Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Monroe Community Hospital
Rochester, NY · 566 certified beds · Last Life Safety survey December 20, 2024
CMS Certification Number 335197 · first certified January 1967
Ownership
Independently operated (no chain recorded by CMS) · Government - County
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
16 citations — more than 61% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: June 2026 to February 2027. This facility’s last Life Safety survey was December 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 16 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 16 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 16 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 15, 2021 | 3 |
| May 1, 2023 | 10 |
| December 20, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2024-12-20 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2024-12-20 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2023-05-01 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-05-01 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 1 | 2021-07-15 |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | 1 | 2023-05-01 |
| K-0271 | Have exits that are accessible at all times. | 1 | 2021-07-15 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2021-07-15 |
What the citations cover
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 3
- Emergency Preparedness Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 20, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 18, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (February 18, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 18, 2025) |
May 1, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Waiver has been granted (June 30, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 30, 2023) |
July 15, 2021 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (August 20, 2021) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (August 20, 2021) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (August 20, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.