Madonna Towers of Rochester

In the surveyor’s words

From the most serious findings on record at Madonna Towers of Rochester, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 26, 2024

  Based on interview and record review the facility failed to provide adequate supervision for R2. This resulted in an immediate jeopardy (IJ) for R2 who was identified as an elopement risk and was able to leave the facility through a fire door without staff knowledge. R2 was last seen on August 14 at 9:15 p.m. and found approximately two blocks away from the facility and brought back to the facility by police at 11:13 p.m. Staff was unaware that R2 had eloped due to the the door alarm not sounding. The IJ began on 8/14/24 when R2 eloped from the facility. The IJ was identified on 8/23/24. The Director of Nursing was notified of the IJ on 8/23/24 at 3:10 p.m. […]

• Immediate jeopardy, isolatedF689Aug 4, 2022

  Based on observation, interview and document review, the facility failed to comprehensively assess falls and identify causative factors to determine the reason for falls and identify potential effective interventions to decrease the risk for future falls for 2 of 3 residents (R1, R2) reviewed for accidents. R1 who had 11 falls, nine falls from a Broda chair with six falls unwitnessed. On 7/10/22 R1 was left alone in her room after placed in her Broda chair, fell and sustained a fracture. On 5/18/22, R2 fell during the night after she got up unattended to go to the bathroom resulting in a fracture. R2 has fallen an additional 14 times; each of the 14 falls occurred in R2 ' s room when alone and unsupervised. […]

• Immediate jeopardy, isolatedF600Jul 5, 2022

  Based on observation, interview, and document review the facility failed to protect 1 of 1 residents (R2) from physical abuse and aggressive behaviors from R1 who demonstrated an escalation in aggressive abusive behaviors after admission to the facility. In addition, the facility failed to determine the possible causes of the behavior and put interventions in place to mitigate the risk of physical agression toward others. The immediate jeopardy began on 6/24/22, when R1 demonstrated verbal and physical behaviors towards staff in R2's room, R1 dug her nail into R2 and staff then left the room, leaving R1 alone with R2. R1 then barricaded the door so that staff could not enter. The administrator and director of nursing (DON) were notified of the IJ on 7/1/22, at 12:15 p.m. […]

• Immediate jeopardy, isolatedF695May 28, 2021

  Based on observation, interview, and document review, the facility failed to ensure physician ordered respiratory devices were functioning appropriately, notify the physician with a change in cognition and failed to monitor and identify signs/symptoms of respiratory distress for 2 of 3 residents (R1 and R2). The facility's failures resulted in an immediate jeopardy for R1 who suffered serious harm when she displayed respiratory distress, subsequently transferred to the hospital, and admitted to the intensive care unit. The facility's failures had the potential to effect addition 3 of 3 residents who continued to reside in the facility who required physician ordered respiratory devices. […]

• Actual harm, isolatedF689Jun 4, 2026

  Based on observation, interview, and record review the facility failed to ensure safety during van transport by ensuring safety straps were appropriately applied for 1 of 1 resident (R1). The failure resulted in actual harm when the van came to a sudden stop throwing R1 from the wheelchair causing fractures to her right and left femurs. The facility had completed corrective measures by 5/26/26 and prior to the start of the survey so citation was issued at past non-compliance (PNC). […]