A list of the most recent deficiencies for Rochester East Health Services. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-29 | 2024-01-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-29 | 2024-01-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-29 | 2024-01-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-11-29 | 2024-01-04 | 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 | 2023-11-29 | 2024-01-04 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-11-29 | 2024-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-29 | 2024-01-04 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-11-29 | 2024-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-29 | 2024-01-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-29 | 2024-01-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-29 | 2024-01-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-08 | 2023-11-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-18 | 2023-08-15 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-07-18 | 2023-08-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-20 | 2023-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-20 | 2023-05-15 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-12 | 2023-02-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-12 | 2023-02-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-12 | 2023-02-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-12 | 2023-02-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-01-12 | 2023-02-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-12 | 2023-02-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-12 | 2023-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-02-21 | 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 | 2023-01-12 | 2023-02-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-12 | 2023-02-21 | 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 | 2023-01-12 | 2023-02-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-12 | 2023-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-10 | 2023-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-10 | 2023-02-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-10 | 2023-02-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-10 | 2023-02-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-10 | 2023-02-08 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-01-10 | 2023-01-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-07-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-16 | 2022-07-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-27 | 2022-07-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-27 | 2022-07-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-27 | 2022-07-11 | Y |
| 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 | 2022-05-27 | 2022-07-11 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-27 | 2022-07-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-27 | 2022-07-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-27 | 2022-07-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-09 | 2022-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-24 | 2022-03-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-21 | 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 | 2021-10-21 | 2021-12-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-21 | 2021-12-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-21 | 2021-12-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-12-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-21 | 2021-12-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-21 | 2021-12-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-21 | 2021-12-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-21 | 2021-12-01 | 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 | 2021-10-21 | 2021-12-01 | 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 | 2021-10-21 | 2021-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-12-01 | 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 | 2021-10-21 | 2021-12-01 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-20 | 2021-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-20 | 2021-12-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-20 | 2021-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-09-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-28 | 2021-08-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-25 | 2021-04-28 | Y |
