Rochester Rehabilitation And Living Center
Rochester Rehabilitation And Living Center in ROCHESTER, MN — inspection on March 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
characteristics listed as deteriorated; Pressure ulcer staging as a Stage 4 pressure ulcer; wound in
moderate drainage that was seropurulent (thin, watery, cloudy wound discharge that is yellow to tan
moderate dressing saturation. R1's skin focus care plan was revised on 3/17/26 to include the following:-Provide prompt incontinence care and keep skin clean and dry to prevent moisture related skin breakdown. R1's elimination focus care plan revised on 3/17/26, identified R1 had incontinence due to neurogenic bladder.
Goal to cooperate in establishing a routine for urine elimination.
Interventions as follows:-Use bedside commode and no longer use the bedpan.-Offer bedside commode every 2-3 hours and as needed.
Able to state when need to use the bathroom and will also ask for assistance.
During an interview on 3/24/26 at 3:57 p.m., nursing assistant (NA)-D stated when she worked with R1 she would sometimes fall asleep on the bedpan and forget to ask for staff to take her off, however, NA-D stated staff should be aware if they placed a resident on a bedpan to ensure to take them off in a timely manner to prevent a sore from developing. NA-D had not heard R1 was not supposed to use the bedpan until after her sore had already worsened.
During an interview on 3/25/26 at 4:11 p.m., DON stated R1care plan had not been revised to include a turning and repositioning schedule, nor did her toileting care plan revised to not have R1 use the bedpan until 3/17/26. DON explained R1's care plan should have been revised as soon as she heard that R1 was falling asleep while sitting on the bedpan and not waited until 3/17/26 until after R1's pressure ulcer had worsened.
Review of the facility's Comprehensive Care Plan Policy dated 4/11/25.
Identified The purpose of this policy is to ensure that all residents receive individualized, person-centered care through the timely development, implementation, and ongoing review of comprehensive care plans.
This policy ensures alignment with federal regulations and professional standards by outlining processes that assess resident needs and preferences, coordinating interdisciplinary team input, and promoting culturally competent and trauma-informed care.Development of the Care Plan.
The comprehensive care plan must be:(a) Developed both: Within seven (7) days after completion of the comprehensive assessment, and Within 21 days after the resident's admission.(b) Prepared by an IDT that includes but is not limited to:The attending physician or, if unavailable, the designated non-physician practitioner (NPP) who is involved in the resident's care, to the extent permitted by state law.A registered nurse with responsibility for the resident.
245626 03/27/2026
Rochester Rehabilitation and Living Center 1900 Ballington Boulevard NW Rochester, MN 55901
Orders:Wound treatments will be provided in accordance with provider orders, including:The cleansing
the assigned licensed nurse in theabsence of the treatment nurse.Treatment orders will be guided by
specialist, dietician, therapy staff).Pain associated with wound care will be assessed and managed in accordance with provider.orders and pain management policies and procedures.IV.
Treatment Decisions:Treatment decisions will be based on:Etiology of the wound:Pressure injuries.Non-pressure wounds (e.g., arterial, venous, diabetic, moisture-related skindamage).Surgical wounds.Incidental injuries/wounds (e.g., skin tear, medical adhesive-related injury).Atypical injury/wound (e.g., dermatological, or cancerous lesion, pyoderma,calciphylaxis).Characteristics of the wound:Pressure injury stage or level of tissue destruction if not a pressure injury.Size, including shape, depth, and presence of tunneling and/or undermining.Volume and characteristics of exudate.Presence of pain.Presence of infection or need to address bacterial bioburden.Condition of the tissue in the wound bed.Condition of peri-wound skin.Location of the wound; andGoals and preferences of the resident or their representative.Guidelines for dressing selection may be utilized in obtaining provider orders.
245626 03/27/2026
Rochester Rehabilitation and Living Center 1900 Ballington Boulevard NW Rochester, MN 55901
During an interview on 3/26/26 at 4:07 p.m., physician assistant (PA) stated she had been informed via SBAR to see if she was available to assess R1's worsening buttocks wound in person on 3/19/26, however, there was not physician available to assess R1's wound in person, so she gave recommendation for monitoring in the facility until her ˆwound could be assessed on 3/20/26. PA stated she was aware of R1's pressure ulcer and had been informed by the NP that the likely cause was due to R1 sitting on a bedpan for an undetermined time.ˆ PA stated her expectation for the facility was to put pressure relieving measures in place immediately to prevent a pressure ulcer and/or to avoid deterioration of an existing pressure ulcer.ˆ During a return phone call on 4/1/25 at 11:36 a.m., NP stated when he had assessed R1's wound on 3/20/26 it appeared to be infected and had a large amount of purulent drainage and had foul odor and proceeded to send R1 to the ED for further evaluation of her wound.ˆ NP stated she had been informed at an earlier time that R1 had been left on the bedpan for an unknown amount of time and this likely caused the unstageable pressure ulcer. NP stated R1's toileting plan should have been changed as soon as it was identified she had been sitting on the bedpan for a long time and that she had not been informed R1's gel mattress had not been in place on her bed since 3/4/26. NP explained that by R1 not having her gel mattress in place could have likely caused R1's buttocks wound to deteriorate, and her pressure ulcer could have been avoided if all of the interventions had been in place. ˆ During an interview on 3/26/26 at 2:12 p.m., medical director (MD) stated it is his expectation for the facility to ensure all residents who are at risk for pressure ulcers have interventions put in place immediately to mitigate the risk of developing a pressure ulcer.ˆ If the resident develops a pressure ulcer the treatment/interventions need to be continually evaluated to ensure the pressure ulcer does not deteriorate.ˆ R1 not having a gel air mattress, by not altering pressure reducing interventions could have caused deterioration in her pressure ulcer thus making the pressure ulcer avoidable.ˆ During an interview on 3/24/26 at 2:29 p.m., administrator stated during the facility investigation of R1's worsened
245626 03/27/2026
Rochester Rehabilitation and Living Center 1900 Ballington Boulevard NW Rochester, MN 55901
the EBP sign that was outside of R3's room and identified that EBP was needed during any high
Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact
multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO.
The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs to employees' hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids.
High-Contact Resident Care Activities include:DressingBathing/showeringTransferringProviding hygieneChanging linensChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube.Wound care: any skin opening requiring a dressing.
ProcedureStandard Precautions should be applied to all residents at all times.Transmission-based precautions should be applied to all residents when standard precautions alone do not prevent pathogen transmission.Enhanced Barrier Precautions are to be implemented in addition to Standard Precautions when other Transmission-Based precautions do not apply, when facility identifies any resident with:MDRO infection or colonization when Contact Precautions do not otherwise apply. If resident is infected or colonized with any MDRO and has secretions or excretions that are unable to be covered or contained, the resident should be placed on contact precautions.Wounds or skin openings such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers Shorter-lasting wounds such as skin breaks or skin tears covered with an adhesive bandage would not need Enhanced Barrier PrecautionsAny indwelling medical device, regardless of MDRO colonization status, for example: Central linesPeripheral intravenous line is not considered an indwelling medical device for the purposes of EBP.2Urinary cathetersFeeding tubesTracheostomy/ventilatorPersonal Protective equipment is required for all staff providing high-contact resident care activities to include: Gown and gloves with: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care:any skin opening requiring a dressing.