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 Samaritan Bethany Home On Eighth during CMS and state inspections, most recent first.
The facility failed to ensure call lights were accessible for two residents, one with cognitive impairment and another with mobility limitations. Both residents were unable to reach their call lights, which were placed out of reach, preventing them from requesting assistance. Staff interviews confirmed that call lights should be within reach, as per facility policy.
The facility failed to adhere to transfer care plans, resulting in falls and injuries for two residents. One resident, with severe cognitive impairment, fell during an unsupervised transfer without the prescribed walker, leading to serious injuries and ICU hospitalization. Another resident, with moderate cognitive impairment, was transferred without using the required walker, causing difficulty in ensuring a safe transfer. The facility's failure to ensure staff followed care plans led to preventable accidents.
A resident with severe cognitive impairment and a history of atrial fibrillation received 14 incorrect doses of aspirin due to a transcription error in the EHR. Despite a physician's order to reduce the dosage from 325 mg to 81 mg due to frequent nosebleeds, the resident continued to receive the higher dose. The error was identified by a family member, and the DON was unaware of the issue, which was not documented or reported as per facility policy.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were accessible. Resident R60, who has cognitive impairment and various diagnoses including Parkinson's and non-Alzheimer's dementia, was observed in a wheelchair with the call light placed out of reach on a nightstand behind him. R60 expressed that he was unable to locate or reach the call light, which hindered his ability to request assistance. His care plan specifically required that the call light be within reach and that he be encouraged to use it for assistance. Similarly, Resident R187, who has limitations in range of motion, requires extensive assistance for mobility, and is on continuous oxygen, was found lying in bed with the call light three feet away on a nightstand, making it inaccessible. R187 stated a preference for having the call light on her body to use it when needed. Interviews with nursing assistants and the director of nursing confirmed that call lights should always be within reach of residents, aligning with the facility's policy. However, both residents were unable to access their call lights, indicating a failure to meet this standard.
Failure to Follow Transfer Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to follow the care plan for transfers, leading to a fall and significant injuries for two residents. One resident, who had severe cognitive impairment and multiple health issues, was at moderate risk for falls. Despite this, the care plan requiring the use of a front-wheeled walker and gait belt with contact guard assist was not followed during a transfer. The resident fell, resulting in serious injuries, including brain hemorrhages and fractures, necessitating an eight-day ICU hospitalization. The incident occurred when a nursing assistant, who was still in orientation and unsupervised, attempted to transfer the resident without using the prescribed walker. The assistant was unaware of the need to lock the brakes on the shower chair and did not realize the care plan required the use of a walker. This lack of adherence to the care plan and inadequate supervision during the transfer process directly contributed to the resident's fall and subsequent injuries. Another resident, with moderate cognitive impairment and a history of dementia, was also transferred without following the care plan. The care plan required the use of a front-wheeled walker and gait belt, but the nursing assistant did not use the walker, leading to difficulty in ensuring the resident's safe transfer. The facility's failure to ensure staff followed individualized care plans for transfers resulted in preventable accidents and injuries.
Medication Transcription Error Leads to Incorrect Aspirin Dosage
Penalty
Summary
The facility failed to accurately transcribe a physician's order into the electronic health record (EHR) for a resident who received 14 incorrect doses of aspirin. The resident, who had severe cognitive impairment and a history of atrial fibrillation, thrombocytopenia, and hypertension, was initially prescribed aspirin 325 mg daily. However, due to frequent nosebleeds, the physician ordered a change to aspirin 81 mg daily. Despite this change, the resident continued to receive the higher dose of 325 mg daily from February 23, 2024, through March 5, 2024. The error was identified during a phone interview with a family member who expressed concern that the dosage change was not implemented. The Director of Nursing (DON) was unaware of the transcription error and explained that medication errors should be documented, assessed, and reported according to facility policy. The facility's policy requires that significant medication errors, which could jeopardize a resident's health or safety, be reported to the medical doctor, the resident or their representative, and documented in the resident's record. However, this process was not followed in this case.
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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 | 0.4 mi | — | 3 | 0 |
| Rochester Restorative Care Center | 1.1 mi | — | 36 | 1 |
| Edenbrook Of Rochester | 1.7 mi | — | 16 | 0 |
| Edenbrook Rochester West | 1.8 mi | — | 25 | 1 |
| Madonna Towers Of Rochester | 2.7 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.