Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rochester Restorative Care Center during CMS and state inspections, most recent first.
The facility failed to consistently follow dysphagia-related diet orders and aspiration precautions for two residents, including ensuring correct mechanical soft textures, nectar/mildly thick liquids, supervision during meals, and safe positioning. One resident with a stroke and significant cognitive deficits frequently ate unsupervised in bed despite orders and SLP recommendations for supervision and out-of-bed meals, and was later hospitalized with pneumonitis due to inhalation of food and vomit after a suspected aspiration event. After returning, this resident continued to receive incorrect diet textures and liquid consistencies, with tray tickets, Kardex entries, and dietary production reports not matching physician orders. Another resident on a pureed diet with nectar thick liquids was observed drinking thin hot milk, developed repeated coughing and thick phlegm, and did not receive an immediate respiratory assessment, while hospice was not informed of the incident. Staff interviews and observations showed systemic inconsistencies and confusion between diet orders, Kardex information, and tray tickets, and a lack of reliable processes to ensure appropriate supervision and accurate diet implementation for residents at risk of aspiration.
A resident with COPD and asthma, who was oxygen dependent and had moderate cognitive impairment, was self-administering Ventolin and Dulera inhalers without a comprehensive assessment or a physician's order. Staff were aware of the resident's actions for at least two weeks, but no assessment was completed as required by facility policy.
The facility did not maintain accurate and complete medical records for two residents, resulting in discrepancies between physician orders, treatment records, and progress notes for oxygen therapy and antibiotic administration. Staff failed to consistently document changes in orders and care provided, and there was no clear process for integrating outside medical records into the facility's EHR.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not review or update its assessment to specify the minimum number of direct care and licensed staff needed to meet residents' needs, including staffing hours per resident day (PPD) and the division between licensed and direct care staff. Staffing decisions were made daily based on census and acuity, but the assessment lacked a formalized plan, potentially affecting all residents.
The facility failed to maintain a documented plan describing the process for conducting QAPI and QAA activities, as required. Surveyors found no evidence of a structured approach or written procedures for these quality initiatives.
The facility did not set up an ongoing quality assessment and assurance group, resulting in the lack of a formal process to review quality deficiencies and develop corrective plans of action.
The QAA group did not include all required members and failed to meet at least quarterly, as shown by facility records and documentation.
The facility did not allow a resident or the resident's legal representative to access or purchase copies of the resident's records, as required.
A resident was admitted without a plan being created or implemented to address their most immediate needs within 48 hours. The facility did not ensure that a comprehensive assessment and plan were completed in the required timeframe, resulting in the resident's immediate needs not being systematically addressed.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, including improper catheter care and insufficient measures to prevent UTIs.
Annual performance evaluations were not completed for four nursing assistants employed for over a year. Staff interviews indicated a lack of awareness about receiving reviews, and the DON confirmed that these evaluations had not been performed. Requested policies on performance reviews were also not provided.
The facility failed to ensure proper dishwashing sanitization and monitoring, as a dietary aide was observed using a dish machine with incorrect chemical levels. Additionally, expired food was found in a unit refrigerator meant for residents' personal food, despite policies requiring regular cleaning and labeling. The dietary manager and registered dietician confirmed the expectations for sanitization and food storage, which were not met.
The facility failed to ensure proper use of PPE for two residents on enhanced barrier precautions (EBP). A resident with a gastrostomy tube was administered medication without the nurse wearing a gown, and the necessary EBP signage was missing. Another resident with a pressure ulcer received care without the nurse donning a gown, despite EBP signage being present. These lapses indicate non-compliance with the facility's infection prevention protocols.
Two residents were found with medications in their rooms without proper assessment or authorization for self-administration. One resident had Voltaren gel without a physician's order or care plan for self-administration, while another had glucose tablets, aspirin, and iron without a self-administration order. The DON confirmed the lack of necessary orders and assessments, indicating non-compliance with facility policy.
The facility failed to notify resident representatives after two residents experienced falls and were transferred to the hospital. One resident, who was cognitively intact, was not able to have her emergency contact informed despite her request. Another resident with mild cognitive impairment had a similar issue, with the facility failing to make adequate attempts to contact the emergency contact. The facility's policy required immediate notification, but this was not followed, leading to dissatisfaction and concern from the residents' representatives.
A facility failed to complete a baseline care plan for a newly admitted resident requiring post-op orthopedic after-care. The resident's MDS assessment showed moderate impaired cognition and a need for ADL assistance. Neither the resident nor their family received a care plan, and the DON confirmed the required form was incomplete. The facility's policy lacked guidance on baseline care plan development.
A facility failed to develop a comprehensive care plan for a resident with urinary retention and an indwelling urinary catheter. The resident's care plan did not include necessary details about the urinary catheter, leg bag, or drainage bag, despite these being documented needs. The RN responsible for care plans acknowledged the oversight, and the DON confirmed the expectation for these elements to be included in the care plan.
A resident with a history of Alzheimer's and cardiovascular issues did not receive consistent application of prescribed compression wraps for edema management. Observations and interviews revealed that staff were often unaware of the requirement or unsure of their responsibilities, leading to missed applications and increased swelling. The Director of Nursing confirmed the need for daily application, but a policy on edema prevention and treatment was not provided.
Two residents at an LTC facility experienced multiple falls due to inadequate assessment and intervention. One resident, with a history of falls and Alzheimer's, had seven falls over three months, with inconsistent interventions and poor communication among staff. Another resident, admitted for rehabilitation, fell three times in a week, with incomplete incident reports and lack of root cause analysis. The facility's fall prevention policy was not effectively implemented, leading to missed opportunities to prevent future falls.
A resident with urinary retention and an indwelling catheter did not have their leg bag switched to a urinary drainage bag at night, contrary to the facility's catheter care policy. Observations and staff interviews confirmed the oversight, which could lead to urine backflow and potential infection. The facility's policy required the use of a drainage bag at night to ensure proper urine drainage.
The facility failed to maintain the second-floor tub/shower room in good repair and sanitary conditions, affecting 30 residents. Missing tiles exposed wood and plaster, creating an unsanitary environment. The corporate maintenance director and facility maintenance director were unaware of the issue, and a housekeeper could not recall reporting it. A maintenance policy was requested but not provided.
The facility failed to serve meals at a warm and palatable temperature, affecting residents' quality of life and nutritional intake. Observations showed meal trays left unattended, leading to food temperatures below safe levels. Residents reported dissatisfaction with cold meals, and staff acknowledged the issue, citing a broken plate warmer and insufficient staff as contributing factors.
The facility failed to maintain proper food temperatures, leading to resident complaints about cold meals. Observations showed that meal trays were distributed late, and nursing staff did not check temperatures before serving. Dietary management confirmed that recorded temperatures were unacceptable, with some hot foods below the required standards. The facility's policy required food to be served at safe and appetizing temperatures, but practices did not align with these standards.
A resident with chronic respiratory failure did not receive oxygen as per physician orders, leading to a significant drop in oxygen saturation and shortness of breath. The resident's oxygen was set incorrectly, and the nasal cannula was not properly placed. Staff interviews revealed a lack of understanding of oxygen delivery protocols, contributing to the deficiency.
Failure to Follow Dysphagia Diet Orders and Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor known aspiration precautions and prescribed diets for residents with dysphagia, including ensuring correct diet texture, liquid consistency, supervision during meals, and safe positioning. One resident with a history of stroke, dysphagia, and significant cognitive impairment was ordered a mechanical soft diet with mildly thick liquids and required supervision and aspiration precautions. Despite these orders and SLP recommendations for supervision and for the resident to be out of bed for meals, the resident frequently ate in bed, often unsupervised, and the care plan and Kardex did not fully reflect the need for aspiration precautions, supervision level, or specific positioning during meals. Staff reported that the resident often refused to get out of bed, and there was no consistent system to ensure that residents eating in their rooms were supervised or that safe swallowing strategies were followed. On one occasion, the resident was given a dinner tray in bed without staff remaining to assist or supervise. The resident subsequently appeared to choke while eating, with coughing and production of phlegm, and was sent to the hospital. Hospital records documented admission for pneumonitis due to inhalation of food and vomit after a suspected aspiration event while eating at the facility. Prior to and after this event, SLP documentation showed that the resident had thin liquids in the room at times despite an order for mildly thick liquids, and SLP staff had to educate nursing staff about the need to maintain the ordered liquid consistency and to keep the resident out of bed for meals. The resident’s care plan was not updated to include directives for being out of bed for meals or specific safe swallowing strategies, and staff interviews revealed inconsistent awareness of the need for supervision and appropriate positioning. The facility also failed to consistently provide the correct diet texture and liquid consistency after the hospitalization. Observations showed that the resident received regular broccoli instead of chopped broccoli despite being on a dysphagia mechanical soft diet, and the incorrect food remained on the plate long enough for the resident to eat some of it before it was removed. On another day, the resident was served pureed food and honey-thick liquids when the order called for mechanical soft solids and nectar/mildly thick liquids; dietary and nursing staff confirmed that the meal and liquids did not match the physician’s orders. Dietary staff and the dietary manager reported problems with the tray ticket system, including tray tickets not matching diet orders and confusion about how mechanical soft, ground, chopped, and pureed textures were represented and printed. Nursing assistants and other staff relied on Kardexes and tray tickets that did not always reflect current diet orders, and there was no clear, consistently used assessment or process to determine which residents required supervision during meals. A second resident with dementia and dysphagia, on a pureed diet with nectar thick liquids, was observed drinking thin hot milk despite a diet slip indicating nectar thick liquids. The resident began coughing repeatedly and spitting out the liquid, with ongoing coughing and production of thick white phlegm. Staff identified that the liquid in the cup was regular thin milk and removed it to thicken, but the nurse did not perform a respiratory assessment at the time. The resident’s hospice case manager later confirmed that hospice had not been notified of this coughing/aspiration concern. Staff interviews showed that some were unsure of residents’ diet consistencies without checking multiple sources, and that there was inconsistency between diet orders, Kardex entries, and tray tickets regarding thickened liquids. Overall, the facility did not ensure that menus and meal service met residents’ prescribed nutritional and texture needs, that diet orders were accurately communicated and followed by nursing and dietary staff, or that residents with dysphagia received appropriate supervision and monitoring during meals.
Failure to Assess Resident for Self-Administration of Inhalers
Penalty
Summary
The facility failed to complete a comprehensive assessment for self-administration of medications for a resident with chronic obstructive pulmonary disease (COPD) and asthma, who was oxygen dependent and had moderately impaired cognition. The resident's care plan included interventions for respiratory impairment, and physician orders specified the use of Ventolin and Dulera inhalers. Despite these orders, the resident was found to be self-administering both inhalers, keeping them in her pocket, and had not received a comprehensive assessment to determine her ability to safely self-administer these medications. There was also no physician order authorizing self-administration, as required by facility policy. Multiple staff members, including RNs, were aware that the resident had been self-administering her inhalers for at least two weeks, but no assessment had been completed. The resident reported keeping the inhalers on her person for quick access and had informed staff of her desire to self-administer, but was told the inhalers should be kept in the medication cart. The DON confirmed that no self-administration assessment had been completed, and the facility's policy required both a prescriber's order and an interdisciplinary team determination of safety before allowing self-administration of medications.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For one resident with chronic obstructive pulmonary disease and asthma, there were discrepancies between physician orders, treatment administration records (TAR), and progress notes regarding oxygen therapy. The physician ordered a change from 3 liters per minute (L/min) to 2 L/min of oxygen, but this change was not transcribed into the official physician orders. The TAR continued to reflect administration of 3 L/min, while progress notes documented administration of 2 L/min on several occasions. Additionally, refusals of oxygen therapy were not consistently documented, and notifications to the physician were based on verbal reports rather than written documentation. Nursing staff and the director of nursing acknowledged that the medical record was inaccurate due to these inconsistencies. For another resident with chronic kidney disease, cellulitis, diabetes, and heart failure, there was a lack of documentation regarding the discontinuation of an antibiotic prescribed after a hospital visit. The hospital after visit summary included an order for Augmentin, but the facility's electronic health record (EHR) showed a verbal order for the medication with a start and stop date, without any corresponding written order or physician note explaining the discontinuation. Staff interviews revealed uncertainty about the process for retrieving and incorporating outside medical records into the facility's EHR, and the director of nursing confirmed that the record did not address the discontinuation of the antibiotic. The facility's medical record policy required documentation according to the resident's level of care and for any unusual activity, event, or change in assistance. However, the lack of accurate transcription of physician orders, inconsistent documentation of care provided, and unclear processes for integrating external medical records led to incomplete and inaccurate records for the residents involved.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Identify and Document Minimum Staffing Requirements in Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to identify the minimum or baseline number of direct care and licensed staff required to meet residents' needs during both routine operations and emergencies. The assessment did not specify staffing hours per resident day (PPD) goals or the breakdown between licensed and direct care staff necessary to provide care based on residents' diagnoses, assessed needs, and comprehensive care plans. The assessment process described was fluid and based on daily evaluations by the nursing department and interdisciplinary team, but lacked concrete staffing numbers or ratios. The special memory care unit was noted to require special staffing considerations, but no specific minimums were documented. Interviews with staff revealed that daily staffing decisions were made based on the DON's direction and current census, with a general target of 3.3 to 3.4 PPD, but without a formalized or documented staffing plan in the facility assessment. The scheduler and DON both confirmed that the assessment did not identify the number or type of staff needed for each shift. Additionally, the facility assessment policy was requested but not provided. This deficiency had the potential to affect all 51 residents in the facility.
Lack of QAPI and QAA Process Plan
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or evidence outlining the procedures or steps the facility uses to carry out these required quality activities.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no formal mechanism in place to ensure that quality deficiencies were consistently identified or that appropriate corrective actions were developed and implemented.
QAA Group Lacked Required Members and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) group was composed of the required members and that meetings were held at least quarterly. This deficiency was identified through review of facility records and documentation, which showed that the QAA group did not consistently meet the mandated membership requirements and did not convene at the required frequency.
Failure to Provide Access to Resident Records
Penalty
Summary
The facility failed to ensure that each resident or the resident's legal representative was able to access or purchase copies of all the resident's records. This deficiency was identified based on the facility's actions or inactions that did not provide residents or their legal representatives with the required access to their records as mandated.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address the resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency occurred due to the facility's failure to ensure that a comprehensive assessment and plan were developed and put into place promptly after the resident's admission. The lack of timely planning resulted in the resident's immediate needs not being systematically identified or addressed within the required timeframe.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These findings indicate that the facility did not meet the required standards for ensuring proper continence management, catheter maintenance, and infection prevention for its residents.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five nursing assistants who had been employed for over one year. Staff records for these nursing assistants showed hire dates ranging from 1996 to 2024, but no annual performance evaluations were provided upon request. Interviews with the nursing assistants revealed that they did not recall receiving annual performance reviews, and the DON confirmed that she was responsible for conducting these evaluations but had not completed them for the identified staff. Additionally, the facility was unable to provide policies regarding performance reviews when requested.
Dishwashing and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper dishwashing sanitization levels and monitoring during the dishwashing process. During a kitchen tour, a dietary aide was observed placing dishes through a dish machine, with the wash dial indicating a temperature of 130 degrees Fahrenheit and the rinse dial at 140 degrees Fahrenheit. The dietary aide stated that the dish machine sanitized dishes with hot water and used test strips to check chemical levels after dishwashing. However, the test strips did not change color, indicating a failure in the sanitization process. The dietary manager confirmed that the dish machine used chemical sanitization, not temperature, and acknowledged ongoing issues with the dish machine. Additionally, the facility failed to ensure expired food was identified and removed from a unit refrigerator storing residents' personal food. A refrigerator on the second floor was observed with a sign indicating it was cleaned weekly, and all items must be labeled with the resident's name and date. However, the refrigerator contained several expired food items, including a plastic container with red sauce and pasta, an ice-cream sandwich, miracle whip, yogurt, cantaloupe, a piece of lemon pie, and pizza. The registered nurse confirmed the presence of expired food and removed it from the refrigerator. The facility's policies on ware washing and food storage were not adhered to, as evidenced by the failure to maintain proper dishwashing sanitization levels and the presence of expired food in the refrigerator. The dietary manager and registered dietician confirmed the expectations for checking chemical levels during dishwashing and ensuring expired food was not present in unit refrigerators. The director of nursing and district dietary manager also acknowledged the deficiencies in cleaning and monitoring the refrigerator.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for two residents, R54 and R23, who were on enhanced barrier precautions (EBP). R54, who had severe cognitive impairment and a gastrostomy tube, was observed during a medication administration without the registered nurse (RN-A) donning a gown as required. The nurse confirmed that R54 was on EBP due to the g-tube, but the necessary signage indicating EBP was missing from the resident's door. Additionally, the trained medication aide (TMA-A) was unaware of R54's EBP status, indicating a lack of communication and adherence to protocols. R23, who had a stage 2 pressure ulcer and was on EBP, was assisted by RN-E without wearing a gown during peri care. Although the EBP sign was present on R23's door, RN-E admitted to forgetting to wear the gown during the care process. The infection preventionist (RN-B) confirmed that R23 was on EBP due to skin alterations and reiterated the expectation for staff to wear gowns and gloves during high-contact care activities. The facility's policy on enhanced barrier precautions, dated 8/8/24, requires signage on resident doors and the availability of PPE outside rooms for residents with wounds or indwelling medical devices. The policy also mandates that staff be aware of which residents require EBP before providing care. However, the observations and interviews revealed lapses in adherence to these protocols, leading to deficiencies in infection prevention and control measures.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, who were observed to have medications in their rooms, were appropriately assessed and deemed safe to self-administer medications. Resident 6, diagnosed with rheumatoid arthritis and dementia, had a tube of Voltaren gel in her room without a physician's order for self-administration or an assessment for safe self-administration documented in her electronic medical record (EMR). During an interview, Resident 6 mentioned that she did not apply the medication herself, indicating a lack of self-administration. The care plan for Resident 6 did not include self-administration of medication. Resident 49, with a history of stroke, type 1 diabetes, and dementia, was found with several medications in his room, including glucose tablets, aspirin, and iron, without a self-administration order or assessment in the EMR. Although Resident 49 stated he brought the medications from home and did not use them anymore, the presence of these medications in his room was not in compliance with the facility's policy. The Director of Nursing confirmed the absence of self-administration orders for both residents and acknowledged that the medications should not have been in their rooms without proper authorization and assessment.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to notify resident representatives following falls and subsequent hospital transfers for two residents. Resident R20, who had a history of falls and was cognitively intact, experienced a fall resulting in a femur fracture. Despite R20's request to notify her emergency contact, FM-A, the facility did not make the notification. FM-A only learned of the incident when R20 contacted her from the emergency department. The administrator and director of nursing were aware of the policy to notify resident representatives but did not follow through, citing R20's ability to make her own decisions, despite her being in considerable pain and unable to contact FM-A herself. Resident R164, who had mild cognitive impairment and a history of falls, was also not properly notified. After a fall that led to a hospital transfer, FM-B, R164's emergency contact, was not informed by the facility. The facility's documentation indicated an attempt to contact FM-B, but no follow-up was made when there was no answer. The director of nursing acknowledged that staff should have made additional attempts to contact FM-B or informed the next shift to try again. The facility's policy required immediate notification of resident representatives in the event of an accident involving injury or a significant change in condition. However, in both cases, the facility failed to adhere to this policy, resulting in a lack of communication with the residents' emergency contacts during critical situations. This oversight led to dissatisfaction and concern from the residents' representatives, who were not able to provide support during the hospital transfers.
Failure to Complete Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to complete a baseline care plan for a newly admitted resident, identified as R164, who had been admitted for post-operative orthopedic after-care following neck surgery. The resident's admission Minimum Data Set (MDS) assessment indicated moderate impaired cognition, clear speech, and a need for assistance with activities of daily living (ADLs), as the resident did not walk independently. Despite these needs, neither the resident nor their family member received a copy of a baseline care plan after admission. Upon review of the resident's electronic medical record and paper chart, it was found that a baseline care plan was not documented. A carbonless form titled Baseline Care Plan Summary was found in the paper chart with only the resident's name and room number filled in, leaving the rest of the form blank. The Director of Nursing (DON) confirmed that this form was intended for documenting the baseline care plan and acknowledged that it had not been completed. Additionally, the facility's Comprehensive Care Plan policy did not include language about developing a baseline care plan and providing a summary to residents or their representatives.
Failure to Develop Comprehensive Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R163) who was reviewed for urinary catheter use. The resident's facesheet indicated a diagnosis of urinary retention, and the Minimum Data Set (MDS) assessment showed dependency on staff for most activities of daily living and the presence of an indwelling urinary catheter. Despite these documented needs, the care plan dated 1/27/25 did not include the resident's urinary retention, the use of an indwelling Foley catheter, leg bag, or urinary drainage bag. During interviews, the registered nurse (RN-C) responsible for updating care plans acknowledged the omission, stating it was a mistake and that she would correct it immediately. The Director of Nursing (DON) also confirmed that the urinary retention and catheter use should have been included in the care plan to ensure staff were aware of the necessary care interventions. The facility's policy requires a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Apply Compression Wraps for Edema Management
Penalty
Summary
The facility failed to comprehensively assess and provide ongoing treatment for a resident (R5) who required leg wraps to prevent and treat edema. R5 had a history of multiple medical conditions, including Alzheimer's disease and impaired cardiovascular status, and was prescribed low stretch compression wraps for both legs. However, the facility's records indicated that the compression wraps were not applied consistently, with several instances of missed applications due to the resident sleeping or other undocumented reasons. Additionally, R5 refused the wraps multiple times, but there were no documented reattempts to apply them. Observations and interviews revealed that R5 was often found without the prescribed compression wraps, and staff members were either unaware of the requirement or unsure of their responsibilities regarding the application of the wraps. Family members expressed concerns about the lack of care, noting increased swelling in R5's legs and the absence of necessary interventions such as massaging and moisturizing before applying the wraps. Staff interviews highlighted a lack of communication and understanding of roles, with some staff believing that only nurses could apply the wraps, while others thought nursing assistants could do so. The Director of Nursing confirmed the presence of an order for bilateral leg wraps and stated that staff should apply them daily and remove them at bedtime. The DON also mentioned that residents who refuse care should be approached a minimum of three times. Despite these expectations, the facility's policy on edema prevention and treatment was not provided, indicating a possible gap in procedural guidance. The deficiency was further compounded by the lack of consistent documentation and follow-up on R5's care needs.
Inadequate Fall Prevention and Intervention for Residents
Penalty
Summary
The facility failed to adequately assess and implement interventions to prevent falls for two residents, R5 and R164, who were at risk for accidents. R5, who had a history of falls and multiple medical conditions including Alzheimer's disease and impaired mobility, experienced seven falls over a period of three months. Despite these incidents, the facility's interventions were inconsistent and not effectively communicated to staff. Observations revealed that R5's room lacked a 'call don't fall' sign, and necessary items were not within reach, contributing to the resident's attempts to self-transfer and subsequent falls. R164, admitted for short-term rehabilitation following neck surgery, also experienced multiple falls within a week of admission. The facility's response to these falls was inadequate, as incident reports were incomplete, and the interdisciplinary team (IDT) failed to conduct thorough root cause analyses or implement new interventions. The lack of communication and follow-up on fall incidents resulted in missed opportunities to address the underlying causes and prevent future falls. The facility's fall prevention and management policy was not effectively implemented, as evidenced by the failure to conduct timely fall risk assessments and update care plans with appropriate interventions. The director of nursing acknowledged the shortcomings in the facility's response to falls, highlighting a need for improved communication and adherence to established protocols to ensure resident safety.
Failure to Switch Catheter Leg Bag to Drainage Bag at Night
Penalty
Summary
The facility failed to provide appropriate management of an indwelling catheter for a resident diagnosed with urinary retention. The resident, who was dependent on staff for most activities of daily living, had an indwelling urinary catheter. Observations revealed that the resident's leg bag was not switched to a urinary drainage bag at night, as required by the facility's catheter care policy. This oversight was noted during multiple observations, where the resident was found with a leg bag in place, which was not changed to a urinary drainage bag at night. Interviews with staff, including an LPN and a nursing assistant, confirmed that the catheter should have been connected to a urinary drainage bag at night to ensure proper urine drainage and prevent backflow, which could lead to a urinary tract infection. The Director of Nursing also acknowledged the importance of switching to a urinary drainage bag at night to prevent urine backflow. The facility's catheter care policy, revised in March 2023, clearly stated that leg bags should be removed and replaced with a bedside drainage bag at night, which was not adhered to in this case.
Deficiency in Tub/Shower Room Maintenance
Penalty
Summary
The facility failed to maintain the second-floor tub/shower room in good repair and sanitary conditions for the 30 residents who could potentially use the area. During an observation, it was noted that a wall partially enclosing the shower area was missing six tiles, exposing wood and plaster. The corporate maintenance director was unaware of the missing tiles and acknowledged the unsanitary and non-homelike environment. A housekeeper was aware of the issue but could not recall to whom it was reported. The facility maintenance director, new to the position, was also unaware of the missing tiles and was dealing with a backlog of repairs. A policy on building maintenance was requested but not provided.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a warm and palatable temperature, affecting the quality of life and nutritional intake for residents on the second floor. Three residents, each with specific dietary needs and cognitive impairments, reported that their meals were consistently served cold. Observations confirmed that meal trays were left unattended on the second floor for extended periods, leading to food temperatures significantly below the recommended safe levels. The dietary manager acknowledged that the food should be served at temperatures closer to 135 degrees Fahrenheit, but the facility's plate warmer had been out of service for two weeks, contributing to the issue. Interviews with residents and staff revealed that the lack of sufficient staff to deliver meal trays promptly was a contributing factor. Residents expressed dissatisfaction with the temperature of their meals, and the registered dietician confirmed concerns about food safety and palatability due to the low temperatures. The facility's policy stated that food should be prepared and served at safe and appetizing temperatures, but this was not adhered to, as evidenced by the observations and resident feedback.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food was maintained at proper temperatures, resulting in complaints from six residents about receiving cold meals. Observations and interviews revealed that residents consistently received meals that were lukewarm or cold, regardless of whether they dined in their rooms or the dining room. Specific instances included a resident receiving lunch at 2:00 p.m. with food that was not as ordered and often cold, and another resident who found the food cold but did not request reheating. During observations, it was noted that meal trays were distributed late, and nursing staff did not check food temperatures before serving. A Licensed Practical Nurse (LPN) mentioned that trays sometimes arrived late, and dietary staff did not pass out trays, leaving this task to nursing staff. The LPN also noted that hot plates were rarely used, and food was often reheated in microwaves before serving. Temperature checks conducted by dietary staff showed that food items were below the required temperature standards, with some hot foods measuring significantly below the minimum 135 degrees Fahrenheit. Interviews with dietary management confirmed that the temperatures recorded were unacceptable. The dietary account manager stated that food was taken from the oven to the steam table, but space limitations affected temperature maintenance. Observations showed that food was plated without lids, and cold items were placed on warm plates. The facility's policy required food to be served at safe and appetizing temperatures, but the practices observed did not align with these standards, leading to dissatisfaction among residents.
Failure to Deliver Oxygen According to Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen was delivered according to physician orders for a resident with chronic respiratory failure and other related conditions. The resident was supposed to receive continuous oxygen at 1 liter per minute (LPM) via nasal cannula, as per physician orders. However, during an observation, the resident was found with the oxygen concentrator set at 2 LPM, and the nasal cannula was not properly placed in the resident's nose. Additionally, the resident's head of bed was not elevated as required by the care plan. When the resident was transferred to a wheelchair, the oxygen saturation dropped significantly, and the resident experienced shortness of breath, prompting staff to increase the oxygen to 3 LPM, which was not in accordance with the physician's order. Interviews with staff revealed a lack of understanding and adherence to the oxygen delivery protocol. Nursing assistants were not aware of the importance of continuous oxygen delivery and were not trained to titrate oxygen levels, although they were involved in tasks that required temporary removal of oxygen. The facility's oxygen policy emphasized the necessity of oxygen for survival, yet the staff's actions did not align with this policy, leading to a deficiency in providing safe and appropriate respiratory care for the resident.
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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) |
|---|---|---|---|---|
| Charter House Inc | 0.8 mi | — | 3 | 0 |
| Samaritan Bethany Home On Eighth | 1.1 mi | — | 8 | 0 |
| Edenbrook Of Rochester | 2.6 mi | — | 16 | 0 |
| Edenbrook Rochester West | 2.8 mi | — | 25 | 1 |
| Madonna Towers Of Rochester | 3.8 mi | — | 4 | 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 August 2026) and official state health department websites.