Rochester Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Rochester Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Oct 31, 2023

  Based on interviews and record review conducted during the Recertification Survey from [DATE] to [DATE], the facility failed to ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (medical interventions in the event of a life-threatening episode) that would be honored for 5 (Residents #57, #76, #104, #364, and #508) of 35 residents reviewed. Specifically, the facility failed to ensure residents' advance directive (code status) identifiers were consistently documented for Resident #57, #104, #364 and #508, whose Medical Orders for Life-Sustaining Treatment (MOLST) identified their code status as Do Not Resuscitate (DNR -meaning to allow natural death and not initiate Cardiopulmonary Resuscitation (CPR) in the… […]

• Actual harm, isolatedF693Apr 22, 2026

  Based on observations, interviews, and record review, the facility failed to ensure residents receiving enteral nutrition, (tube placed in the stomach via the abdomen to receive nutritional support) were provided treatment and services in accordance with physician orders and professional standards of practice to prevent complications for three (3) of four (4) residents reviewed (Resident #5, Resident #7, and Resident #9). Specifically, Resident #5 did not receive prescribed enteral nutrition and hydration for multiple days and was hospitalized ; Resident #7 and Resident #9 had significant inconsistencies in the administration of prescribed enteral nutrition and hydration without physician orders, clinical justification, or documented refusals. […]

• No harm, potential for more than minimal, widespreadF725Apr 22, 2026

  Based on interviews and record review, the facility failed to ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility. Specifically, staffing levels were insufficient to meet resident care needs, the facility did not consistently meet its own identified minimum staffing levels, and the facility failed to implement sufficient contingency staffing measures to address known staffing shortages, resulting in missed medication administrations, delayed medication administration, and inability to complete ordered treatments.The findings include: The Facility assessment dated [DATE] documented the facility was licensed for 124 beds with a daily census of 120… […]

• No harm, potential for more than minimal, widespreadF760Apr 22, 2026

  Based on observations, interviews, and record review, the facility failed to ensure medications were administered in accordance with physician orders, resulting in clinically significant medication errors, for 11 of 11 residents reviewed (Residents #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13). Specifically, Resident #8 received duplicate dosing of a controlled medication (drugs regulated due to their potential for abuse, misuse, or dependence), and several residents experienced omissions of ordered medications, and/or medications administered outside the ordered timeframe and there was no documented evidence a medical provider was notified. […]

• No harm, potential for more than minimal, widespreadF835Apr 22, 2026

  Based on observations, interviews, and record review, the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure administrative systems, including staffing oversight, medication administration monitoring, and quality assurance processes, were implemented and functioning to identify and correct deficient practices, resulting in a pattern of noncompliance across multiple areas of care, including sufficient nursing staffing, medication administration, and enteral nutrition management.The findings include:The facility policy Quality Assurance and Performance Improvement… […]