below the facility's stated range, with multiple readings in the mid-60s to upper-60s Fahrenheit. Observations also showed several PTAC units were damaged or not functional, including units that were bent away from the wall, dispensing cold air, painted shut, or missing a control knob. Staff interviews confirmed ongoing heat problems for three to four weeks, that the heat in resident rooms did not work and had not worked for a while, and that the third floor was mostly dementia residents. Residents also reported being cold, with one stating it was freezing and another stating it was always cold; one resident was observed fully wrapped in blankets while in bed in a room measured at 69.2 F.
Missing Documentation for PICC Care and Vital Signs
Penalty
Summary
Services provided to a resident with a PICC line did not meet professional standards of quality because required assessments, flushes, dressing changes, cap changes, and vital sign monitoring were not documented on numerous occasions, and the facility could not provide evidence that these ordered services were completed. The resident had diagnoses including sepsis due to streptococcus group B, diabetes with a foot ulcer, and chronic kidney disease, and the resident’s assessment showed cognitive intactness, active septicemia, antibiotic use, intravenous access, and receipt of IV medications. The care plan identified a central venous access device in the left upper arm with instructions to keep the dressing clean, dry, and intact and to change it weekly and as needed. The resident had orders to assess the PICC site every shift, change the dressing weekly, change caps every three days and as needed with bloodwork, flush with normal saline every day and evening shift, and obtain vital signs every shift for seven days and then weekly. Review of the treatment and medication administration records showed missing nursing signatures for PICC site assessments on 19 of 43 opportunities, cap changes on 3 of 5 opportunities, dressing changes on 1 of 2 opportunities, flushes on 14 of 29 opportunities, and vital signs on 5 of 24 opportunities. Progress notes did not show that the missed documentation had been addressed. Staff interviews confirmed that nurses were expected to complete and sign these tasks, and the DON stated that if a task was not signed for, there was no way to verify it was done.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
During an abbreviated survey, it was observed that the facility failed to ensure food and beverages were served at palatable and safe temperatures for residents. On the day of observation, a tray delivery cart was loaded in the main kitchen and sent to a residential unit, with the last meal tray being delivered 26 minutes later. At the time of delivery, a test tray measured by a surveyor and the Food Services Director showed that the roasted potatoes, honey ham, and cooked asparagus were all served at temperatures significantly below recommended hot holding standards, with readings of 101.3°F, 110.6°F, and 101.8°F respectively. The black coffee was also measured at 127.3°F. The Food Services Director acknowledged that the food was cold and expressed unawareness that the temperature would drop so much during transit. Additionally, a resident interviewed confirmed that food intended to be hot was sometimes served cold.
Failure to Implement and Document Pressure Ulcer Prevention and Timely Treatment
Penalty
Summary
A deficiency was identified when a resident at risk for pressure ulcers did not have care planned interventions in place to prevent skin breakdown, which resulted in the development of a pressure ulcer. The resident had significant risk factors, including a history of stroke with right-side paralysis, severe malnutrition, incontinence, and dependence on staff for mobility and personal care. Despite these risks, the resident's care plan and Kardex did not include specific interventions or measurable goals related to pressure ulcer prevention, and there was no documentation of preventative measures being implemented. Upon identification of a new deep tissue injury to the resident's sacrum, there was a delay of three days before wound treatment orders were documented and implemented. Progress notes indicated that the wound was first noted as a reddened area, and a note was placed in the medical provider book, but no immediate interventions or treatment orders were initiated. The wound care provider assessed the injury the following day and recommended specific treatments and preventative measures, but these were not ordered until three days after the initial identification of the wound. Interviews with facility staff revealed inconsistent understanding and implementation of pressure ulcer prevention protocols. Certified nursing assistants and nurses reported relying on the Kardex for instructions, but the Kardex did not address the resident's pressure ulcer risk. Staff described general prevention strategies such as repositioning and incontinence care, but these were not consistently documented or included in the resident's care plan. The Director of Nursing confirmed that care plans should include wounds and appropriate interventions, but in this case, the necessary preventative and treatment measures were not in place or documented in a timely manner.
Failure to Maintain Safe and Clean Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, and homelike environment in one resident room, as evidenced by the presence of mold, water leaks, and physical damage in the bathroom. Observations revealed stained and mold-spotted ceiling tiles, a missing ceiling tile, and an unsealed gap in the concrete slab between floors. The baseboard cove molding was peeled off, exposing wall damage, and several floor tiles were missing or loose below the sink. A strong odor of urine was also noted in the bathroom. These conditions were directly observed during the survey. Review of the facility's work order system showed multiple entries for a clogged toilet in the same room over several months and a work order for a fallen ceiling tile, but no entries specifically addressing ceiling leaks. During interviews, the Acting Director of Maintenance was unaware of leaks in the room but acknowledged that toilet overflows sometimes affect rooms below. A resident reported a ceiling leak occurring a few months prior. These findings indicate that the facility did not provide adequate housekeeping and maintenance services necessary to ensure a safe and comfortable environment for residents.
Deficiency in CPR Certification and Training
Penalty
Summary
The facility failed to ensure an adequate number of staff were properly trained and certified in cardiopulmonary resuscitation (CPR) at all times, as required by their policy. The policy, revised in February 2018, mandates that clinical staff obtain and maintain certification in Basic Life Support (BLS)/CPR and participate in periodic mock codes for training. However, the facility did not maintain an updated list of staff with current CPR certifications and lacked evidence of nursing staff education and training related to CPR procedures. This deficiency was highlighted during an incident involving a resident with severe cognitive impairment, where the facility was unable to provide a comprehensive list of CPR-certified staff. During the investigation, it was found that the facility could only verify the CPR certification of two nurses present during the incident. Interviews with staff revealed that some were unaware of the number of CPR-certified staff required at any given time, and one nurse had lost their CPR certification card. Additionally, the Corporate Infection Control Registered Nurse admitted to the absence of documentation regarding staff education on emergency preparedness and CPR. This lack of documentation and training contributed to the facility's inability to ensure that staff were adequately prepared to respond to emergencies, as evidenced by the incident involving the resident.
Deficiency in Monitoring CPR Certification Among Staff
Penalty
Summary
The facility was found to be deficient in its administration and use of resources, specifically in maintaining a system to monitor staff certifications in cardiopulmonary resuscitation (CPR). The facility's policy required clinical staff to be certified in Basic Life Support (BLS)/CPR and to conduct periodic mock codes for training. However, the facility failed to maintain a list of staff with current CPR certification, which is crucial for responding to cardiac or pulmonary arrest incidents. This deficiency was highlighted during an Abbreviated Survey, where it was discovered that the facility did not have a system in place to ensure that staff certifications were up-to-date. Interviews conducted during the survey revealed that the Registered Nurse Manager, who had been at the facility for two weeks, had not received training on emergency preparedness and was unaware of the number of CPR-certified staff required per shift. Additionally, the Corporate Infection Control Registered Nurse could not provide documentation of staff education on emergency preparedness and was only able to verify the CPR certification of two nurses present during a cardiac arrest incident. The facility had experienced turnover in its educator/trainer position, contributing to the lack of a comprehensive system for tracking CPR certifications.
Facility Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents across all three resident-use floors and the basement. Observations revealed non-functional exhaust ventilation in several areas, including bathrooms and utility rooms, which compromised air quality. Plumbing issues were prevalent, with fixtures either not working properly or being clogged, such as a hand wash sink that only discharged a trickle of water and a clogged hopper in the utility room. Additionally, hot water temperatures were not maintained within the required range, and lighting issues were noted with cracked and missing light lenses. Structural damages were observed, including cracked tiles and damaged doors and walls, contributing to an unsafe environment. The facility also failed to provide adequate maintenance and housekeeping services, as evidenced by the accumulation of bugs in stairwells and improper storage of resident care items on the floor. The basement laundry room lacked a hand washing sink, and the mechanical exhaust fan was non-functional and dusty. Equipment in the kitchen, such as the plate warmer, had exposed wires, posing a safety hazard. Furthermore, a resident reported theft due to a lack of secure storage for valuables, and there was pooling water in the basement boiler room from a leaking pipe. Interviews with staff indicated delays in addressing maintenance issues, partly due to financial constraints with vendors.
Deficiencies in Wound Care Documentation and Execution
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by deficiencies in wound care for two residents. Resident #30, who had chronic ulcers, COPD, and diabetes, did not receive the physician-ordered ace wrap for their left leg wound. Observations revealed that the ace wrap was not applied after dressing changes, and there was missing documentation for several dressing changes. Interviews with staff indicated confusion regarding the wound care orders, with the LPN unaware of the separate order for ace wraps and the LPN Manager suggesting that the order should have been written separately. Resident #42, who had diabetes, morbid obesity, and a recent surgical abdominal wound, did not receive wound care as ordered on several occasions. The Treatment Administration Record showed missing documentation for wound care on multiple opportunities, with no evidence of resident refusal. Interviews with the medical provider and the Acting Director of Nursing confirmed that orders should be followed as written, and any inability to complete treatments should be communicated to the medical provider. The lack of documentation indicated that the treatments were not signed off or completed.
Facility Fails to Address Fire Hazards and Resident Vaping
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by several deficiencies observed during the recertification survey. In the basement laundry room, there was a significant buildup of lint behind the dryers, which posed a fire hazard. This was confirmed when a spark from a dryer ignited the lint, causing a fire that was extinguished by the Director of Maintenance. Additionally, the facility did not maintain safe water temperatures in resident rooms, with multiple instances of water temperatures exceeding 120 degrees Fahrenheit, as recorded in the facility's logs without any documented corrective actions. Resident #42, who was known to vape in their room, was not properly assessed or care planned for the use of electronic cigarettes, despite the facility's tobacco-free policy. The resident, who was cognitively intact and dependent on staff for all activities of daily living, frequently refused to surrender vaping materials to staff and continued to vape in their room. The facility's policy prohibited smoking and vaping, yet there was no smoking assessment conducted for Resident #42, and incident reports were not consistently completed when staff became aware of the resident's non-compliance. Interviews with facility staff revealed a lack of consistent documentation and monitoring of Resident #42's vaping activities. The Regional Director of Clinical Services acknowledged the need for ongoing monitoring to ensure the safety of Resident #42 and other residents. Despite the facility's non-smoking policy, staff did not conduct frequent checks for vaping materials, and the resident's non-compliance with the care plan was not adequately recorded. The facility's failure to address these issues contributed to the deficiencies identified during the survey.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substances, specifically narcotic medications, on two of its residential care units. During the recertification survey, it was found that the narcotic count logs were not consistently signed by two nurses to verify the completion and accuracy of the narcotic count at the end of each shift. The facility's policy requires that narcotics be counted by two professional nurses, with documentation of the count's completion and accuracy at the beginning and end of each shift. However, the review of the second-floor south medication cart revealed numerous missing signatures on the Controlled Substance Inventory logs, indicating that the required shift-to-shift narcotic count was not consistently verified by two nurses. Licensed Practical Nurse #2 acknowledged that the narcotic sheets should be signed as a legal document, but was unaware of the whereabouts of the inventory log from the prior day. Similarly, the first-floor south medication cart's logs also contained numerous missing signatures, further indicating a lack of compliance with the facility's policy. Licensed Practical Nurse #4 explained the process of filling out the narcotic sheets and the importance of the count at the end of each shift to ensure the correct medication was given and the count was accurate. Despite this understanding, the logs still showed missing signatures. Licensed Practical Nurse Manager #2 confirmed that all nurses were aware of the requirement to sign the narcotic sheets and to inform a nursing supervisor if there were missing signatures, yet the issue persisted, highlighting a systemic failure in maintaining accurate narcotic counts.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential mechanical and resident care equipment in safe operating condition, as observed during the Recertification Survey. Specifically, in the basement laundry room, one of two dryers and one of three washing machines were found to be non-functional. A housekeeping/laundry staff member confirmed during an interview that all laundry is processed in-house and that having all machines operational would be beneficial.
Failure to Provide Ordered Lab Services for Residents
Penalty
Summary
The facility failed to ensure that lab services were provided as recommended by the pharmacy and ordered by the physician for two residents. Resident #70, who had diagnoses including dysphagia, pneumonitis, and diabetes, required tube feeding and had a care plan that included obtaining and monitoring labs. Despite a pharmacist's recommendation and physician's agreement for a Basic Metabolic Panel due to the resident's use of Lasix, there was no evidence in the medical record that the lab work was completed or refused by the resident. Similarly, Resident #9, with diagnoses of diabetes, chronic kidney disease, and schizoaffective disorder, had physician orders for a hemoglobin A1C and a lipid panel. The pharmacist also recommended these tests, and the physician agreed and ordered them again. However, the medical records showed no evidence of the lab work being completed or refused. Interviews with staff revealed that the lab work was not done as ordered, and there was no documentation of refusals or reasons for the oversight. The Acting Director of Nursing acknowledged the oversight but had not reviewed the Medication Regimen Reviews since assuming their role.
Medication Administration Error for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of clozapine, an antipsychotic medication. The resident, diagnosed with paranoid schizophrenia, Crohn's disease, and diabetes, did not receive their prescribed clozapine on multiple occasions. The Medication Administration Record indicated that the medication was on hold or refused on several days, and there was no documented evidence of physician orders to hold the medication or resident refusals. Additionally, there was no evidence of the required blood work being completed, which was necessary for the pharmacy to refill the prescription. Interviews with facility staff revealed a lack of clarity and responsibility regarding the management of the resident's medication and required blood work. The Registered Nurse Manager explained the process for lab work collection, but there was no follow-up on the missing lab results. The Physician was unaware of the medication issues, and the Acting Director of Nursing stated that medical providers should handle blood work but did not know who was responsible for the Risk Evaluation and Mitigation Strategy Assessments. This lack of coordination and communication contributed to the medication errors experienced by the resident.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a Recertification Survey. During an exterior tour, surveyors noted that one of three dumpsters was uncovered, and there was trash scattered around and behind the dumpsters. Items found included part of a lift chair, plastic gloves, various paper and plastic items, and an empty medication blister pack displaying a resident's name and drug information. The Acting Director of Nursing acknowledged that the medication blister pack should have been shredded instead of being discarded in the garbage. Further observations revealed that two of the three dumpsters were left with their covers open, indicating a continued issue with proper waste containment. These findings demonstrate non-compliance with regulations regarding the disposal of garbage and refuse, as specified in 10 NYCRR: 415.29 (i)(1), 415.29(j)(6)(i), 415.14(h), Subpart 14-1.150.
Non-compliance with Carbon Monoxide Detection Requirements
Penalty
Summary
The facility was found to be non-compliant with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which mandates the use of carbon monoxide detection in buildings with fuel-burning appliances. During the Recertification Survey, it was observed that the facility had a carbon monoxide detector in the basement kitchen above the prep sink area, where a natural gas-powered range was also present. Additionally, natural gas boilers and a natural gas-powered generator were located in the basement, indicating the presence of multiple fuel-burning appliances. Further observations revealed carbon monoxide detectors on the walls in the corridor on the second floor outside resident rooms. However, the facility failed to provide documentation of the locations of all carbon monoxide detectors within the facility or any records of monthly inspection and testing of these detectors. The 2015 IFC and the 2012 Edition of NFPA 720 require carbon monoxide alarms to be maintained and tested monthly according to the manufacturer's instructions, which the facility did not comply with, leading to the deficiency.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that a Baseline Care Plan summary was provided to residents and/or their representatives within 48 hours of admission, as required by their policy. This deficiency was identified during a Recertification Survey for eight residents reviewed for Baseline Care Plans. The facility's policy, revised in March 2022, mandates that a baseline plan of care be developed to meet the resident's immediate health and safety needs within 48 hours of admission, and that a written summary be provided to the resident or their representative in an understandable language. However, there was no evidence that such summaries were provided to any of the residents or their representatives, as the designated area for confirmation on the Baseline Care Plan was left blank. Specific cases highlighted include residents with various medical conditions such as diabetes, chronic kidney disease, schizoaffective disorder, dysphagia, pneumonitis, osteoarthritis, and a stage four pressure ulcer. Despite the development of written summaries following admission, the facility did not provide these to the residents or their representatives. Interviews with the Director of Social Work and the Acting Director of Nursing revealed a lack of clarity regarding responsibility for the Baseline Care Plans, with the Director of Social Work only recently being made aware of their role in this process. The Acting Director of Nursing acknowledged the broken system and the need for improvement, indicating that training had been provided to ensure documentation of the provision of care plan copies, especially for families unable to visit the facility.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of resident-identifiable information, as observed during a Recertification Survey. On two of the three residential care units, as well as outside the facility by the garbage receptacle, empty medication blister packets with resident-identifiable information were found in open bins accessible to staff, residents, and visitors. Specifically, on the second and third floors, these packets were found in unsecured nurse's stations, and one packet was observed outside near the garbage dumpsters. The facility's policy mandates that such information should be disposed of in designated shredding bins, but this was not adhered to. Interviews with staff revealed a lack of consistent practice in handling these packets. The acting Director of Nursing acknowledged that the packets should have been shredded. A Licensed Practical Nurse Unit Manager and an Environmental Service Supervisor both indicated that the packets should be placed in special bins for shredding, but this was not consistently done. The acting Director of Nursing confirmed that the medication blister packets are considered resident-identifiable information and should be disposed of in a secure manner, which was not the case as observed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 128 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Ann's Community | 0.2 mi | ★★★★★ | 0 | 0 |
| The Brook At High Falls Nursing Home And Rehabilit | 1.7 mi | ★★★★★ | 10 | 0 |
| Lilac Manor Rehabilitation And Nursing Center | 2.5 mi | ★★★★★ | 3 | 0 |
| Kirkhaven | 2.7 mi | ★★★★★ | 10 | 0 |
| Blossom Health Care Center Inc. | 3.5 mi | ★★★★★ | 1 | 0 |
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