Rochester Restorative Care Center

In the surveyor’s words

From the most serious findings on record at Rochester Restorative Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880May 27, 2022

  Based on observation, interview and document review, the facility failed to ensure staff implemented infection control practices to prevent and/or minimize a facility wide outbreak of coronavirus 2019 (COVID 19) for 29 residents who resided at the facility. This systemic system failure resulted in an immediate jeopardy (IJ) and had the potential to affect all 59 residents and staff residing in the facility. The immediate jeopardy began on [DATE], when the facility failed to implement appropriate infection control practices to mitigate or reduce the spread of COVID-19 in the facility. Facility staff did not isolate and/or cohort COVID-19 positive residents appropriately who had shared rooms and bathrooms. […]

• Immediate jeopardy, patternF689Jul 28, 2021

  Based on observation, interview and document review, the facility failed to follow manufacturer's guidelines for proper use of slings for eight residents (R2, R11, R18, R13, R8, R10, R12, R9) of 14 residents who utilized full body lifts. This deficient practice resulted in an immediate jeopardy (IJ) for R1, who fell from the full body lift and had the potential for injury for R2, R11, R18, R13, R8, R10, R12, R9 as a result of not following the manufacturer's guidance for proper use. Furthermore, the facility failed to assess and evaluate causal factors for falls, and failed to ensure adequate supervision and interventions were implemented to reduce falls for 2 of 2 resident (R3 and R4) reviewed who sustained multiple falls. The IJ began on 7/18/21, at 11:00 p.m. […]

• Immediate jeopardy, isolatedF803Apr 13, 2026

  Based on observation, interview, and record review the facility failed to implement and monitor known aspiration precautions for residents with dysphagia, including ensuring correct diet texture, prescribed liquid consistency, supervision during meals, and safe meal positioning. This resulted in an Immediate Jeopardy (IJ) for R1 when the facility failed to ensure these requirements were consistently communicated to and followed by nursing and dietary staff for R1 which resulted in R1's hospitalization for diagnoses of pneumonitis due to inhalation of food and vomit and following hospitalization, the facility failed to follow R1's prescribed diet putting R1 at risk for additional choking and or aspiration events. […]

• Immediate jeopardy, isolatedF689Jul 29, 2025

  Based on observation, interview, and document review, the facility failed to comprehensively assess each fall, identify causal factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, and failed to comprehensively evaluate and implement fall interventions for 3 of 3 residents (R1, R2, and R3) reviewed for resident safety. The facility's failures resulted in an immediate jeopardy (IJ) for R1 who sustained fractures after his first and second fall.The IJ began on 5/23/25, when the facility failed to complete a comprehensive fall assessment along with root cause analysis and implement appropriate interventions after R1 attempted to self-transfer, resulting in an unwitnessed fall requiring hospitalization with a right frontal sinus… […]

• Immediate jeopardy, isolatedF684May 27, 2022

  Based on observations, interviews, and record review, the facility failed to promptly identify and intervene for an acute change in condition for 1 out of 11 residents (R39), when R39 was exhibiting signs and symptoms of cardiopulmonary distress and was left unattended resulting an unwitnessed arrest and ultimate death. This resulted in an Immediate Jeopardy (IJ) for R39. The IJ began on [DATE] at 9:00 p.m.when the facility failed to provide ongoing assessment and monitoring of R39 who was having shortness of breath, chest discomfort, dizziness, which ultimately resulted in cardiac arrest. The vice president of operations (VPO), director of clinical services (DOCS), director of nursing (DON), and infection preventionist (IP) were notified of the IJ on [DATE] at 6:02 p.m. […]