Inspection Reports for
Life Care Center of Rochester

The facility was found deficient in multiple areas including unnecessary use of antipsychotic medications, failure to complete PASRR screenings after psychiatric diagnosis changes, incomplete care plans for residents, failure to follow physician orders for insulin administration, inadequate nutrition provision for dialysis patients, improper preparation and storage of food, and failure to maintain infection control related to urinary catheter care.

Complaint IN00445259 was substantiated with federal/state deficiencies cited at F689 related to allegations of inadequate supervision and sexual inappropriate behavior between residents.

The facility failed to provide adequate supervision to prevent an alert male resident from entering a cognitively impaired female resident's room and exposing himself. The incident was investigated, and both residents were placed on 1:1 observation. Resident C was discharged from the facility. The facility implemented education and care plan updates to address sexual behaviors and prevent recurrence.

This citation relates to Complaint IN00445259. The complaint involved an incident of sexual inappropriateness between two residents, which was investigated and substantiated with findings of inadequate supervision and failure of door alarm systems.

The facility failed to provide adequate supervision to prevent a male resident from entering a cognitively impaired female resident's room and exposing himself while kneeling on her bed. Both residents were placed on 1:1 observation, and the incident was investigated with no physical abuse found. The facility notified family, police, and the physician and implemented interventions including education and monitoring.

The facility was found not in compliance with several emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, policies and procedures, communication plan, training and testing program, and failure to include volunteers and staffing strategies. Life safety deficiencies included failure to test emergency lighting monthly, incomplete documentation of battery-operated smoke alarms, lack of self-closing device on a hazardous area door, incomplete semiannual kitchen exhaust system inspections, exposed electrical wiring in junction boxes, failure to conduct quarterly fire drills on all shifts, and lack of annual testing of non-hospital-grade electrical receptacles. Additionally, staff training on oxygen trans-filling procedures was not documented.

The facility was found deficient in multiple areas including failure to provide required transfer/discharge and bed hold forms for hospitalized residents, untimely transmission of Minimum Data Set (MDS) assessments, incomplete comprehensive care plans for residents with edema and itching, failure to provide timely notification and treatment for changes in condition, improper storage of respiratory equipment, presence of discontinued medications and ice buildup in medication refrigerator, unsanitary food storage and serving practices, and failure to follow infection control hand hygiene protocols.

The facility was found deficient in multiple areas including failure to provide timely transfer and discharge notifications, failure to provide bed hold forms, delayed transmission of Minimum Data Set (MDS) assessments, incomplete care plans for residents with edema and itching, failure to provide timely treatment and notification for changes in condition, improper storage of respiratory equipment, failure to remove discontinued medications and maintain medication refrigerator, unsanitary food storage and serving practices, and inadequate infection control practices related to glove use and hand hygiene.

Complaint IN00428075 was investigated with federal and state deficiencies cited related to the allegation. The facility was found not in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1. The complaint was substantiated with deficiencies cited at F921 and F803.

The facility was found not in compliance with federal and state regulations related to the complaint. Deficiencies included failure to follow the menu for all residents during meal service and failure to maintain a sanitary and comfortable environment in one of four halls observed, with multiple bathrooms showing stains, odors, and black slimy substances.

This Federal tag relates to complaint IN00428075.

The facility failed to ensure the menu was followed for 54 of 54 residents consuming food, including incorrect portion sizes and missing items for special diets. Additionally, the facility failed to maintain a sanitary and comfortable environment in one of four halls observed, with multiple bathrooms showing stains, strong urine odors, and black slimy substances.

Complaint IN00419069 had federal/state deficiencies related to misappropriation of property (F602). Complaint IN00420938 had deficiencies related to quality of care and infection control (F684 and F880). Other complaints had no deficiencies cited.

The facility was found deficient in preventing misappropriation of resident property, failure to notify a state agency of an attempted suicide, failure to follow physician's orders for lab reporting and medication administration, failure to act on resident's suicidal statements and remove environmental hazards, and failure to report a positive tuberculosis test to the Indiana Department of Health.

The complaint involved allegations of misappropriation of resident property, failure to report an attempted suicide, failure to follow physician orders, failure to ensure resident safety after a suicide attempt, and failure to report a positive tuberculosis test. The investigation substantiated these issues with Resident B and Resident D.

The facility was found to have failed to prevent misappropriation of resident property, failed to notify the State agency of an attempted suicide, failed to follow physician orders for lab reporting and medication administration, failed to ensure environmental safety and supervision after a resident's suicide attempt, and failed to report a positive tuberculosis test to the Indiana Department of Health.

The facility was found not in compliance with emergency preparedness testing requirements and multiple life safety code deficiencies including missing emergency drills, obstructed exit discharge paths, non-illuminated exit signs, incomplete maintenance records for emergency lighting and smoke detectors, improperly maintained hazardous area doors, kitchen hood extinguishing system issues, fire alarm and sprinkler system policy deficiencies, and electrical system testing documentation issues.

Complaint IN00400676 was investigated with no deficiencies related to the allegations cited.

The facility was found deficient in multiple areas including failure to prevent abuse for 2 residents, untimely care plan meetings for 1 resident, failure to follow physician orders for pacemaker monitoring for 1 resident, failure to prevent new pressure ulcers for 1 resident, medication storage issues, unsanitary kitchen conditions, and environmental maintenance deficiencies.

The complaint investigation substantiated multiple issues including abuse allegations involving threatening a resident with lotion and roommate aggression, failure to follow physician orders for pacemaker monitoring, inadequate care planning, pressure ulcer prevention failures, medication storage violations, kitchen sanitation problems, and environmental maintenance deficiencies.

The facility failed to prevent abuse for 2 residents, failed to follow physician orders for a pacemaker monitoring device, failed to conduct timely care plan meetings, failed to prevent pressure ulcers, failed to maintain medication storage standards, and failed to maintain a sanitary and safe environment in multiple areas.

Complaint IN00394946 was substantiated with federal deficiencies cited at F803 related to menu and food preference issues.

The facility failed to ensure resident menus and individual food plans met resident preferences, with complaints about lack of variety and no posted menus. Additionally, the facility failed to store foods in a sanitary manner, including undated and expired food items in the walk-in cooler and freezer, and poor cleanliness of food storage areas.