A list of the most recent deficiencies for Madonna Towers of Rochester Inc. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-30 | 2024-02-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-28 | 2024-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-28 | 2024-01-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-22 | 2023-07-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-25 | 2023-07-14 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-25 | 2023-07-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-23 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-08-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-04 | 2022-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-05 | 2022-07-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-05 | 2022-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-05 | 2022-07-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-05 | 2022-07-28 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-05-18 | 2022-06-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-21 | 2022-04-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-07 | 2022-02-02 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-01-07 | 2022-02-02 | 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 | 2022-01-07 | 2022-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-07 | 2022-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-07 | 2022-02-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-07 | 2022-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-02-02 | 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 | 2022-01-06 | 2022-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-06 | 2022-02-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-06 | 2022-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-06 | 2022-02-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-20 | 2021-11-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-28 | 2021-07-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-28 | 2021-07-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-10 | 2021-06-01 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-19 | 2020-04-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-19 | 2020-03-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-02-19 | 2020-03-30 | 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 | 2020-02-19 | 2020-03-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-19 | 2020-03-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-19 | 2020-03-30 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-19 | 2020-03-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-19 | 2020-03-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-02-19 | 2020-03-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-19 | 2020-03-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-19 | 2020-03-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-19 | 2020-03-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-19 | 2020-03-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-19 | 2020-03-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-02-19 | 2020-03-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-02-19 | 2020-03-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-19 | 2020-03-30 | 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 | 2020-02-19 | 2020-03-30 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2020-02-19 | 2020-03-30 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-02-19 | 2020-03-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-19 | 2020-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-19 | 2020-03-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-19 | 2020-03-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-19 | 2019-02-21 | N |
