Rochester Restorative Care Center

Inspectors wroteBased on observation, interview, document review the facility failed to ensure the physician was notified of a change in pressure ulcer status for 2 of 3 residents (R2, R3) reviewed for pressure ulcers who had pressures ulcers that deteriorated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess, monitor, evaluate, and implement individualized interventions to prevent and treat pressure ulcers, including timely physician notification following significant changes in wound condition, for 2 of 3 residents (R2 and R3) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement individualized fall prevention interventions for 1 of 3 residents (R1) reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a clinically significant medication was transcribed correctly, made available, and administered as prescribed, leading to repeated omissions of a treatment used for chronic hyponatremia, for 1 of 1 residents (R2) reviewed for quality of care

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 3 residents (R3) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and monitor known aspiration precautions for residents with dysphagia, including ensuring correct diet texture, prescribed liquid consistency, supervision during meals, and safe meal positioning. This resulted in an Immediate Jeopardy (IJ) for R1 when the facility failed to ensure these requirements were consistently communicated to and followed by nursing and dietary staff for R1 which resulted in R1's hospitalization for diagnoses of pneumonitis due to inhalation of food and vomit and following hospitalization, the facility failed to follow R1's prescribed diet putting R1 at risk for additional choking and or aspiration events. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food stored in the refrigerator were labeled, dated and free of expired foods. This deficient practice had the potential to affect all residents, staff and visitors who received food from facility kitchen.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to provide a home like dining experience in 2 dining rooms when meals were left served to residents on a plastic food tray.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess transfers with a mechanical lift or develop and implement policies to ensure safety and supervision for 7 of 7 residents (R6, R36, R2, R8, R51, R60, R62) reviewed for accidents. Additionally, the facility failed to identify fall risk resulting in two falls for 1 of 1 resident (R77) reviewed for repeated falls.

Inspectors wroteBased on observation and interview, the facility failed to dispose of discontinued, expired, and discharged residents' medications. This had the potential to affect any resident who received medication from all facility medication rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed to self-administer medications for 1 of 1 resident (R4) reviewed for self-administration of medication (SAM).

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the provider timely of ordered medication refusals for 2 of 2 residents (R4, R44) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to complete baseline care plan within 48 hours of admission for 1 of 1 resident (R77) reviewed for care plans.

Inspectors wroteBased on observation, interview and document review, the facility failed to revise and update a care plan for 1of 1 resident (R33) reviewed for care plan timing and revision.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide professional standards of practice when staff completed treatments without a provider order, failed to request orders for treatment, and failed to document treatment completion for 1 of 1 resident (R77) reviewed for ostomy cares. Findings Include:R77's admission Minimum Data Set (MDS) assessment was not available at time of survey. A facility document title Nursing-Admissions/readmission Observation dated 3/5/26, noted R77 was alert and oriented to person, place, time, and situation. R77's cognition was intact. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure physician orders were in place to provide treatment and monitoring for a colostomy (opening to allow waste to exit the body and be collected in a pouch) for 1 of 1 resident (R77) reviewed for ostomy care. Findings Include:R77 was admitted to the facility on [DATE]R77's admission Minimum Data Set (MDS) assessment was not available at time of survey. A facility document titled Nursing-Admissions/readmission Observation dated 3/5/26, noted R77 was alert and oriented to person, place, time, and situation. R77's cognition was intact. R77 requires transfer assistance, assistance with activities of daily living (ADL), and assistance managing new colostomy (a surgical procedure that creates an opening (stoma) in the abdomen, allowing stool to exit the body when the colon cannot function normally). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy as ordered for 1 of 1 resident (R44) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete ongoing assessment of the resident's condition and monitoring complications before and after dialysis treatments received at a certified dialysis facility for 1 of 1 resident (R44) reviewed for dialysis.

Inspectors wroteBased on interview and record review, the facility failed to monitor effectiveness of a medication prescribed for sleep by not completing sleep monitoring for 1 of 1 resident (R33) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper personal protective equipment (PPE) usage for 3 of 3 residents (R6, R4, R14) reviewed for enhanced barrier precautions (EBP) who receive tube feeding (R6, R14) and dialysis care (R4).

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a bathroom call light was functioning for the shower room on the 3rd floor having the potential to affect all residents that use the toilet in the shower room, 7 of 7 (R6, R36, R2, R8, R51, R60, R62) residents were brought to and used an EZ stand for toileting.

Inspectors wroteBased on observation, interviews, and documents review, the facility failed to include the daily census and actual hours worked by nursing staff groups on the daily staffing data document. This deficient practice had the potential to affect all residents who resided in the facility and/or any visitors who may have wanted to view the information.

Inspectors wroteBased on observation, interview, and document review, the facility failed to complete a comprehensive assessment for self-administration of medications for 1 of 1 resident (R1) reviewed for respiratory and oxygen.

Inspectors wroteBased on interview and document review the facility failed to maintain a complete, accurate, and readily accessible medical record for 2 of 4 residents (R1, R4) reviewed for medical record accuracy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess each fall, identify causal factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, and failed to comprehensively evaluate and implement fall interventions for 3 of 3 residents (R1, R2, and R3) reviewed for resident safety. The facility's failures resulted in an immediate jeopardy (IJ) for R1 who sustained fractures after his first and second fall. The IJ began on 5/23/25, when the facility failed to complete a comprehensive fall assessment along with root cause analysis and implement appropriate interventions after R1 attempted to self-transfer, resulting in an unwitnessed fall requiring hospitalization with a right frontal sinus fracture. [...]

Inspectors wroteBased on interview and document review, the facility failed to review and update the facility assessment to identify the facility's staffing plan for number of staff needed to ensure sufficient qualified staff were available to meet residents' needs. This deficient practice had the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance committee effectively identified quality deficiencies, developed and implemented appropriate actions; and provided its written Quality Assurance and Performance Improvement plan when requested at the time of survey. This deficient practice had the potential to affect all 51 residents in the facility at the time of the survey.

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 51 residents in the facility. Actual harm occurred related to the quality of care to one resident (R1).

Inspectors wroteBased on interview and record review, the facility failed to ensure that its Quality Assessment and Assurance Committee (QAA) consisted of the required members and to meet at least quarterly, which had the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 1 resident (R1) received a copy of their medical record per request in a timely manner, within 2 working days upon request excluding weekends and holidays.

Inspectors wroteBased on interview and document review the facility failed to ensure the baseline care plan was revised and updated as needed to meet 1 of 1 resident (R1) toileting needs reviewed for falls. R1's admission Evaluation dated 5/19/25, identified under section J., R1 was incontinent of bladder more than a month, but less than a year. R1 was wet one to two times daily during the day and the nighttime, also exhibited dribbling. Bladder incontinence care plan identified a goal will be maintained in as clean and dry dignified state as possible. Continence in the last 14 days identified R1 was frequently incontinent of bladder daily but some control present. R1's baseline care plan dated 5/19/25, at 7:30 p.m., identified initial goals were to rehab and go home. Section titled, Personal Care, had a list of tasks going down the page vertically, that included: [...]

Inspectors wroteBased on interview and document review the facility failed to ensure a comprehensive care plan was developed to maintain or restore bladder continence for 1 of 3 residents (R2) reviewed for falls.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a comprehensive fall care plan was revised for 2 of 3 residents (R2 and R3) reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to complete a comprehensive assessment and implement individuals interventions to ensure a resident who was continent of bladder upon admission received appropriate treatment and services to maintain/restore or prevent increased incontinence for 1 of 3 residents (R2) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to complete annual performance evaluations for 4 of 5 nursing assistants (NA-A, NA-B, NA-C and NA-D) who had been employed by the facility for over one year.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure dishwashing sanitization at the correct level and was appropriately monitored during dishwashing. Further, staff failed to ensure expired food was identified and removed from a unit refrigerator that stored resident personal food.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure personal protective equipment (PPE) was utilized for 2 of 2 residents (R54, R23) reviewed for medication administration and performed cares on these residents that were on enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 2 of 2 residents (R6, R49) who were observed to have medications in their rooms, had been appropriately assessed and deemed safe to self-administer medications.

Inspectors wroteBased on interview and document review, the facility failed to notify resident representatives following falls with subsequent transfer to the hospital for 2 of 2 residents (R20, R164) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to complete a baseline care plan for 1 of 2 residents (R164) reviewed who was newly admitted to the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop a comprehensive care plan for 1 of 2 residents (R163) reviewed for urinary catheter.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and provide ongoing treatment for edema for 1 of 2 residents (R5) who required leg wraps to prevent and treat edema.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess and evaluate causal factors for a fall and failed to ensure interventions were implemented to reduce the risk of falls for 2 of 2 (R5, R164) who were reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate management of an indwelling catheter was provided for 1 of 1 residents (R163) reviewed for urinary catheter, when his leg bag had not been changed to a urinary drainage bag at night.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at a warm and palatable temperature to promote quality of life and nutritional intake for 3 of 3 residents (R6, R9, R35) reviewed for dining. This had the potential to affect all 30 residents who resided on second floor.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 of 1 tub/shower room on second floor was maintained in good repair and in sanitary conditions for the 30 residents on second floor who could potentially use the area.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was maintained at proper temperatures to ensure palatability for 6 of 6 residents (R6, R12, R13, R14, R15, R16) interviewed who complained about cold food.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was delivered according to physician orders for 1 of 3 residents (R8) reviewed for respiratory care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety by failing to label and date food, to remove expired food from food storage areas. In addition , the facility failed to ensure proper cleaning for 1 of 1 commercial mixer, ensure pans in the kitchen were completely dry before storing, accurately monitor chemical sanitization for 1 of 1 dish machine, and perform hand hygiene while serving food. These practices had the potential to affect all residents, staff and visitors consuming food at the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff completed proper hand hygiene and glove use during meal preparation and distribution of meals, and failed to properly disinfect a glucometer for 1 of 2 residents (R2) . This had the ability to affect all 55 residents who consumed food in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure served meals were provided in a dignified, homelike manner when the residents food was served on trays, second floor dining room was used as a plating and serving area in 1 of 2 dining rooms reviewed. In addition, staff failed to ensure privacy during insulin administration for 1 of 1 resident (R31).

Inspectors wroteBased on observation interview and document review the facility failed to ensure all residents were consistently offered and provided a nutrient and/or calorie substantive snack after the dinner meal and before bedtime for 7 of 7 residents (R3, R8, R24, R25, R30, R35, R49) who voiced a concern.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 2 of 2 residents (R51 and R1) who were observed to have medications in their rooms, had been appropriately assessed and deemed safe to self-administer medications.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess the root cause of falls and incorporate new fall interventions to prevent falls and injury for 1 of 1 resident (R45) who had frequent falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to develop and implement activity programming for 1 out of 3 residents (R15) with dementia residing in a secure dementia care unit.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure an insulin pen stored in the medication cart was labeled for one resident (R31) and the facility failed to ensure eye drops were discarded per manufactures instructions for one resident (R26).

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess and monitor for a change in condition after a fall with a head strike for 1 of 1 residents (R1) who had a history of significant bleeding disorder. This resulted in delay of diagnoses and treatment for a subdural hemorrhage (brain bleed) and left hip contusion. The facility's failures resulted in actual harm for R1.

Inspectors wroteBased on interview and document review the facility failed to ensure timely notification of a fall with injury according to the facility policy for 1 of 1 residents (R1) who had a bleeding disorder and a fall with a head injury.