Rochester Rehabilitation And Living Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

been wrapped in the morning like they were supposed to be and would have to ask staff to put them on.

During an interview on 8/15/25 at 10:40 a.m., registered nurse (RN)-B stated Resident R3's compression wraps were supposed to be applied at 7:00 a.m., however, had not applied Resident R3's wraps today due to being too busy.

RN-B was unable to articulate what type of assessment she would perform to evaluate for signs and symptoms of fluid overload related to congestive heart failure, nor the rationale for compression wraps, nor how she would determine if a resident's edema were worsening. RN-B further stated she had not received any formal training for edema monitoring and, I feel I could benefit from some training. During an interview

on 8/11/25 at 4:06 p.m., director of nursing (DON) stated Resident R3 did not have her weight obtained on 8/6/25 or 8/11/25 and should have been obtained.During a follow up interview on 8/15/25 at 2:52 p.m., DON stated Resident R3's compression wraps should have been applied prior to Resident R3 getting up for the day and signed off in the MAR, however, were not signed off on 8/6/25 and 8/11/25. DON stated that residents with heart failure and/or edema should be monitored daily for worsening edema and increased CHF symptoms but had not done consistently. DON further stated that nurses had not received any specific to edema and/or CHF monitoring. Review of the facility's Heart failure patient care policy, revised August 19, 2024, identified Heart failure is a progressive clinical condition in which one or both ventricles of the heart cannot fill with or eject blood efficiently due to a structural or functional disorder. -The role in the care of a patient with heart failure includes assessing and monitoring the patient for signs and symptoms of worsening heart failure, assisting with medication management, fluid management.-Ask the patient about the presence and severity of common heart failure symptoms, including chest pain; shortness of breath at rest and with exertion; difficulty sleeping and the number of pillows needed for positioning; the presence and description of cough, fatigue, weakness, dizziness, syncope, abdominal pain, decreased appetite or early satiety, nausea and vomiting, decreased urination during the day and increased urination at night, sudden weight gain, and swelling. Note any changes or trends in the patient's symptoms. ---Assess the patient for confusion, disorientation, and other cognitive difficulties (such as impaired memory or concentration) because decreased cardiac output may impair blood flow to the brain and affect mentation.-Obtain the patient's vital signs because tachypnea, tachycardia, hypertension, and hypotension may be signs of heart failure.-Weigh

the patient in similarly weighted clothing, on the same scale, and at the same time of day that the patient normally performs daily weight measurements to ensure comparable data.-Assess the skin of the patient's extremities, and note their color and temperature, Pale, cyanotic, and cool extremities suggest poor peripheral perfusion. Assess capillary refill time in the patient's fingers and toes. Delayed capillary refill time suggests poor peripheral perfusion. Palpate the patient's peripheral pulses and note their strength on a scale from 0 (absent) to +3 (bounding) because weak or absent pulses may indicate poor peripheral perfusion. Palpate the patient's extremities for pitting edema. If edema is present, note the degree on a scale from 0 (no edema) to +4 (pitting).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rochester Rehabilitation and Living Center

1900 Ballington Boulevard NW Rochester, MN 55901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

prescriptions being delivered from the pharmacy are correct to prevent a similar error. During an interview

on 8/13/25 at 12:18 p.m., NP stated Resident R4 began having symptoms of increased blood pressure and weight gain over the past week. Resident R4 was currently in the ED due to shortness of breath, chest pain, and was currently in atrial fibrillation with ventricular rate. Resident R4 received multiple increased doses of prednisone likely caused his symptoms and even if the pharmacy had dispensed the incorrect dose when Resident R4 was re-admitted to the facility on [DATE REDACTED]. NP stated Resident R4 receiving so many higher doses of prednisone put Resident R4 at risk for serious harm or even death. NP stated Resident R1's Metolazone being administered when it should not have been given could have led to her syncopal episode on 7/18/25. NP stated Resident R1's Metolazone had been discontinued on 7/21/25, and the med card should have been removed from the medication cart at the time of it being discontinued. Resident R1 having multiple cards of torsemide in the cart with different doses/directions put her at risk for an incorrect dose being given and could be the contributing factor to Resident R1 not having improvement in her CHF symptoms. NP stated the type of errors for Resident R1 had the potential to cause serious harm or even death. During a phone interview on 8/12/25 at 12:55 p.m., consultant pharmacist (CP) was not aware of several recent medication errors that were found regarding transcription, not available and omission of medications with several different residents and several different nurses. CP stated she meets with the quality assurance committee quarterly and attended lasts months meeting, stating they discuss significant medication errors but could not remember if it was discussed what prevention measures were in place. CP further stated for prevention with each medication error there should be a root cause analysis performed, the nurse making the error should be notified and educated. The facility could be performing education with staf

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rochester Rehabilitation and Living Center

1900 Ballington Boulevard NW Rochester, MN 55901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) plan and program identified, analyzed, implemented corrective actions, and re-evaluated corrective actions to address adverse events and quality deficiencies. This deficient practice had the potential to affect all 35 residents in the facility. Actual harm occurred related to the quality of care to two residents (Resident R4 and Resident R1). Findings include:See F-F755, facility failed to identify and prevent medication errors due to complete systemic failure. The facility's failures resulted in an immediate jeopardy (IJ) with over 79 medication errors occurred in six weeks, resulting in actual harm for 2 of 5 residents (Resident R4, Resident R1) reviewed who had medication errors. Resident R4 (cardiac ICU admission) and Resident R1 (ongoing CHF exacerbation).

The facility lacked systems to prevent errors, notify providers, and investigate incidents-demonstrating a widespread failure in medication management. Further review of medication errors revealed a lack of analysis of root causes, and there were no implemented corrective actions, and re-evaluated corrective actions to address adverse events and quality deficiencies.Review of the requested facility QAPI plans and minutes for April, May, June and July 2025, did not identify a focused topic of medication errors, had not mention of medication error rates, and not evident quality activities to identify and monitor the effectiveness of the facility's pharmacy services were developed or implemented. During an interview on 8/22/25 at 4:00 p.m., interim administrator reviewed QAPI minutes from April 2025 to July 2025 and verified the quality plans did not address medication errors and should have. Facility policy, Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) Committee Policy and Procedure dated 11/21, identified when improvement or innovation is indicated based on outcomes and/or new information, Performance Improvement Plans (PIP's) will be chartered as needed, a Root Cause Analysis (RCA) or equivalent process will be completed when needed to define the problem or need, the QAPI team will define who is on the PIP team which will utilize the Model for Improvement process to determine what change is indicated based on the RCA findings and additional information identified, the team then proceeds with testing the change, making any necessary changes, and then designing an implementation plan and once the plan is completed a sustainability (monitoring) plan is created. The metric or process to monitor this issue will be added to the QAPI Surveillance Data and Reporting Schedule as the feedback loop for on-going monitoring.

Event ID:

Facility ID:

If continuation sheet