Rochester Rehabilitation and Living Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 2 of 2 residents (R3, R15) reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities of daily living (ADL) for 2 of 2 residents (R41, R20) who were dependent on staff for timely assistance for personal hygiene. Findings Include: R41 R41's quarterly Minimum Data Set (MDS) was not completed at time of survey; R41 admitted to the facility on [DATE]. R41's care plan dated 6/9/26 indicated R41 required extensive assistance to total assistance with personal hygiene and grooming. R41's care plan lacked resident-specific directions about facial hair/removal. R41's provider orders dated 6/9/26 indicated R41 was to have weekly skin checks and vital signs every evening shift every Saturday for bath day, if resident refuses, document reason and attempts. The treatment administration record (TAR) indicated the skin checks and vital signs had been completed; [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to monitor, comprehensively assess, develop, and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 3 of 4 residents (R1, R4, R5) reviewed for pressure ulcers. This caused actual harm to R1 who developed an avoidable unstageable pressure ulcer on her coccyx which needed surgical debridement and hospitalization.

Inspectors wroteBased on observation, interview, and document review the facility failed to timely revise the care plan to include an individualized toileting/incontinence plan for 1 of 3 residents (R1) who were reviewed for impaired skin integrity that had impaired skin integrity.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess an area of moisture associated skin damage and failed to notify the physician for 1 of 1 resident (R3) reviewed for non-pressure skin issues.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R3) observed during wound care. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during a transfer for 1 of 3 residents (R3).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the safe and accurate administration of prescribed medications to residents, resulting in Immediate Jeopardy. Systemic Failures were identified across multiple areas, including transcription errors, incorrect dosing, and medication omissions. The facility did not consistently follow the five rights of medication administration, nor did it implement effective systems to identify, prevent, investigate, or track medication errors. These failures directly impacted two residents. Resident R1 did not receive two prescribed diuretic (manage fluid overload) medications, resulting in ongoing congestive heart failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) plan and program identified, analyzed, implemented corrective actions, and re-evaluated corrective actions to address adverse events and quality deficiencies. This deficient practice had the potential to affect all 35 residents in the facility. Actual harm occurred related to the quality of care to two residents (R4 and R1).

Inspectors wroteBased on observation, interview and document review the facility failed to provide the necessary care and services in accordance with the professional standards of practice to comprehensively assess, monitor and evaluate 3 of 4 residents (R3, R1, R4) for congestive heart failure management.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure timely identification, evaluation, and treatment of a worsening skin infection for 1 of 3 residents (R1) reviewed for quality of care. This resulted in actual harm for R1 who developed a worsening infection in the wound in which necessary treatment and care were delayed. In addition, the facility failed to complete comprehensive skin assessments for non-pressure skin impairments (surgical wounds) for 3 of 3 residents (R1, R4, R5) reviewed for non-pressure (surgical incisions) skin impairments.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to wound assessments not being completed by developing and implementing action plans for process improvement. This had the potential to affect all 36 residents that resident in the facility.

Inspectors wroteBased on interview, observation, and document review, the facility failed to follow physician orders, complete assessments, monitor or input appropriate interventions and recognize changes in condition, for 6 of 6 residents (R31, R201, R21, R194, R6, R18) reviewed for quality of care. As a result of the facility's failures, an immediate jeopardy (IJ) situation was identified for R31 who had displayed respiratory distress with labored breathing, increased anxiety and required additional medication, R201 who had displayed signs of a UTI and was transferred to the ER for treatment, R21 who had displayed signs of a urinary tract infection (UTI) and was transferred to the hospital ER for treatment. [...]

Inspectors wroteBased on interview and document review, the facility failed to accurately complete comprehensive assessment of a resident's needs, strengths, goals, life history and preferences to determine a resident's functional capacity. In addition, the facility failed to ensure Minimum Data Set (MDS) was completed in a timely and/or in a comprehensive manner to facilitate accurate evaluation of resident' conditions for 5 of 5 residents (R6, R24, R194, R199, and R201) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for 2 of 2 (R138, R140) residents reviewed for infection prevention related to presence of peripherally inserted central catheter (PICC) line (enters a peripheral vein and extends to the supervisor vena cava of the heart).

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R194 and R199) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow up on a resident requested medication change in a timely manner for 1 of 1 residents (R138) reviewed for choices.

Inspectors wroteBased on interview and record review, the facility failed to notify resident representative following provider order changes in a timely manner for 1 of 1 residents (R18) who received an order for antibiotics for a urinary tract infection (UTI).

Inspectors wroteBased on interview and document review, the facility failed to implement person-centered interventions for cardiac diagnosis for 1 of 1 residents (R194) reviewed for care plans. R194's admission Minimum Data Set (MDS) assessment was not completed in full at time of survey. R194's cognitive function was noted to be intact. R194 admitted on [DATE], following surgical repair of spinal stenosis (condition that narrows the space in the spine, putting pressure on the spinal cord or nerves). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper management of indwelling urinary devices for 1 of 1 residents (R6) reviewed for catheter care. R6's quarterly Minimum data Set (MDS) assessment dated [DATE] indicated R6 had severe cognitive impairment with no behaviors, is dependent on staff for all activities of daily living (ADLs) and has an indwelling catheter and ostomy. MDS also included R6 had diagnoses of multiple sclerosis (a progressive disease of the nervous system), neurogenic bladder (disease where the bladder does not function properly), and history of recurrent urinary tract infections. R6's care plan for catheter/urostomy/nephrostomy indicated R6 would remain free from signs and symptoms of urinary tract infections. Interventions included: [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) (enters a peripheral vein and extends to the supervisor vena cava of the heart) was appropriately managed based on professional standards of practice and in accordance with physician orders for 2 of 2 residents (R138, R140) reviewed for intravenous (IV) medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to identify and treat pain for 1 of 1 residents R194 reviewed for pain management.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure before and after-dialysis access site monitoring and daily weights was consistently completed, and failed to document finding to provide continuity of care and reduce the risk of complication (i.e., bleeding) for 1 of 1 resident (R405) reviewed for dialysis care and services.

Inspectors wroteBased on interview and document review the facility failed to ensure clinical laboratory (lab) reports were filed into the medical record for 1 of 3 residents (R237) reviewed for laboratory reports. R237's face sheet dated 4/22/25, identified diagnoses of osteomyelitis (bone infection) and pyelonephritis (kidney infection). Review of R237's hospital Discharge summary dated [DATE], identified R237 received intravenous (IV) antibiotics until 3/26/25 and was to have weekly bloodwork tests performed. Review of R237's clinic laboratory reports dated 3/14/25 and 3/21/25, identified R237 had labs completed. Review of R237's medical record from 3/11/25 through 4/21/25 did not identify any laboratory results in chart or notification of laboratory results were faxed to infectious disease. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to assess for removal of an indwelling urinary catheter for 1 of 3 residents (R6) as soon as possible to restore urinary continence to the extent possible, reviewed for catheter care.

Inspectors wroteBased on interview and document review the facility failed to report a significant medication error (an error that causes the resident discomfort or jeopardizes the residents health and safety) was reported to the state agency (SA) for 1 of 3 (R1) residents reviewed for medication errors.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow physician orders, labs, and administer anticoagulant medications and failed to have a system in place to identify, record and report omitted medications as medication errors for 2 of 3 (R1 and R2) residents reviewed for medication errors.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in actual harm when 1 of 1 residents (R1) admitted with a stage 1 pressure ulcer developed into an unstageable pressure ulcer that caused pain and required antibiotic treatment.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP)-(an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were implemented for management of a pressure ulcer wound to reduce the risk of infection to others for 1 of 1 resident (R1) reviewed for transfers. Further the facility failed to implement hand hygiene for 1 of 1 resident (R1) observed during toileting and transfers.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to report an accusation of abuse to the administrator and State Agency (SA) within the two-hour time frame for 1 of 3 residents (R2) when the facility staff had knowledge of the abuse situation two days prior to the reported allegation.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement enhanced barrier precautions (EBP) for 3 of 3 (R2, R3, R4) residents reviewed for infection prevention. R2's Diagnoses List undated included open wound of abdominal wall. R2's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition with open lesions, and application of non-surgical dressings. R2's Physician's Orders dated 6/18/24 instructed wound care to abdominal wall wound. Remove old dressing. Clean with Vashe cleanser (a wound cleanser). Gently pat dry. Cover with Xeroform (a wound dressing). Cover with 4x4 Mepilex boarder (a wound dressing). Change daily. The orders lack direction on enhanced barrier precautions. On 6/27/2024 at 2:01 p.m., R2 stated facility staff wear only gloves when completing the daily dressing changes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident resuscitation status were accurately documented in the medical record of 1 of 2 residents (R199) reviewed for advance directives.

Inspectors wroteBased on interview and document review, the facility failed to notify the ombudsman of transfers to the hospital for 2 of 2 residents (R34, R28 ) reviewed for hospitalization.