Care Citations

Waterview Heights Rehabilitation and Nursing Cente

135 Meridan St., Rochester, NY, 14612 · 5856630930

What CMS has flagged

  • CMS status on record: SFF.

On the CMS record

Certified beds
229
Ownership type
For profit - Partnership
Chain
HURLBUT CARE

Inspection findings on record (86)

Quoted exactly as CMS published them. We do not rewrite findings.

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity K · immediate jeopardy

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity K · immediate jeopardy

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0675 · scope/severity I · actual harm

Honor each resident's preferences, choices, values and beliefs.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0554 · scope/severity G · actual harm

Allow residents to self-administer drugs if determined clinically appropriate.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity G · actual harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity G · actual harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity G · actual harm

Provide enough food/fluids to maintain a resident's health.

Recorded as corrected on .

— Administration Deficiencies

Tag 0840 · scope/severity G · actual harm

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity F · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Administration Deficiencies

Tag 0865 · scope/severity F · potential for more than minimal harm

Have a plan that describes the process for conducting QAPI and QAA activities.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0925 · scope/severity F · potential for more than minimal harm

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity E · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0645 · scope/severity D · potential for more than minimal harm

PASARR screening for Mental disorders or Intellectual Disabilities

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0688 · scope/severity D · potential for more than minimal harm

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0693 · scope/severity D · potential for more than minimal harm

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0804 · scope/severity D · potential for more than minimal harm

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0582 · scope/severity B · potential for minimal harm

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0675 · scope/severity L · immediate jeopardy

Honor each resident's preferences, choices, values and beliefs.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity L · immediate jeopardy

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity L · immediate jeopardy

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity L · immediate jeopardy

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity K · immediate jeopardy

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity I · actual harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity G · actual harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity G · actual harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity F · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Administration Deficiencies

Tag 0837 · scope/severity F · potential for more than minimal harm

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Recorded as corrected on .

— Administration Deficiencies

Tag 0865 · scope/severity F · potential for more than minimal harm

Have a plan that describes the process for conducting QAPI and QAA activities.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0882 · scope/severity F · potential for more than minimal harm

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0565 · scope/severity E · potential for more than minimal harm

Honor the resident's right to organize and participate in resident/family groups in the facility.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity E · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0804 · scope/severity E · potential for more than minimal harm

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Recorded as corrected on .

— Administration Deficiencies

Tag 0836 · scope/severity E · potential for more than minimal harm

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0868 · scope/severity E · potential for more than minimal harm

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0805 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0912 · scope/severity D · potential for more than minimal harm

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0914 · scope/severity D · potential for more than minimal harm

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0917 · scope/severity B · potential for minimal harm

Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity L · immediate jeopardy

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Administration Deficiencies

Tag 0837 · scope/severity L · immediate jeopardy

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity K · immediate jeopardy

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity K · immediate jeopardy

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

The facility has formally disputed this citation through CMS's dispute-resolution process.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity K · immediate jeopardy

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity I · actual harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

The facility has formally disputed this citation through CMS's dispute-resolution process.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity I · actual harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity H · actual harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0565 · scope/severity F · potential for more than minimal harm

Honor the resident's right to organize and participate in resident/family groups in the facility.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity F · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity F · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0813 · scope/severity F · potential for more than minimal harm

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity E · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity E · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0693 · scope/severity D · potential for more than minimal harm

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0810 · scope/severity D · potential for more than minimal harm

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity D · potential for more than minimal harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity E · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity E · potential for more than minimal harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity E · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity E · potential for more than minimal harm

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity E · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0557 · scope/severity D · potential for more than minimal harm

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0558 · scope/severity D · potential for more than minimal harm

Reasonably accommodate the needs and preferences of each resident.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0745 · scope/severity D · potential for more than minimal harm

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity D · potential for more than minimal harm

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0582 · scope/severity B · potential for minimal harm

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity B · potential for minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 335082