Rochester Center for Rehabilitation and Nursing

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents receiving enteral nutrition, (tube placed in the stomach via the abdomen to receive nutritional support) were provided treatment and services in accordance with physician orders and professional standards of practice to prevent complications for three (3) of four (4) residents reviewed (Resident #5, Resident #7, and Resident #9). Specifically, Resident #5 did not receive prescribed enteral nutrition and hydration for multiple days and was hospitalized ; Resident #7 and Resident #9 had significant inconsistencies in the administration of prescribed enteral nutrition and hydration without physician orders, clinical justification, or documented refusals. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility. Specifically, staffing levels were insufficient to meet resident care needs, the facility did not consistently meet its own identified minimum staffing levels, and the facility failed to implement sufficient contingency staffing measures to address known staffing shortages, resulting in missed medication administrations, delayed medication administration, and inability to complete ordered treatments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were administered in accordance with physician orders, resulting in clinically significant medication errors, for 11 of 11 residents reviewed (Residents #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13). Specifically, Resident #8 received duplicate dosing of a controlled medication (drugs regulated due to their potential for abuse, misuse, or dependence), and several residents experienced omissions of ordered medications, and/or medications administered outside the ordered timeframe and there was no documented evidence a medical provider was notified. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure administrative systems, including staffing oversight, medication administration monitoring, and quality assurance processes, were implemented and functioning to identify and correct deficient practices, resulting in a pattern of noncompliance across multiple areas of care, including sufficient nursing staffing, medication administration, and enteral nutrition management.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assessment and Assurance committee met at least quarterly, in accordance with regulatory requirements. Specifically, the facility had a lapse of approximately five (5) months between scheduled meetings.

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for six (Residents #34, #36, #44, #70, #71, and #92) of six residents reviewed, the facility did not ensure that concerns voiced by residents during Resident Council meetings related to resident care and life in the facility were responded to and a rationale given for the response. Specifically, during a special Resident Council meeting, multiple residents voiced multiple care concerns that they felt had not been followed up on. Review of the previous six months of meeting minutes did not include any follow ups, resolution, or a rationale for lack of resolution to the resident's concerns. This is evidenced by the following: [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (first, second, and third floors) of three resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, exhaust ventilation was not functional, ready stand lifts were dirty, there was wall and window damage, chairs were in disrepair, a microwave oven was dirty, an exit stairwell was dirty, and an exit door was not tight fitting into the door frame.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025 the facility did not ensure they established and maintained an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #34, #45, and #99) of 24 of residents reviewed. Specifically, appropriate Personal Protective Equipment (PPE) was not worn by nursing staff in residents' room that were identified by the facility as requiring Enhanced Barrier Precautions while preforming high contact care to residents. [...]

Inspectors wroteNY00352644 NY00348465 Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (Residents #9, #47, and #96) of 15 residents reviewed, the facility did ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, all residents were observed being served meals using disposable cutlery (plastic utensils) and dishware (paper/plastic plates) and stated it was ongoing. This was evidenced by the following: Review of the facility policy, Quality of Life/Dignity, dated 05/28/2024, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for four (Resident #31, #53, #99 and #220) of seven residents reviewed, the facility did not ensure that a comprehensive assessment of residents' needs, strengths, goals, life history, and preferences were conducted per the regulatory timeframes using the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument (RAI) process. Specifically, Residents #53 and #220 did not have their comprehensive admission assessments completed within 14 calendar days of admission, and Resident #99 did not have their comprehensive assessment completed within 14 calendar days of the assessment reference date. This is evidence by the following: [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for four (Residents #31, #47, #80, and #99) of seven residents reviewed, the facility did not ensure the Minimum Data Set Resident Assessment accurately reflected the residents' status. Specifically, the issues involved inaccurate coding for Section I - Active Diagnoses (Resident #47) and Section N - Medications (Residents #31, #80, and #99). This is evidenced by the following: Review of the current Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, Section I included the disease conditions in the section required a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure law) in the last 60 days. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (Residents #53, #104, and #220) of 26 residents reviewed, the facility did not develop and/or implement the comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet all the resident's medical, nursing, mental, and psychosocial needs. Specifically, Resident #53's Comprehensive Care Plan did not include goals and interventions related to the resident's post-traumatic stress disorder diagnosis. Resident #220's Comprehensive Care Plan did not include goals and interventions related to care of the resident's nephrostomy tube (tube inserted into the kidney that drains urine directly into a drainage bag and bypassing the bladder). [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025 for one (Resident #21) of nine residents reviewed, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #21 did not receive assistance with shaving and fingernail care as requested. This is evidenced by the following. The facility policy Activities of Daily Living Care and Support, revised 03/13/2024, included activities of daily living care and support will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care including grooming. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for one (Resident #45) of one resident reviewed, the facility did not ensure the resident received the necessary care, treatment, and services consistent with professional standards of practice to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, Resident #45 did not receive a thorough wound assessment upon re-admission to the facility after a hospitalization with a pressure ulcer and no pressure ulcer care or treatments were documented as provided for multiple days. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for one (Resident #99) of one resident reviewed, the facility did not ensure a resident maintained acceptable parameters of nutritional status and was offered sufficient fluid intake to maintain proper hydration and health. Specifically, the facility could not provide documented evidence for a resident that required total nutrition and hydration via a gastrostomy tube (the delivery of nutrients through a feeding tube directly into the stomach also referred to as an enteral feeding) was provided nutritional and hydration care and services consistent with the resident's comprehensive assessment. [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for three (Unit Three medication cart North, Unit Three medication cart South, Unit Two medication cart North) of three medication carts reviewed. Specifically, multiple medication carts contained several insulin pens labeled by pharmacy to refrigerate until opened that were unopened and stored in the medication carts and a vial of insulin stored in the medication cart that was not opened. Additionally, two nicotine patches were observed stuck to the shower room wall and an opened insulin was observed at a resident's bedside. This evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure each resident received the influenza or the pneumococcal immunizations (vaccine) for two (Resident #8 and #74) of five residents reviewed. Specifically, the facility was unable to provide any evidence the residents or their representatives had been provided educational material, been offered, or declined the immunizations. The facility policy Infection Control-Influenza Vaccine/Pneumococcal Vaccine, dated 11/24/2024, documented that all residents and/or the resident representative will be offered and provided influenza vaccine and pneumococcal vaccine. Residents have the opportunity to refuse the vaccine. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure the daily nurse staffing information was posted on a daily basis. Specifically, the nursing staff information was not posted daily at the beginning of each shift during the survey, the information on the form was not updated to reveal current staffing changes, and the facility did not maintain the daily nursing staffing data for a minimum of 18 months. This is evidenced by the following: During observations on 01/06/2025 at 12:12 PM and 3:03 PM, 01/07/2025 at 11:24 AM and 4:17 PM, and 01/08/2025 at 8:29 AM, the daily nurse staffing information was not posted. During an interview on 01/08/2025 at 11:22 AM, the Director of Human Resources stated they are responsible for completing and posting the daily nurse staffing information. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (complaint #NY00311416), for one (Resident #11) of two residents reviewed, the facility did not ensure parenteral fluids/medications (liquids given via intravenous, also known as IV) were administered and treatments completed were consistent with professional standards of practice and in accordance with the physician's orders, the resident's comprehensive person-centered care plan and the resident's goals and preferences. Specifically, there was inconsistent documented evidence that nursing assessments for proper placement of a catheter, signs and symptoms of infection and dressing changes were completed per physician orders for a peripherally inserted central catheter (a catheter that is inserted through a vein in your arm and ends up in a large vein in the chest, also known as a PIC line). [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from [DATE] to [DATE], the facility failed to ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (medical interventions in the event of a life-threatening episode) that would be honored for 5 (Residents #57, #76, #104, #364, and #508) of 35 residents reviewed. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey completed on 10/31/23, it was determined that for seven of seven newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and/or misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry abuse screening was not completed for newly hired employees prior to starting work.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 10/23/23 to 10/31/23, it was determined that the facility did not ensure medications were stored in two (Unit two cart #2 and Unit three cart #1) of three medication carts reviewed and in one (Unit one) of two medication rooms reviewed in accordance with current State and Federal regulations. Specifically, multiple loose and unlabeled pills were found in two medication carts, resident medications were not labeled or dated with open date on one cart and several bottles of expired medication were stored in one medication room. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey from 10/23/23 to 10/31/23, it was determined that for one (Resident #559) of four residents reviewed for dignity, the facility did not ensure the resident was treated with respect and dignity and care for the resident in a manner and environment that promotes enhancement of their quality of life. Specifically, staff did not provide privacy during care on multiple observations. This is evidenced by the following: Resident #559 had diagnoses which included chronic obstructive pulmonary disease (a chronic lung disease that causes difficulty breathing), a right leg amputation and Alzheimer's Disease. In a progress note dated 10/11/23 the Social Worker documented that the resident had moderate impairment of cognitive function. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey 10/23/23 to 10/31/23, it was determined for 3 (Residents #7, #92, and #559) of 24 residents reviewed for Minimum Data Set (MDS) Assessments (a resident assessment tool completed, at a minimum, after admission to a facility to identify resident specific areas that require care planning for each resident), the facility did not ensure that residents had the required Comprehensive admission Assessment including the Care Areas Assessments (CAAs) conducted within 14 days following admission per the regulatory timeframes using the Centers for Medicare & Medicaid Services specified Resident Assessment Instrument (RAI) process. Specifically, Residents #7, 92, and #559 did not have their Comprehensive admission Assessments completed within 14 calendar days of admission. The finding is: 1. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey 10/23/23 to 10/31/23, it was determined that for 1 (Resident #99) of 13 residents reviewed for activities of daily living (ADLs) the facility did not ensure a dependent resident received the assistance needed with their ADLs. Specifically, the facility did not assist the resident with meal set up. This is evidenced by the following: Resident #99 had a diagnosis of stroke, expressive aphasia (difficulty speaking and affecting communication), and left sided hemiplegia (paralysis on one side of the body). The Minimum Data Set assessment dated [DATE] included that Resident #99 required set up assist for meals. Therapy recommendations dated 8/30/23 included the resident required assist to set up their meals and open beverages as the resident was unable to. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 10/23/23 to 10/31/23, it was determined for 1 (Resident #84) of 15 residents reviewed for dining the facility did not ensure that food was prepared in a consistency to meet the residents needs per the physician order and the resident's care plan. Specifically, Resident #84 was on a ground/minced/moist diet and was food inconsistent with their diet orders and unable to eat. This is evidenced by the following: The facility policy Modified Food Consistency, revised April 2020, documented the food and nutrition services department will be responsible for preparing and serving the diet texture as ordered and that food consistency changes should not be made without a written order. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed on 10/26/21 it was determined that for three (first, second, and third floors) of three resident use floors, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, wall tiles were missing in bathrooms, sections of walls were in disrepair, baseboard coving was missing, exhaust ventilation was not working, the lower parts of corridor walls were brown with residue, sinks were damaged, and ceiling tiles were dirty and broken.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed on 10/26/21, it was determined that for three (first, second, and third floors) of three resident use floors, the facility did not maintain an effective pest control program. Specifically, house flies and drain flies were present throughout in the facility.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey completed on 10/26/21, it was determined that for one (Resident #50) of one resident reviewed the facility did not ensure the resident's right to personal privacy, including personal care. Specifically, staff were observed giving personal care to the resident through the resident's window that was accessible to the public. This is evidenced by the following: The facility policy Quality of life/Dignity, dated September 2014, documented that staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Resident #50 had diagnoses including legal blindness, cellulitis (infection in the skin and underlying tissue) and kidney failure. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigations (#NY00277949, #NY00277458 and # NY00282915) it was determined that for 1 (Resident #13) of nine residents reviewed the facility did not provide the necessary services to maintain good grooming and personal hygiene. The issues involved the lack of incontinence care. This is evidenced by the following: Resident #13 had diagnoses including metabolic encephalopathy (brain injury or disease), dementia, and unspecified intellectual disabilities. The Minimum Data Set Assessment, dated 4/29/21, revealed the resident was moderately impaired cognitively and required the extensive assistance of two staff members for personal hygiene. [...]