Rochester Rehabilitation And Living Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

64.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 342 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 77 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 56 beds and averages 35.4 residents a day — about 63% occupied, or roughly 21 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.09 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.58 hrs/resident/day on weekends vs 5.29 on weekdays — 13% thinner on weekends. RN hours go from 2.24 to 1.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 74% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-08-22 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the safe and accurate administration of prescribed medications to residents, resulting in Immediate Jeopardy. Systemic Failures were identified across multiple areas, including transcription errors, incorrect dosing, and medication omissions. The facility did not consistently follow the five rights of medication administration, nor did it implement effective systems to identify, prevent, investigate, or track medication errors. These failures directly impacted two residents. Resident R1 did not receive two prescribed diuretic (manage fluid overload) medications, resulting in ongoing congestive heart failure. Resident R4 received 50 mg of prednisone instead of the prescribed 5 mg of a potent anti-inflammatory medication, leading to new cardiac symptoms, hospitalization, and admission to the intensive care unit (ICU), where he remains. The facility's lack of oversight and failure to implement corrective actions placed all…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to follow physician orders, complete assessments, monitor or input appropriate interventions and recognize changes in condition, for 6 of 6 residents (R31, R201, R21, R194, R6, R18) reviewed for quality of care. As a result of the facility's failures, an immediate jeopardy (IJ) situation was identified for R31 who had displayed respiratory distress with labored breathing, increased anxiety and required additional medication, R201 who had displayed signs of a UTI and was transferred to the ER for treatment, R21 who had displayed signs of a urinary tract infection (UTI) and was transferred to the hospital ER for treatment. The immediate jeopardy began on 4/12/25, when R31's daily weight were not completed as ordered and facility was not monitoring, which led to R31's respiratory distress, and failed to identify, monitor and assess R201 and R21 for change of condition related to blood in the catheters led to kidney/bladder infections. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to monitor, comprehensively assess, develop, and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 3 of 4 residents (R1, R4, R5) reviewed for pressure ulcers. This caused actual harm to R1 who developed an avoidable unstageable pressure ulcer on her coccyx which needed surgical debridement and hospitalization. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. i Stage 2 Pressure Ulcer: Partial…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure timely identification, evaluation, and treatment of a worsening skin infection for 1 of 3 residents (R1) reviewed for quality of care. This resulted in actual harm for R1 who developed a worsening infection in the wound in which necessary treatment and care were delayed. In addition, the facility failed to complete comprehensive skin assessments for non-pressure skin impairments (surgical wounds) for 3 of 3 residents (R1, R4, R5) reviewed for non-pressure (surgical incisions) skin impairments.Findings include:R1's face sheet dated 6/27/25, identified diagnoses of cellulitis (a potentially serious bacterial skin infection) of left lower limb, absence of left leg below the knee, heart failure (a condition where the heart does not pump as well as it should), and diabetes mellitus (a disease that results in too much sugar in the blood).R1's hospital after visit summary (AVS) dated 5/9/25, identified R1 had been hospitalized for a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in actual harm when 1 of 1 residents (R1) admitted with a stage 1 pressure ulcer developed into an unstageable pressure ulcer that caused pain and required antibiotic treatment. Findings include: Definitions of pressure ulcers: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. The appearance will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-24 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 2 of 2 residents (R3, R15) reviewed for self-administration of medications.Findings include:R3R3's quarterly Minimum Data Set (MDS) assessment, dated 4/27/26, indicated R3 was cognitively intact with no signs of delirium or behaviors. R3 had no upper body impairment and bilateral lower body impairment. R3 required setup for eating and oral hygiene, partial assist for toilet hygiene, bathing, and upper body dressing, and substantial assist for lower body dressing, footwear, and personal hygiene. R3 also required substantial assist with bed mobility and transfers to/from bed/chair.R3's careplan indicated R3 required 1 assist for transfers and activities of daily living.During observation and interview on 6/22/26 at 6:45 p.m., an unlabeled bottle of fluticasone nasal spray was noted on R3 bedside table. R3 stated she administers it on her own in the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · D2026-06-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide activities of daily living (ADL) for 2 of 2 residents (R41, R20) who were dependent on staff for timely assistance for personal hygiene.Findings Include: R41 R41's quarterly Minimum Data Set (MDS) was not completed at time of survey; R41 admitted to the facility on [DATE]. R41's care plan dated 6/9/26 indicated R41 required extensive assistance to total assistance with personal hygiene and grooming. R41's care plan lacked resident-specific directions about facial hair/removal. R41's provider orders dated 6/9/26 indicated R41 was to have weekly skin checks and vital signs every evening shift every Saturday for bath day, if resident refuses, document reason and attempts. The treatment administration record (TAR) indicated the skin checks and vital signs had been completed; the TAR lacked documentation a bath had been performed. R41's 30 day look back for point of care task history for bathing/showering indicated R41 had not had a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · D2026-03-27 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to timely revise the care plan to include an individualized toileting/incontinence plan for 1 of 3 residents (R1) who were reviewed for impaired skin integrity that had impaired skin integrity. Findings include: R1's face sheet dated 3/27/26, identified diagnoses of primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, pressure induced deep tissue damage to left heel.R1's Significant Change Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no behaviors, no rejection of care, dependent for toileting hygiene, had lower extremity limitation of range of motion, used a wheelchair, substantial/maximum assistance to roll left and right in bed, dependent for transfers, did not ambulate, occasionally incontinent of urine, always continent of bowel, was at risk for pressure ulcers, had one or more unhealed pressure ulcers/injuries, had one unstageable pressure ulcer that was not present on admission,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess an area of moisture associated skin damage and failed to notify the physician for 1 of 1 resident (R3) reviewed for non-pressure skin issues. Findings include:R3's face sheet dated 3/27/26, identified diagnoses of diabetes, Crohn's disease, and kidney transplant.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had intact cognition, no behaviors, no rejection of care, needed partial/moderate assistance for transfers, was occasionally incontinent of bowel, has no pressure ulcers, had no venous or arterial ulcers, had no moisture associated skin damage, had an application of non-surgical dressing other than feet, application of ointment other than feet and receives dialysis. R3's Wound assessment dated [DATE], identified R3 had a resolved moisture associated skin damage (MASD) to his right gluteus. R3's progress note dated 3/9/26, identified sacral wound cleansed and creams applied to sacrum as well.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-27 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R3) observed during wound care. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during a transfer for 1 of 3 residents (R3).Findings include:R3's face sheet dated 3/27/26, identified diagnoses of diabetes, non-pressure chronic ulcer of right lower leg, and kidney transplant.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had intact cognition, no behaviors, no rejection of care, needed partial/moderate assistance for transfers, was occasionally incontinent of bowel, has no pressure ulcers, had no venous or arterial ulcers, had no moisture associated skin damage, had an application of non-surgical dressing other than feet, application of ointment other than feet and received dialysis. R3's care plan dated 7/24/25, identified R3 needed EBP. Goal that staff will maintain enhanced barrier precautions when…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-22 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) plan and program identified, analyzed, implemented corrective actions, and re-evaluated corrective actions to address adverse events and quality deficiencies. This deficient practice had the potential to affect all 35 residents in the facility. Actual harm occurred related to the quality of care to two residents (R4 and R1). Findings include:See F755, facility failed to identify and prevent medication errors due to complete systemic failure. The facility's failures resulted in an immediate jeopardy (IJ) with over 79 medication errors occurred in six weeks, resulting in actual harm for 2 of 5 residents (R4, R1) reviewed who had medication errors. R4 (cardiac ICU admission) and R1 (ongoing CHF exacerbation). The facility lacked systems to prevent errors, notify providers, and investigate incidents-demonstrating a widespread failure in medication management. Further review of medication errors revealed a lack of analysis of root causes, and there…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and document review the facility failed to provide the necessary care and services in accordance with the professional standards of practice to comprehensively assess, monitor and evaluate 3 of 4 residents (R3, R1, R4) for congestive heart failure management. Findings include: R3's face sheet dated 8/12/25, identified R3 had diagnoses of heart failure (a condition where the heart does not pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and edema (swelling).R3's care plan focus dated 8/1/25, identified R3 had a cardiac diagnosis requiring monitoring and medication/treatments. Interventions included the following: notify physician and family with any change in condition and medications per physician orders.R3's nurse practitioner (NP) note dated 8/5/25, identified a physician order to continue daily weights for 7 days until 8/12/25 and leg compression/wraps on bilateral legs: apply in the morning and take off in the evening.R3's physician orders included the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-06-27 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to wound assessments not being completed by developing and implementing action plans for process improvement. This had the potential to affect all 36 residents that resident in the facility. Findings include:See F684: Based on observation, interview, and document review the facility failed to ensure timely identification, evaluation, and treatment of a worsening skin infection for 1 of 3 residents (R1) reviewed for quality of care. This resulted in actual harm for R1 who developed a worsening infection in the wound that delayed treatment and care. In addition, the facility failed to complete comprehensive skin assessments for non-pressure skin impairments (surgical wounds) for 3 of 3 residents (R1, R4, R5) reviewed for non-pressure (surgical incisions) skin impairments.During the facility resident record review on 6/25/25 for resident sample selection revealed from 5/9/25 to 6/25/25, the facility had…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-22 · tag F0636 — pattern
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to accurately complete comprehensive assessment of a resident's needs, strengths, goals, life history and preferences to determine a resident's functional capacity. In addition, the facility failed to ensure Minimum Data Set (MDS) was completed in a timely and/or in a comprehensive manner to facilitate accurate evaluation of resident' conditions for 5 of 5 residents (R6, R24, R194, R199, and R201) reviewed for MDS accuracy. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified the MDS as an assessment tool which facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning. The CMS RAI manual also identified the RAI process (i.e., MDS) was completed to help evaluate resident' strengths and areas for care-planning. The manual listed all types…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-22 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for 2 of 2 (R138, R140) residents reviewed for infection prevention related to presence of peripherally inserted central catheter (PICC) line (enters a peripheral vein and extends to the supervisor vena cava of the heart). Findings include: R138 quarterly Minimum Data Set (MDS) assessment dated [DATE] was incomplete at the time of survey; cognitive function was intact. R138 was receiving IV antibiotic infusions. R138 was admitted on [DATE] with a diagnosis of right knee prosthesis infection and inflammation. R138 had a PICC line inserted into a peripheral vein in the upper right chest. R138's orders dated 3/31/25 did not include orders to change the PICC line dressing. Medication orders stated to administer ertapenem (IV antibiotic) 1 gram every 24 hours starting 3/28/25 at 11pm. R138's orders did not include orders for enhanced barrier precautions. During observation on 4/14/25 at 6:32 p.m., a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

• Medicare payment denial — starting 2024-09-28 for 6 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to VOLUNTEERS OF AMERICA SENIOR LIVING — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 30 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MN