Rochester Restorative Care Center
Rochester Restorative Care Center in ROCHESTER, MN — inspection on September 10, 2025.
Found 2 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
During an interview on 9/10/25 at 1:43 p.m., director of nursing (DON) stated R1 had not had a self-administer medication assessment completed due to her not being aware R1 had the inhalers on her person and wanted to self-administer and keep at bedside. DON stated all residents who chose to self-administer medication should have a comprehensive assessment completed to determine if they are able to administer the medications safely and appropriately, however, R1 had not had this completed.
Review of the facility's Self-Administration by Resident Policy dated 1/23, identified residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team (IDT) has determined that the practice would be safe and the medications are appropriate and safe for self-administration.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Rochester Restorative Care Center
501 Eighth Avenue Southeast Rochester, MN 55904
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 9/10/25 at 5:30 p.m. RN-D reviewed R4's facility electronic records and was unable to find a physician order and/or visit note that addressed the discontinuation of the Augmentin on 8/29/25 and indicted she did not know where it would be or came from.
During an interview on 9/10/25 at 9:06 a.m. health unit coordinator (HUC) stated she had access to the outside medical records but was not aware of the process on who was responsible for pulling the notes out of the outside EHR to make sure they got into the resident's medical record at the facility.
During an interview on 9/10/25 at 5:40 p.m., DON reviewed R4's facility electronic records and confirmed the record did not address the discontinuation of Augmentin. DON referenced a clinic/hospital outside record system that the facility staff had access to so that they could retrieve clinic and/or hospital records. DON logged into the outside EHR system and was able to locate a nurse practitioner note dated 8/29/25 that identified R4 was to receive intravenous cefepime (antibiotic) with dialysis through 9/5/25. DON explained there was only certain staff that had access to the clinic/hospital EHR; herself, nurse managers, and health unit coordinator.
During the interview the DON did not specify a process/system pertaining to how the documents were downloaded from the outside EHR and uploaded to the facility's EHR.
Review of the facility's Medical Record Policy dated 11/12/19, identified medical record documentation will be done according to the resident's level of care.
Documentation will occur when an activity, event, or incident that is not usual for the resident or change in level of assistance occurs.
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