Madonna Towers Of Rochester

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper personal protective equipment (PPE) was used during high-contact cares for 1 of 1 residents (R20) reviewed for enhanced barrier precautions (EBP) who had an indwelling catheter (R20). Findings include: R20's quarterly Minimum Data Set, dated [DATE] indicated R20 was cognitively intact, required partial assistance for activities of daily living (hygiene, toileting, transfers, ambulation), and had a urinary catheter. R20's diagnoses list included: neuromuscular dysfunction of bladder, need for assistance with personal care, unsteadiness on feet, muscle weakness, arthritis of knee, and a history of falling. R20's careplan indicated R20 had a urinary catheter that required catheter care per facility protocol. R20 required extensive assistance from 1 staff member for transfers, bed mobility and activities of daily living. An infection careplan indicated R20 required enhanced barrier precautions related to the presence of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled, dated and discarded properly. This deficient practice had the potential to affect all 55 residents, staff and visitors who received food from facility kitchen. Findings include: During the initial kitchen tour on 6/9/25 at 1:42 p.m., dietary manager (DM) stated the dates listed on the food was the date of opening or when it was prepped and should be tossed after one week. The following items were observed in the fridge expired or undated food: -Mushrooms dated 5/30/25 -Undated, opened celery appearing soft and browning -Undated, opened lettuce -Undated, opened chopped celery appearing with browning spots -Undated, opened carrots During interview on 6/9/25 at 1:42 p.m., culinary director (CD) stated the normal practice they follow is once foods are opened, the opened date is written on the container. The dated food is good for one week; the staff on evening shift will throw undated and expired foods every evening. CD confirmed the mushrooms, celery,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively monitor and assess for edema (swelling) so intervention effectiveness could be determined, and new interventions developed if needed for 1 of 1 residents (R43) assessed for edema management. Findings include: R43's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R43 had intact cognition and was diagnosed with heart failure and debility. R43's care plan dated 5/23/25, indicated R43 was receiving a diuretic, which placed her at a high risk for adverse reactions staff were to monitor for an infective dose such as an increase in edema. The care plan indicated R43 was at risk for skin alteration related to a history of lymphedema (swelling from an accumulation of protein-rich fluid usually drained by the body's lymphatic system). The care plan indicated staff were to apply R43's left upper extremity edema wraps in the morning, leave them on until the next morning, take off and assess the skin, and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 3 of 5 residents (R43, R14, R22) reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV)20 as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infections. Findings include: A CDC Shared Clinical decision-making document titled PCV20 or PCV21 Vaccination for Adults 65 years or older dated 9/11/24 indicated: Adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 [pneumococcal polysaccharide vaccine] and meet the following criteria: -Previously received one dose of PCV13 (but not PCV15, PCV20, or PCV21) at any age, and -Previously received all recommended doses of PPSV23 (including 1 dose of PPSV23 at or after [AGE] years of age) The determination to administer PCV20 or PCV21 is based on a shared clinical decision-making (SCDM)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and document review, the facility failed to provide the opportunity to make choices related to toileting for 2 of 3 residents (R1, R2) reviewed for choices. Findings include: R1's face sheet dated 2/12/25, identified diagnoses of stress fracture of left tibia (hairline crack in the shin bone) and fracture of middle phalanx of left finger. R1's admission minimum data set (MDS) dated [DATE], identified resident to be cognitively intact. R1 was dependent for all transfers and frequently incontinent of bowel. R1's care plan dated 2/12/25, identified R1 was dependent for all transfers with a total mechanical lift. During an interview on 2/11/25 at 3:50 p.m., R1 stated it had been two days since she has been able to have a bowel movement due to having to use the bedpan instead of using the toilet. R1 stated, I don't feel like I have any power over anything anymore, they tell me when to eat, when to bathe, and when to get up. R1 stated when she puts her call light on to bathroom to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed to implement care and services for catheter care and bowel continence for 1 of 1 resident (R1) reviewed for bowel and bladder incontinence/catheter. Findings include: R1's face sheet dated 2/12/25, identified diagnoses of diabetes mellitus, stress fracture of left tibia, chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had an indwelling urinary catheter and frequent bowel incontinence. R1's care area assessment (CAA) dated 12/19/24, identified R1 needed assistance for toileting due to indwelling catheter. R1's physician progress note dated 12/18/24, identified R1 had an indwelling urinary catheter placed during a hospitalization for urinary retention. R1's nursing assistant care guide updated 2/5/25, directed staff that R1 had a catheter. However, did not give any direction to staff to provide catheter care or toileting plan.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to comprehensively reassess and demonstrate adequate justification for the continued use of indwelling catheter for 1 of 1 resident (R1) reviewed for falls. In addition the facility failed to ensure a resident who was continent of bowel received services to maintain bowel continence for 1 of 1 resident (R1) reviewed for resident safety. Findings include: Catheter justification: R1's care plan dated 12/13/24, identified R1 required Enhanced Barrier Precautions (EBP) related to presence of indwelling catheter device .R1's care plan was reviewed and identified no indication for a foley catheter with no interventions to monitor for signs and symptoms of infection. R1's Care Area Assessment (CAA) dated 12/14/24, section 6 urinary incontinence identified CAA triggered due to use of an indwelling catheter and need for assistance with toileting. R1 has a catheter in for skin care management, due to history of incontinence and reduced mobility with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bedrails as a part of the regular maintenance program to identify areas of possible entrapment. All of the residents at the facility have the same beds. The facility census was 55 and 50 of those residents had the same quarter siderails on the beds. The bed manufacturer guidelines indicated to visually inspect the bed and accessories monthly. This failure had the potential to affect 50 residents in the facility. Findings include: A side rails safety environment inspection form dated 9/20/22 indicated one resident with bedrails was assessed with revisions made and again on 5/24/24 one resident with siderails was inspected with revisions made. Upon observation on 8/23/24 at 10:10 a.m. all residents' rooms at the facility were observed for bedrails. Fifty residents had beds with quarter sized bedrails attached by the head of the bed and five residents did not have any bedrails.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to attempt to try alternative devices before using bedrails on resident's beds for 7 of 7 resident (R1, R2, R3, R4, R5, R6, R7) when the facility failed to accurately assess the resident for risk of entrapment by assessing residents medical diagnoses, size and weight, cognition, communication, mobility, and risk of falling. In addition, the facility failed to provide ongoing assessments to assure the bedrail is used to meet the resident's needs. Findings include: Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 indicated a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to one's body. The important consideration is the effect of the device on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure process's were followed for safe mechanical lift transfers for 3 of 18 residents (R1, R2, R3) reviewed for safety with mechanical lift transfers. Findings include: R1: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 had impaired range of motion (ROM) on one side of lower extremity and was completely dependent on staff for all transfers. R1's undated Facesheet identified diagnoses of right leg above the knee amputation, history of falling, and dementia. R1's care plan dated 12/8/23, identified R1 had a self-care deficit with transfers. An intervention on 12/22/23, identified R1 required assist of two staff for transfers with a ceiling lift for all transfers. Must use gold full body sling for all transfers; however, did not identify the size of gold sling to be used. R1's physical therapy (PT) treatment encounter note dated 12/22/23, identified R1 utilized a ceiling lift with an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to complete neurological assessments and comprehensively assess and monitor skin injuries following falls for 4 of 4 residents (R1, R2, R3, R4) who had unwitnessed falls or unwitnessed falls with injuries. Findings include: R4's face sheet included diagnoses of trochanteric bursitis, left hip, type 2 diabetes mellitus with diabetic nephropathy, age related osteoporosis without current pathological fracture, mild neurocognitive disorder, history of falling. R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact, was dependent on staff for lower body dressing, was substantial to max assistance from staff for hygiene, and was partial to moderate assist from staff for toileting, mobility, and transfers. MDS also indicated R4 had a fall in the last month and another in the last 2-6 months. R4's Safety Events report-Falls dated 10/26/23, indicated R4 had an unwitnessed fall at 7:05 p.m., that resulted in a bump on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.