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Deficiency Records for Madonna Towers of Rochester Inc
A list of the most recent deficiencies for Madonna Towers of Rochester Inc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Madonna Towers of Rochester Inc. 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? |
|---|---|---|---|---|
| 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 | 2024-08-26 | 2024-10-01 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-08-26 | 2024-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-26 | 2024-08-16 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2024-04-24 | 2024-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-24 | 2024-05-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-24 | 2024-05-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-04-24 | 2024-05-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-24 | 2024-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-24 | 2024-04-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-24 | 2024-04-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-30 | 2024-02-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-28 | 2024-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-28 | 2024-01-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-22 | 2023-07-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-25 | 2023-07-14 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-25 | 2023-07-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-23 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-08-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-04 | 2022-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-05 | 2022-07-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-05 | 2022-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-05 | 2022-07-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-05 | 2022-07-28 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-05-18 | 2022-06-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-18 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-21 | 2022-04-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-07 | 2022-02-02 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-01-07 | 2022-02-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-07 | 2022-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-07 | 2022-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-07 | 2022-02-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-07 | 2022-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-02-02 | 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 | 2022-01-06 | 2022-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-06 | 2022-02-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-06 | 2022-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-06 | 2022-02-02 | N |
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