A list of the most recent deficiencies for Hickory Creek at Rochester. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-30 | 2023-06-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-30 | 2023-06-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-05-30 | 2023-06-29 | N |
| Develop a communication plan. | Fire Safety | 2023-05-30 | 2023-06-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-30 | 2023-06-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-05-30 | 2023-06-29 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-21 | 2023-05-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-21 | 2023-05-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-05 | 2023-04-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-08 | 2021-12-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-19 | 2021-12-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-11-19 | 2021-12-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-19 | 2021-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-19 | 2021-12-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-19 | 2021-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-19 | 2021-12-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-19 | 2021-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-19 | 2021-12-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-19 | 2021-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-19 | 2021-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-19 | 2021-12-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-19 | 2021-12-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-19 | 2021-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2021-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-12-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-06 | 2021-10-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-06 | 2021-10-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-06 | 2021-10-29 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-10-06 | 2021-10-29 | Y |
| Keep complete, dated laboratory records in the resident's record. | Health | 2021-10-06 | 2021-10-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-06 | 2021-10-29 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-06 | 2021-10-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-06 | 2021-10-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-06 | 2021-10-29 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-08-12 | 2020-08-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-03-04 | 2020-03-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-04 | 2020-03-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-04 | 2020-03-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-03-04 | 2020-03-23 | N |
