Deficiency Records for Pomeroy Living Rochester Skilled Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Pomeroy Living Rochester Skilled Rehabilitation. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-23 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-27 | 2023-05-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-02 | 2023-03-07 | 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 | 2023-02-02 | 2023-03-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-02 | 2023-03-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-02 | 2023-03-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-02 | 2023-03-07 | 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 | 2023-02-02 | 2023-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-02 | 2023-03-07 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-02-02 | 2023-03-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-02 | 2023-03-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-02-02 | 2023-03-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-02 | 2023-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-02 | 2023-03-07 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-02 | 2023-03-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-02 | 2023-03-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-02 | 2023-03-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-02 | 2023-03-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-02 | 2023-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-02 | 2023-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-02 | 2023-03-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2021-12-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-10 | 2021-11-23 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-14 | 2021-11-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-14 | 2021-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-14 | 2021-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-11-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-14 | 2021-11-08 | 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 | 2021-10-14 | 2021-11-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-10-14 | 2021-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-14 | 2021-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-14 | 2021-11-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-14 | 2021-11-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-14 | 2021-11-08 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-14 | 2021-11-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-14 | 2021-11-05 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-13 | 2021-11-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-05 | 2021-06-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-05 | 2021-05-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-21 | 2021-05-10 | Y |
| 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 | 2019-10-15 | 2019-12-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-15 | 2019-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-15 | 2019-12-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-15 | 2019-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-15 | 2019-12-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-15 | 2019-12-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-15 | 2019-11-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-10 | 2019-11-11 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-10-10 | 2019-11-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-10-10 | 2019-11-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-10 | 2019-11-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-10 | 2019-11-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-10 | 2019-11-11 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-10-10 | 2019-11-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-10 | 2019-11-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-10 | 2019-11-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-10 | 2019-11-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-10 | 2019-11-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-10-10 | 2019-11-11 | 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 | 2019-10-10 | 2019-11-11 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-10-10 | 2019-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-10 | 2019-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-11 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-10-10 | 2019-11-11 | N |
