A list of the most recent deficiencies for Rochester Health Services West. 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 and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-30 | 2024-01-09 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-30 | 2024-01-09 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-30 | 2024-01-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-30 | 2024-01-09 | Y |
| 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 | 2023-11-02 | 2023-12-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-02 | 2023-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-02 | 2023-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-02 | 2023-12-20 | 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 | 2023-11-02 | 2023-12-20 | 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 | 2023-11-02 | 2023-12-20 | 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 | 2023-11-02 | 2023-12-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-11-02 | 2023-12-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-11-02 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-12-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-02 | 2023-12-20 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-02 | 2023-12-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-02 | 2023-12-20 | 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 | 2023-11-02 | 2023-12-20 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-02 | 2023-12-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-24 | 2023-11-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-24 | 2023-11-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-24 | 2023-11-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-24 | 2023-10-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-22 | 2023-09-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-02 | 2022-12-05 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-27 | 2022-06-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-27 | 2022-06-02 | 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 | 2022-04-27 | 2022-06-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-27 | 2022-06-02 | 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 | 2022-04-27 | 2022-06-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-27 | 2022-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-27 | 2022-06-02 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-04-27 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-27 | 2022-06-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-27 | 2022-06-02 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-20 | 2022-06-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-20 | 2022-05-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-04 | 2021-12-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-26 | 2021-09-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-14 | 2021-08-12 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-01-24 | 2020-03-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-01-24 | 2020-02-29 | 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 | 2020-01-24 | 2020-02-29 | 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 | 2020-01-24 | 2020-02-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-24 | 2020-02-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-24 | 2020-02-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-24 | 2020-02-29 | 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 | 2020-01-24 | 2020-02-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-24 | 2020-02-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-24 | 2020-02-29 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2020-01-24 | 2020-02-29 | 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 | 2020-01-22 | 2020-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-22 | 2020-02-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-22 | 2020-02-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-22 | 2020-02-29 | N |
