Inspection Reports for
The Hurlbut
1177 East Henrietta Rd, Rochester, NY, 14623
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 31, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 07/24/2025 to 07/31/2025 to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including pressure ulcer care, medication self-administration, pharmacist medication regimen review, food safety, and infection control practices. Deficiencies included failure to follow wound treatment orders, inadequate monitoring of pressure ulcers, unsafe medication storage and administration, lack of timely response to pharmacist recommendations, improper food storage and handling, and failure to maintain enhanced barrier precautions for residents with wounds.
Deficiencies (5)
F 0686: The facility failed to ensure residents with pressure ulcers received treatment consistent with professional standards. Resident #43's wound treatment orders were not consistently followed and documentation was incomplete. Resident #95 lacked consistent weekly pressure ulcer assessments and had conflicting wound documentation.
F 0689: The facility did not ensure Resident #52's environment was free from accident hazards related to medication self-administration. Zinc supplements were stored at bedside without medical orders or interdisciplinary review for safe self-administration.
F 0756: The facility failed to ensure pharmacist-reported medication irregularities were reviewed and acted upon timely by medical providers for Residents #68 and #77, resulting in delayed responses to recommendations for medication dose reductions.
F 0812: Raw shell eggs were stored above ready-to-eat foods in the kitchen, bare-hand contact with ready-to-eat food was observed, and a section of floor tile was missing and dirty, violating food safety standards.
F 0880: The facility failed to maintain an effective infection prevention program. Resident #43 received wound care without appropriate gown use despite enhanced barrier precautions signage. Resident #95 lacked enhanced barrier precautions despite having a chronic wound, and wound care was performed without proper glove changes or hand hygiene.
Report Facts
Residents reviewed for pressure ulcers: 3
Residents reviewed for medication irregularities: 5
Months of pharmacist recommendations not acted upon: 10
Months of pharmacist recommendations not acted upon: 9
Length of wound on Resident #43: 2
Width of wound on Resident #43: 1
Size of pressure ulcer on Resident #95: 1.7
Duration Resident #52 took zinc: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant #1 | Physician Assistant | Involved in wound care orders and medication regimen review responses |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed providing wound care without gown and involved in medication administration |
| Licensed Practical Nurse Manager #2 | Licensed Practical Nurse Manager | Provided statements regarding wound care and medication self-administration policies |
| Pharmacist #2 | Consultant Pharmacist | Provided medication regimen reviews and recommendations |
| Administrator #2 | Administrator | Provided statements on wound care, medication review process, and infection control |
| Nurse Practitioner #1 | Nurse Practitioner | Observed providing wound care and interviewed about infection control practices |
| Food Service Director | Food Service Director | Provided statements on food storage and handling practices |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed assisting Resident #95 without enhanced barrier precautions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Jul 31, 2025
Visit Reason
Inspection identified 5 standard health citations and 3 life safety code citations related to drug regimen review, food safety, accident hazards, infection control, pressure ulcer treatment, and fire safety systems.
Findings
Inspection identified 5 standard health citations and 3 life safety code citations related to drug regimen review, food safety, accident hazards, infection control, pressure ulcer treatment, and fire safety systems.
Deficiencies (8)
Drug regimen review, report irregular
Food procurement, store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection prevention & control
Treatment/services to prevent/heal pressure ulcer
Fire alarm system - testing and maintenance
Maintenance, inspection & testing - doors
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 5
Date: Feb 16, 2024
Visit Reason
The inspection was conducted as a Standard Recertification Survey to assess compliance with regulatory requirements including employee screening, nurse staffing postings, fire safety, quality assurance, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to complete timely nurse aide registry abuse screenings for new employees, inaccurate daily nurse staffing postings with incorrect resident census, lack of documented carbon monoxide detector testing, absence of required Infection Preventionist attendance at Quality Assurance meetings, and incomplete documentation of pneumococcal vaccinations for residents.
Deficiencies (5)
10NYCRR 415.4(b): The facility did not implement timely nurse aide registry abuse screenings for three recently hired employees prior to their start dates.
10 NYCRR 415.13: The facility did not consistently post updated daily nurse staffing information including actual resident census and staffing changes throughout the day.
10NYCRR 415.29(a)(2), 711.2(a)(1), 42 CFR 483.70(b), 2015 IFC Section 915, 915.6: The facility failed to maintain documentation of monthly testing for carbon monoxide detectors as required by the 2015 International Fire Code and NFPA 720.
10 NYCRR 415.19: The facility did not maintain evidence that the Infection Preventionist regularly attended Quality Assurance and Performance Improvement meetings as required.
10 NYCRR 415.19 (a)(3): The facility lacked documentation that a resident eligible for pneumococcal vaccination was offered, educated, or vaccinated prior to admission.
Report Facts
Resident Census: 100
Shifts worked prior to nurse aide registry screening: 7
Shifts worked prior to nurse aide registry screening: 8
Shifts worked prior to nurse aide registry screening: 4
Quality Assurance Meeting Dates Reviewed: 3
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Human Resources and Payroll | Provided explanations regarding delayed nurse aide registry screenings for employees #1, #2, and #5. | |
| Certified Nursing Aide/Scheduler | Responsible for nursing staff schedules and daily nurse staffing postings; unaware of requirement to update postings with staffing changes and resident census. | |
| Director of Nursing | Acknowledged lack of awareness regarding updates needed for daily nurse staffing postings and Infection Preventionist attendance at Quality Assurance meetings. | |
| Director of Environmental Services | Provided information about carbon monoxide detector testing procedures. | |
| Maintenance Worker | Described monthly carbon monoxide detector testing and disposal of old test stickers without maintaining logs. | |
| Administrator | Acknowledged Infection Preventionist absence from Quality Assurance meetings and lack of pneumococcal vaccination documentation. | |
| Infection Preventionist | Reported covering the facility since November 2023 and noted prior gaps in attendance at Quality Assurance meetings. | |
| Quality Care Coordinator | Reported gaps in pneumococcal vaccination documentation and tracking. | |
| Infection Control Nurse | Responsible for ensuring resident vaccinations; noted staffing shortages may have caused vaccination process gaps. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Feb 16, 2024
Visit Reason
Inspection found 5 standard health citations and no life safety code citations related to abuse/neglect policies, immunizations, licensing compliance, nurse staffing info, and quality assurance committee. All deficiencies were corrected by April 15, 2024.
Findings
Inspection found 5 standard health citations and no life safety code citations related to abuse/neglect policies, immunizations, licensing compliance, nurse staffing info, and quality assurance committee. All deficiencies were corrected by April 15, 2024.
Deficiencies (5)
Develop/implement abuse/neglect policies
Influenza and pneumococcal immunizations
License/comply with fed/state/local law/professional standards
Posted nurse staffing information
Qaa committee
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 5
Date: Feb 16, 2024
Visit Reason
The inspection was conducted as a Standard Recertification Survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in several areas including failure to implement timely abuse screening for newly hired employees, inconsistent posting of daily nurse staffing information including resident census, lack of documented testing for carbon monoxide detectors, absence of required Infection Preventionist attendance at Quality Assurance meetings, and incomplete documentation of pneumococcal vaccination offers and administration for residents.
Deficiencies (5)
10NYCRR 415.4(b): The facility did not complete nurse aide registry abuse screening for three recently hired employees prior to their start dates, resulting in employees working multiple shifts before screening completion.
10 NYCRR 415.13: The facility did not consistently post updated daily nurse staffing information including actual resident census and staffing changes throughout the day as required by regulation.
10NYCRR 415.29(a)(2), 711.2(a)(1), 42 CFR 483.70(b), 2015 IFC Section 915, 915.6: The facility failed to maintain documentation of monthly testing for carbon monoxide detectors as required by the 2015 International Fire Code and NFPA 720 standards.
10 NYCRR 415.19: The facility did not maintain evidence that the Infection Preventionist regularly attended the Quality Assurance and Performance Improvement Committee meetings as required.
10 NYCRR 415.19 (a)(3): The facility failed to provide documentation that a resident eligible for pneumococcal vaccination was offered, educated, or vaccinated prior to admission.
Report Facts
Resident Census: 100
Shifts worked prior to abuse screening: 7
Shifts worked prior to abuse screening: 8
Shifts worked prior to abuse screening: 4
Quality Assurance meetings reviewed: 3
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Human Resources and Payroll | Provided explanations regarding delayed nurse aide registry abuse screenings for employees #1, #2, and #5 | |
| Certified Nursing Aide/Scheduler | Responsible for nursing staff schedules and daily nurse staffing postings; unaware of requirement to update postings for call-ins and census changes | |
| Director of Nursing | Acknowledged lack of awareness about failure to update daily nurse staffing postings and described interim Infection Preventionist staffing | |
| Director of Environmental Services | Discussed carbon monoxide detector testing procedures and record keeping | |
| Maintenance Worker | Described monthly carbon monoxide detector testing and disposal of old test stickers without record keeping | |
| Administrator | Acknowledged Infection Preventionist absence from Quality Assurance meetings and vaccination documentation gaps | |
| Infection Preventionist | Reported covering facility since November 2023 and lack of attendance at Quality Assurance meetings | |
| Quality Care Coordinator | Reported vaccination tracking and identified gaps in pneumococcal vaccination documentation | |
| Infection Control Nurse | Responsible for resident vaccinations and noted staffing shortages affecting vaccination process |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 13, 2022
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with health and safety regulations, infection control, and COVID-19 vaccination requirements.
Findings
The facility was found deficient in food service safety due to improper refrigeration and storage conditions. Infection prevention and control practices were inadequate, with staff failing to properly use PPE in transmission-based precaution rooms. Additionally, the facility did not ensure full COVID-19 vaccination compliance among staff, resulting in a 94.1% vaccination rate and ongoing COVID-19 positive residents.
Deficiencies (3)
F0812: The facility did not store, distribute, and serve food in accordance with professional standards. A refrigeration unit was inoperable, door seals were damaged, handwash sink was blocked, and ceiling fan and tiles were dirty.
F0880: The facility failed to implement an infection prevention and control program. Three CNAs did not apply appropriate PPE when entering or exiting rooms on transmission-based precautions for COVID-19.
F0888: The facility did not ensure all staff were vaccinated for COVID-19 as required, resulting in a 94.1% staff vaccination rate and 13 residents positive for COVID-19.
Report Facts
Staff vaccination rate: 94.1
Current COVID-19 positive residents: 13
Total staff members: 153
Fully vaccinated staff: 129
Staff with medical exemptions: 12
Partially vaccinated staff: 7
Staff with no vaccination record: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed not changing PPE between resident rooms and lacked education on PPE use |
| CNA #2 | Certified Nursing Assistant | Observed not wearing full PPE when required in transmission-based precaution rooms |
| CNA #3 | Certified Nursing Assistant | Entered transmission-based precaution room without gown or gloves due to lack of gowns nearby |
| LPN #1 | Licensed Practical Nurse | Stated staff should wear full PPE when entering transmission-based precaution rooms |
| RN/IP | Registered Nurse/Infection Preventionist | Provided guidance on PPE use and staff vaccination tracking |
| Administrator | Declined to comment on staff vaccination rate |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: May 13, 2022
Visit Reason
Inspection identified 3 standard health citations and 3 life safety code citations related to Covid-19 vaccination of staff, food safety, infection control, communication plan, emergency preparedness training, and means of egress. All deficiencies were corrected by July 8, 2022.
Findings
Inspection identified 3 standard health citations and 3 life safety code citations related to Covid-19 vaccination of staff, food safety, infection control, communication plan, emergency preparedness training, and means of egress. All deficiencies were corrected by July 8, 2022.
Deficiencies (6)
Covid-19 vaccination of facility staff
Food procurement, store/prepare/serve-sanitary
Infection prevention & control
Development of communication plan
Ep training program
Means of egress - general
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 18, 2022
Visit Reason
Inspection found a Level 1 standard health citation for Covid-19 vaccination of facility staff, corrected as of April 14, 2022.
Findings
Inspection found a Level 1 standard health citation for Covid-19 vaccination of facility staff, corrected as of April 14, 2022.
Deficiencies (1)
Covid-19 vaccination of facility staff
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 16, 2021
Visit Reason
Inspection identified a Level 2 standard health citation for infection control, corrected as of February 17, 2022.
Findings
Inspection identified a Level 2 standard health citation for infection control, corrected as of February 17, 2022.
Deficiencies (1)
Infection control
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