Pomeroy Living Rochester Skilled Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/19/2026 at 8:45 AM initial kitchen/dietary services tour with Dietary Manager/Chef (DM) Q and Corporate Chef (CC) R. On 04/19/2026 at 9:10 AM in the dry storage area observed the floor soiled with debris along perimeter of room at floor/wall juncture and soil build-up on storage shelving. When queried about cleaning frequency of this area, DM Q agreed that noted areas needed cleaning attention. According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. [...]

Inspectors wroteBased on observation and interview, the facility failed to assure medications were safely secure and inaccessible to unauthorized staff and residents, for two of four medication carts observed for medication storage, and observations within two resident rooms (R47, during medication administration and (R39) during initial pool interviews, and environmental observations of the community shower rooms.

Inspectors wroteBased on interview and record review, the facility failed to operationalize an effective antibiotic stewardship program to ensure appropriate infection criteria was met, this had the ability to affect multiple residents who were prescribed antibiotics including six [R8, R30, R56, R138, R139 and R140] residents identified.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the central shower rooms. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting residents that use the [NAME] Unit and [NAME] Unit central shower rooms. Findings Include: On 04/20/2026 at 9:15 AM toured central shower/spa rooms with Housekeeping Director (HK) K. Observed the following in the two [NAME] Unit central shower rooms: broken/missing tiles around the shower drains and at wall corners, storage room door threshold surface rusted/deteriorating and no longer smooth and cleanable, multiple storage rooms with debris on the floor surface, including cleaning brushes and bucket, bag of grout. Observed perimeter of showering areas soiled with black mold-like substance on tiles, grout, and caulking. [...]

Inspectors wroteBased on interview and record review the facility failed to transcribe a medication as ordered from the hospital for one resident (R115) of one resident reviewed for admissions.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level I evaluation to determine if a Level II Evaluation was needed, or if exemption was identified for one (R12) of one resident reviewed for PASARR (Preadmission Screen and Resident Review).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services according to professional standards of practice related to failure to implement treatment according to physician orders and documenting as completed for one (R110) of one reviewed for edema, and treatment and self-administering medication for one (R135) of one reviewed for medication administration.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure a physician order was implemented for oxygen administration for one (R8) of one resident reviewed for respiratory care.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to prevent the use of an unnecessary antibiotic for one (R11) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to don personal protective equipment (PPE) for one Resident (R135) of one reviewed for isolation.

Inspectors wroteThis citation pertains to the complaint: 2594578. Based on interviews and record reviews the facility failed to timely identify signs/symptoms of a urinary tract infection (uti), failed to consistently inform the Physician/NP (nurse practitioner) of identified signs/symptom, and failed to timely treat a uti for one (R202) of three residents reviewed for a change of condition, resulting in the resident to be hospitalized in the intensive care unit for urosepsis (urinary tract infection spreads to the bloodstream) and ultimately admitted into hospice care.

Inspectors wroteThis citation pertains to the complaint: 2594578. Based on interviews and record reviews the facility failed to order laboratory tests as directed by the Physician/Nurse Practitioner, ensure timely/efficient laboratory services, ensure promptly notify the Physician of abnormal results and failed to develop a policy and/or procedure for ordering laboratory test, obtaining & reporting abnormal values to the Physician for one (R202) of three residents reviewed for a change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility assessment was reviewed and revised in accordance with current regulatory requirements. This has the potential to affect all 117 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure enhanced barrier precautions (EBP)policies and protocols were followed and maintained for three residents (R48, 53, & and 78), maintain linen carts, as well as a system of surveillance that consistently documented signs and symptoms of infections and consistently tracked and trended infections, this had the ability to affect all 117 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored appropriately for one resident (R367) of one resident reviewed for medication storage as well as properly stored, labeled, and dated in five of five medication carts reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water was provided and kept within resident's reach for one resident, (R33) of one resident reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow end of life wishes for one of one resident (R417) reviewed for advance directives.

Inspectors wroteThis citation pertains to intake #MI00148138. Based on observation, interview and record review, the facility failed to follow nursing professional standards of practice related to medication administration for two (R29 and R368) of two residents reviewed for professional standards.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to consistently provide assistance for oral care for a dependent resident, one (R58) of three residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteThis citation pertains to intake #MI00150390. Based on observations, interviews and record reviews the facility failed to timely implement a fungal rash treatment (R372), timely implement treatment for edema (R85) and failed to obtain a physician ordered blood sugar level (R48), for three of 24 sampled residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor documented weights and ensure timely nutritional interventions were implemented to prevent significant weight loss for one resident (R23) of four residents reviewed for nutrition, resulting in a 22.94% weight loss from October 30, 2024 to December 2, 2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% when three medication errors were made for two residents (R#'s 12 and 50) of four residents reviewed during the medication pass observation, resulting in a medication error rate of 10.34%.

Inspectors wroteBased on interview and record review the facility failed to implement an effective antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for three (R418, R29 and R97) of three residents.

Inspectors wroteR406 R406 was a long-term resident, originally admitted to the facility on [DATE]. R406's admitting diagnoses included lung cancer, respiratory failure, heart failure, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Based on the current Minimum Data Set (MDS) assessment, R406 had a Brief Interview for Mental Status (BIMS) score 15/15, indicative of intact cognition. An initial observation was completed on 10/15/24 at approximately 10:30 AM. During an interview R406 reported that they had a concern about cold food. R406 added that they preferred to eat in their room and the food was cold on most days. When queried further if that any pattern such as any particular meal or days, R406 reported that it was lunch and dinner that was served cold. R406 added that cold breakfast was also an issue on some days. R406 reported that meat gets overcooked and tough. [...]

Inspectors wroteThis citation pertains to intake(s): MI00146420, MI00146542, MI00146558, MI00145342, & MI00147417. Based on interviews and record reviews the facility failed to ensure medications and treatments were administered/applied as prescribed by the physician, failed to ensure the timely administration of medications and failed to treat a change of condition timely for three (R's 401, 402, & 403) of five residents reviewed for medications/treatments.

Inspectors wroteThis citation pertains to Intake(s) #'s MI00145342 and MI00146542. Based on interview and record review the facility failed to provide oxygen (O2) services per physician order for two (R401 and R403) out of five residents reviewed for respiratory services resulting in R401's O2 saturation levels dropping to an extremely low level requiring immediate hospitalization.

Inspectors wroteThis citation pertains to Intake Number(s): MI00144974. Based on observation, interview, and record review, the facility failed to complete skin assessments on a consistent basis and thoroughly complete assessments of existing pressure ulcers for one (R702) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen and equipment in a sanitary manner, and failed to ensure food items were dated and discarded when expired. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that meals were served at a preferred temperature and in a palatable manner for two (R212 and R213) and multiple anonymous residents who attended the resident council meeting. This deficient practice had the potential to affect residents that received meals.

Inspectors wroteThis citation has two deficient practices. Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene for six residents (R362, R364, R13, R37, R1, R3) of six observed during medication administration resulting in the potential for the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate size pull-up underwear (facility provided single-use disposable underwear) was provided for two residents (R20 and R218) of two residents reviewed for accommodation of resident needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident's rooms were maintained in a clean, comfortable and homelike manner for five (R1, R13, R17, R30, R49) of five residents reviewed for the environment.

Inspectors wroteDeficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to ensure medications were documented in the medical record accurately per professional standards for two residents (R15 and R362) resulting in the potential for inaccurate medical records and missed care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure necessary labs were completed for a resident with an observed change in condition for one (R219) of three residents reviewed for pain/catheter care/laboratory services.

Inspectors wroteThis citation has two deficient practices Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure interventions to prevent injury from falling were provided for one resident (R93) of one residents reviewed for accidents/hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate urology services was provided for one resident (R98) reviewed for urinary catheters, resulting in the increased likelihood of a urinary tract infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with a history of protein-calorie malnutrition received weekly weights and 1:1 feeding as ordered for one (R219) of two residents reviewed for nutrition/hydration.

Inspectors wroteBased interview and record review, the facility failed to consistently ensure the physicians review, action and rationale of identified medication irregularities documented by the Pharmacy monthly medication reviews were documented and maintained in the resident's medical record for one (R55) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure a laboratory diagnostic was completed in a timely manner per Physician's order for one resident (R20) of one residents reviewed for laboratory diagnostics.