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Deficiency Records for Rochester Community Nursing and Rehabilitation Ctr
A list of the most recent deficiencies for Rochester Community Nursing and Rehabilitation Ctr. 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 Rochester Community Nursing and Rehabilitation Ctr. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-10-01 | 2024-11-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-10-01 | 2024-11-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-10-01 | 2024-11-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-10-01 | 2024-11-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-10-01 | 2024-11-15 | 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 | 2024-10-01 | 2024-11-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-10-01 | 2024-11-15 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-10-01 | 2024-11-15 | N |
| Keep all essential equipment working safely. | Health | 2024-10-01 | 2024-11-15 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2024-10-01 | 2024-11-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-01 | 2024-11-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-01 | 2024-11-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-01 | 2024-11-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-10-01 | 2024-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-01 | 2024-11-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-16 | 2023-03-02 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-16 | 2023-03-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-16 | 2023-03-02 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-05 | 2023-03-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-05 | 2023-03-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-05 | 2023-03-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-05 | 2023-03-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-05 | 2023-03-02 | 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 | 2022-12-05 | 2023-02-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-05 | 2023-02-03 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-12-05 | 2023-02-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-05 | 2023-02-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-12-05 | 2023-02-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-05 | 2023-02-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-05 | 2023-02-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-05 | 2023-02-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-05 | 2023-02-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-05 | 2023-02-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-05 | 2023-02-03 | N |
| Post nurse staffing information every day. | Health | 2022-12-05 | 2023-02-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-05 | 2023-02-03 | N |
| Keep all essential equipment working safely. | Health | 2022-12-05 | 2023-02-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-05 | 2023-02-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-28 | 2022-09-15 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2020-11-06 | 2020-12-21 | N |
| Respond appropriately to all alleged violations. | Health | 2020-11-06 | 2020-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-11-06 | 2020-12-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-11-06 | 2020-12-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-11-06 | 2020-12-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-11-06 | 2020-12-21 | 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 | 2020-11-06 | 2020-12-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-11-06 | 2020-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-06 | 2020-12-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-11-06 | 2020-12-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-11-06 | 2020-12-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-11-06 | 2020-12-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-11-06 | 2020-12-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-11-06 | 2020-12-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-11-06 | 2020-12-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-11-06 | 2020-12-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-11-06 | 2020-12-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-11-06 | 2020-12-21 | N |
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