A list of the most recent deficiencies for Rochester Residence and Care Center. 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? |
|---|---|---|---|---|
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Meet other general requirements. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-19 | 2024-02-14 | 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 | 2023-12-19 | 2024-02-14 | 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 | 2023-12-19 | 2024-02-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-12-19 | 2024-02-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-18 | 2024-02-05 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-18 | 2024-02-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-18 | 2024-02-05 | 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 | 2023-12-18 | 2024-02-05 | N |
| 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 | 2023-12-18 | 2024-02-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-18 | 2024-02-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-18 | 2024-02-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-18 | 2024-02-05 | 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 | 2023-12-18 | 2024-02-05 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-12-18 | 2024-02-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-18 | 2024-02-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-18 | 2024-02-05 | 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 | 2023-12-18 | 2024-02-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-12-18 | 2024-02-05 | 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 | 2023-12-18 | 2024-02-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-18 | 2024-02-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-12-18 | 2024-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-18 | 2024-02-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-18 | 2024-02-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-18 | 2024-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-02-05 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-12-18 | 2024-02-05 | 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 | 2023-12-18 | 2024-02-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-16 | 2023-11-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-16 | 2023-11-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-16 | 2023-11-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-16 | 2023-11-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-16 | 2023-11-28 | Y |
| 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 | 2023-05-19 | 2023-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-28 | 2023-06-08 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-28 | 2023-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-28 | 2023-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-05-03 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-03-30 | 2023-05-03 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-30 | 2023-05-03 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-03-30 | 2023-05-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-30 | 2023-05-03 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-03-30 | 2023-05-03 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-24 | 2023-04-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-24 | 2023-04-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-24 | 2023-04-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-24 | 2023-04-17 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-02-24 | 2023-04-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-24 | 2023-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-24 | 2023-04-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-24 | 2023-04-17 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-02-24 | 2023-04-17 | 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 | 2023-02-24 | 2023-04-17 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-24 | 2023-04-17 | N |
| Meet other general requirements. | Fire Safety | 2023-02-28 | 2023-04-17 | 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 | 2023-02-28 | 2023-04-17 | 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 | 2023-02-28 | 2023-04-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-28 | 2023-04-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-28 | 2023-04-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-28 | 2023-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-28 | 2023-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-28 | 2023-04-17 | 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 | 2022-02-16 | 2022-05-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-16 | 2022-05-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-16 | 2022-05-24 | N |
| Use approved construction type or materials. | Fire Safety | 2022-02-16 | 2022-04-17 | 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 | 2022-02-16 | 2022-04-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-16 | 2022-04-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-11 | 2022-04-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-11 | 2022-04-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-11 | 2022-04-01 | 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 | 2022-02-11 | 2022-04-01 | 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 | 2022-02-11 | 2022-04-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-11 | 2022-04-01 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-02-11 | 2022-04-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-11 | 2022-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-11 | 2022-04-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-11 | 2022-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-11 | 2022-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-11 | 2022-04-01 | 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 | 2022-02-11 | 2022-04-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-11 | 2022-04-01 | 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 | 2022-02-11 | 2022-04-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-11 | 2022-04-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-11 | 2022-04-01 | N |
| Report COVID19 data to residents and families. | Health | 2022-02-11 | 2022-04-01 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-11 | 2022-04-01 | N |
| Keep all essential equipment working safely. | Health | 2022-02-11 | 2022-04-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-11 | 2022-04-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-01-28 | 2022-03-29 | Y |
