Hickory Creek at Rochester

In the surveyor’s words

From the most serious findings on record at Hickory Creek at Rochester, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Feb 6, 2025

  Based on observation, record review and interview, the facility failed to ensure a resident received the necessary treatment and services to promote healing and prevent worsening of a pressure ulcer, as well as prevent the development of additional pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. This deficient practice resulted in the worsening of an identified pressure ulcer, from a Stage 2 to a Stage 4 and the development of multiple pressure ulcers which progressed from a DTI (Deep Tissue Injury) to unstageable wounds with slough, the need for treatment from a local wound treatment center and the need for an upcoming surgical colostomy procedure to reduce contamination and damage to the area. […]

• Actual harm, isolatedF580May 5, 2023

  Based on record review and interview, the facility failed to effectively treat a resident's pain for 14 days and failed to notify the physician of the residents' continued complaint of pain and after receiving results of an x-ray that revealed the resident had a spiral fracture of the left leg for 1 of 3 residents reviewed for notification. (Resident B) Finding includes: A record review was completed, on 5/4/2023 at 9:44 A.M. Resident B's diagnoses included, but were not limited to hypertension, hemiplegia, cerebral vascular accident, dementia, and a spiral fracture of the left leg. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2025

  Based on observation, record review and interview, the facility failed to store food under sanitary conditions related to foods not sealed tightly and outdated foods and failed to ensure opened foods were labeled with an open date for 1 of 1 kitchen observed. This issue had the potential to affect 26 of 26 residents who received food from this kitchen. Findings include: On 6/8/2025 at 9:24 A.M., a kitchen tour was conducted with [NAME] 3. The following was observed in the fridge: - An opened gallon of milk with no open date. - An opened container of whipped topping with no open date. - An opened bag of sliced tomatoes with no open date. - A bowl of vanilla pudding with no use by date. - A container of pasta with a use by date of 5/11/2025. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2024

  Based on observation, interview and record review, the facility failed to ensure kitchen equipment were in good working condition in 1 of 1 kitchen reviewed. Finding includes: During a kitchen tour with the Dietary Manager on 6/4/2024 at 9:26 A.M., the following was observed: -broken seals to both doors of the freezer. -broken seals to both doors on 2 refrigerators. During an interview on 6/4/2024 at 9:45 A.M., the Dietary Manager indicated the seals needed to be fixed. On 6/10/2024 at 1:36 P.M., the Regional Nurse Consultant provided the policy titled,Kitchen Safety Guidelines, dated 4/2024, and indicated the policy was the one currently used by the facility. The policy indicated .2. […]

• No harm, potential for more than minimal, widespreadF727Apr 21, 2023

  Based on record review and interview, the facility failed to have 8 consecutive hours of RN coverage in the facility. This deficient practice affected 31 of 31 Residents who resided in the facility. Finding includes: During an interview, on 4/20/2023 at 2:47 P.M., the Director of Nursing indicated they staff the day and evening shifts with one nurse, one QMA and 3 aides and on the night shift 1 nurse and 2 aides. The DON indicated if the facility were without RN coverage, she would be the one to come in and cover the shift. […]