Inspection Reports for Life Care Center of Rochester
827 W 13TH ST, IN, 46975
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 3, 2024, found the facility in compliance with Emergency Preparedness and Life Safety Code requirements, with no deficiencies noted. Prior inspections showed a pattern of deficiencies related mainly to emergency preparedness, life safety code compliance, resident supervision, care planning, medication management, and sanitary conditions. Complaint investigations included substantiated findings for inadequate supervision leading to inappropriate resident behavior and issues with food service and environmental cleanliness, but many complaints were found unsubstantiated or compliant upon review. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed several prior deficiencies, as recent follow-up inspections showed compliance with previously cited areas.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
345% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
43% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 46
Capacity: 108
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 10/21/24.
Findings
At the Emergency Preparedness PSR, the facility was found in compliance with Emergency Preparedness Requirements. At the Life Safety Code PSR, the facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code.
Report Facts
Certified beds: 108
Census: 46
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 1
Date: Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445259 regarding allegations of inadequate supervision leading to inappropriate sexual behavior between residents.
Complaint Details
Complaint IN00445259 was substantiated with federal/state deficiencies cited at F689 related to allegations of inadequate supervision and sexual inappropriate behavior between residents.
Findings
The facility failed to provide adequate supervision to prevent an alert male resident from entering a cognitively impaired female resident's room and exposing himself. The incident was investigated, and both residents were placed on 1:1 observation. Resident C was discharged from the facility. The facility implemented education and care plan updates to address sexual behaviors and prevent recurrence.
Deficiencies (1)
Failed to provide adequate supervision to prevent an alert male resident from entering a cognitively impaired female resident's room and exposing himself.
Report Facts
Census SNF/NF: 51
Medicare census: 5
Medicaid census: 40
Other payor census: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Wagner | Executive Director | Signed the report and responsible for compliance |
| Social Service Director | Provided statements and was involved in incident observation and follow-up | |
| Administrator | Conducted interviews and coordinated with police and family | |
| LPN 2 | Documented nursing progress notes related to the incident and resident assessments |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints identified as IN00445259.
Complaint Details
Complaint investigation IN00445259 was completed with findings of compliance.
Findings
Life Care Center of Rochester was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Routine
Census: 50
Capacity: 108
Deficiencies: 15
Date: Oct 21, 2024
Visit Reason
An Emergency Preparedness and Life Safety Code Survey was conducted by the Indiana Department of Health to assess compliance with federal and state regulations including emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with several emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, policies and procedures, communication plan, training and testing program, and failure to include volunteers and staffing strategies. Life safety deficiencies included failure to test emergency lighting monthly, incomplete documentation of battery-operated smoke alarms, lack of self-closing device on a hazardous area door, incomplete semiannual kitchen exhaust system inspections, exposed electrical wiring in junction boxes, failure to conduct quarterly fire drills on all shifts, and lack of annual testing of non-hospital-grade electrical receptacles. Additionally, staff training on oxygen trans-filling procedures was not documented.
Deficiencies (15)
Failed to review and update the Emergency Preparedness Plan annually.
Failed to review and update Emergency Preparedness Policies and Procedures annually.
Failed to include use of volunteers and emergency staffing strategies in Emergency Preparedness Policies and Procedures.
Failed to review and update Emergency Preparedness Communication Plan annually.
Failed to address primary and alternate means of communication in Emergency Preparedness Communication Plan.
Failed to review and update Emergency Preparedness Training and Testing Program annually.
Failed to conduct required emergency plan exercises twice per year including unannounced staff drills.
Failed to test and document monthly battery powered emergency lights.
Failed to maintain complete documentation for preventative maintenance of battery operated smoke alarms in resident rooms.
Failed to provide self-closing device on corridor door to hazardous area used for combustible storage.
Failed to inspect kitchen exhaust system semiannually as required.
Exposed electrical wiring in two open junction boxes without covers above fire doors.
Failed to conduct quarterly fire drills on all shifts; missing first shift fire drill in third quarter 2024.
Failed to test all non-hospital-grade electrical receptacles at resident room locations annually.
Failed to ensure staff was properly trained on oxygen trans-filling procedures.
Report Facts
Certified beds: 108
Census: 50
Deficiency count: 15
Fire drills missing: 1
Inspection date: Oct 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Wagner | Executive Director | Interviewed and involved in exit conference regarding emergency preparedness and life safety findings |
Inspection Report
Annual Inspection
Census: 53
Capacity: 53
Deficiencies: 9
Date: Sep 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 16 to 20, 2024.
Findings
The facility was found deficient in multiple areas including failure to provide required transfer/discharge and bed hold forms for hospitalized residents, untimely transmission of Minimum Data Set (MDS) assessments, incomplete comprehensive care plans for residents with edema and itching, failure to provide timely notification and treatment for changes in condition, improper storage of respiratory equipment, presence of discontinued medications and ice buildup in medication refrigerator, unsanitary food storage and serving practices, and failure to follow infection control hand hygiene protocols.
Deficiencies (9)
Failed to provide transfer and discharge forms for 3 of 3 residents reviewed for hospitalization.
Failed to provide bed hold forms for 3 of 3 residents reviewed for hospitalization.
Failed to ensure Minimum Data Set (MDS) assessments were transmitted timely for 2 of 2 resident assessments reviewed.
Failed to develop comprehensive person-centered care plans for a resident with edema and a resident with a history of itching for 2 of 20 residents reviewed.
Failed to provide timely notification of a change in condition and timely treatment for 2 of 3 residents reviewed for hospitalization and insulin usage.
Failed to store respiratory equipment in a sanitary manner for 3 of 3 residents reviewed for oxygen therapy.
Failed to ensure discontinued medications were removed and medication refrigerator was free from large ice buildup in 1 of 2 medication rooms observed.
Failed to store and serve food under sanitary conditions related to undated and unlabeled foods and improper serving practices.
Failed to ensure staff changed gloves and performed hand hygiene when providing perineal care for 1 of 1 resident reviewed for incontinence needs.
Report Facts
Census: 53
Total Capacity: 53
Deficiencies cited: 9
Residents reviewed for transfer/discharge forms: 3
Residents reviewed for bed hold forms: 3
Residents reviewed for MDS transmission: 2
Residents reviewed for care plans: 20
Residents reviewed for change in condition: 3
Residents reviewed for respiratory equipment: 3
Medications found in medication room: 5
Residents observed during meal service: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed failing to change gloves and perform hand hygiene during perineal care for Resident 7 |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding transfer/discharge forms, bed hold forms, respiratory equipment, and notification of condition changes |
| Suzanne Wagner | Executive Director | Signed the report |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The visit was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Life Care Center of Rochester was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: May 15, 2024
Visit Reason
The visit was conducted to investigate multiple complaints identified as IN00433974, IN00433523, IN00433527, IN00433532, IN00433536, and IN00433131.
Complaint Details
Complaints IN00433974, IN00433523, IN00433527, IN00433532, IN00433536, and IN00433131 were investigated and no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census Bed Type: 51
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 6
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430784 and IN00429799.
Complaint Details
Complaint IN00430784 and Complaint IN00429799 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00430784 and IN00429799 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 53
Census total residents: 53
Census Medicare residents: 4
Census Medicaid residents: 45
Census other payor residents: 4
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 2
Date: Feb 19, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00428075, which triggered a federal and state deficiency investigation related to the allegation.
Complaint Details
Complaint IN00428075 was investigated with federal and state deficiencies cited related to the allegation. The facility was found not in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1. The complaint was substantiated with deficiencies cited at F921 and F803.
Findings
The facility was found not in compliance with federal and state regulations related to the complaint. Deficiencies included failure to follow the menu for all residents during meal service and failure to maintain a sanitary and comfortable environment in one of four halls observed, with multiple bathrooms showing stains, odors, and black slimy substances.
Deficiencies (2)
Facility failed to ensure the menu was followed for 54 of 54 residents who consumed food in the facility, including incorrect portion sizes and missing items for pureed and mechanical soft diets.
Facility failed to ensure a sanitary and comfortable environment was maintained in 1 of 4 halls observed (Central Hall), with stained flooring, strong urine odors, and black slimy substances in multiple shared bathrooms.
Report Facts
Census: 54
Total Capacity: 54
Medicare Residents: 4
Medicaid Residents: 45
Other Payor Residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Wagner | Executive Director | Signed the report and responsible for ensuring compliance in the Plan of Correction |
| Food Service Supervisor | Interviewed regarding menu and portion size deficiencies | |
| Cook 4 | Observed serving incorrect portion sizes and missing menu items | |
| Maintenance Director | Observed environmental deficiencies and responsible for audits and repairs | |
| Housekeeping Supervisor | Interviewed regarding housekeeping assignments and environmental conditions |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
Paper compliance review to the investigation of complaints IN00428075 completed on February 19, 2024.
Complaint Details
Investigation of complaints IN00428075; paper compliance review found facility in compliance.
Findings
Life Care Center of Rochester was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 5
Date: Nov 17, 2023
Visit Reason
This visit was for the investigation of complaints IN00419069, IN00419110, IN00420938, IN00421224, and IN00421285 at Life Care Center of Rochester.
Complaint Details
Complaint IN00419069 had federal/state deficiencies related to misappropriation of property (F602). Complaint IN00420938 had deficiencies related to quality of care and infection control (F684 and F880). Other complaints had no deficiencies cited.
Findings
The facility was found deficient in preventing misappropriation of resident property, failure to notify a state agency of an attempted suicide, failure to follow physician's orders for lab reporting and medication administration, failure to act on resident's suicidal statements and remove environmental hazards, and failure to report a positive tuberculosis test to the Indiana Department of Health.
Deficiencies (5)
Failed to prevent misappropriation of resident property for 1 of 1 resident reviewed (Resident B).
Failed to notify a State agency of an attempted suicide for 1 of 4 reportable incidents reviewed (Resident B).
Failed to follow physician's orders for reporting laboratory results timely and providing oral medications as prescribed for 1 of 3 residents reviewed (Resident D).
Failed to act on resident's statements of wanting to die and failed to ensure environmental hazards were removed after a suicide attempt for 1 of 1 resident reviewed (Resident 2).
Failed to report a positive QuantiFERON Gold test (Tuberculosis skin test) to the Indiana Department of Health for 1 of 1 resident reviewed (Resident D).
Report Facts
Census SNF/NF: 53
Medicare Census: 4
Medicaid Census: 45
Other Payor Census: 4
Deficiency Count: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
Paper compliance review to the investigation of Complaints IN00419069 and IN00420938 completed on November 17, 2023.
Complaint Details
Investigation of Complaints IN00419069 and IN00420938; facility found in compliance.
Findings
Life Care Center of Rochester was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Complaint Investigation.
Inspection Report
Follow-Up
Census: 55
Capacity: 141
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/25/23.
Findings
At this Emergency Preparedness PSR, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code PSR, the facility was found in compliance with Life Safety Code requirements, including fire safety and sprinkler systems.
Report Facts
Certified beds: 141
Census: 55
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416190.
Complaint Details
Complaint IN00416190 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 41
Other payor census: 6
Inspection Report
Re-Inspection
Census: 56
Capacity: 56
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-06-21.
Findings
Life Care Center of Rochester was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 8
Inspection Report
Life Safety
Census: 55
Capacity: 141
Deficiencies: 14
Date: Jul 25, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with emergency preparedness testing requirements and multiple life safety code deficiencies including missing emergency drills, obstructed exit discharge paths, non-illuminated exit signs, incomplete maintenance records for emergency lighting and smoke detectors, improperly maintained hazardous area doors, kitchen hood extinguishing system issues, fire alarm and sprinkler system policy deficiencies, and electrical system testing documentation issues.
Deficiencies (14)
Failed to conduct required emergency preparedness exercises twice per year including unannounced staff drills.
Exit discharge path through courtyard was obstructed by a locked gate without key access.
Failed to maintain itemized records of monthly and annual emergency lighting battery backup tests.
Two exit signs were not continuously illuminated.
Failed to maintain complete documentation for preventative maintenance of 55 battery operated smoke alarms; two smoke alarms were over 10 years old.
Corridor door to file storage room (hazardous area) lacked self-closing device.
Kitchen range hood fire extinguishing system nozzles were improperly positioned.
Facility lacked correct written fire watch policy for fire alarm or sprinkler system outages.
Missing documentation for monthly wet and dry sprinkler system inspections for several months in 2022.
Failed to provide correct written policy for sprinkler system impairment and fire watch procedures.
One set of smoke barrier doors did not fully close, leaving a gap that would not restrict smoke movement.
Laundry room fuel-fired dryers lacked fresh air intake from outside due to blocked vent.
Power strip in resident room did not meet required UL rating for patient care areas.
Testing form for hospital-grade electrical receptacles did not clearly document pass/fail status for each receptacle.
Report Facts
Certified beds: 141
Census: 55
Deficiencies cited: 14
Inspection Report
Annual Inspection
Census: 55
Capacity: 55
Deficiencies: 8
Date: Jun 21, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00400676.
Complaint Details
Complaint IN00400676 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including failure to prevent abuse for 2 residents, untimely care plan meetings for 1 resident, failure to follow physician orders for pacemaker monitoring for 1 resident, failure to prevent new pressure ulcers for 1 resident, medication storage issues, unsanitary kitchen conditions, and environmental maintenance deficiencies.
Deficiencies (8)
Failure to prevent mental and physical abuse for 2 of 3 residents reviewed for abuse (Residents 53 and 12).
Failure to ensure timely care plan meetings for 1 of 20 residents reviewed (Resident 33).
Failure to ensure physician's order for pacemaker monitoring device was followed for 1 of 1 resident reviewed (Resident 11).
Failure to prevent development of 2 new deep tissue injuries in 1 of 1 resident reviewed for pressure ulcers (Resident 25).
Medication carts contained loose pills, undated opened medications, and medication refrigerator freezer had ice buildup in 3 of 3 medication storage areas observed.
Unsanitary kitchen environment with food debris, expired sanitation test strips, and improper chemical storage.
Facility failed to maintain a functional, sanitary, and comfortable environment in resident rooms and common areas with gouged doors, stained floors, missing paint, and broken fixtures.
Failure to maintain complete employee records including pre-employment references, physicals, orientation, and resident rights education for multiple employees.
Report Facts
Census: 55
Total Capacity: 55
Deficiencies cited: 8
Date of Compliance: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Wagner | Executive Director | Signed report and involved in abuse education plan |
| RN 9 | Registered Nurse | Responsible for pacemaker monitoring device checks; lacked training |
| LPN 11 | Licensed Practical Nurse | Primary nurse for Resident 11; unaware of pacemaker monitoring device |
| RN 19 | Registered Nurse/Wound Nurse | Provided wound care and education; responsible for staff education |
| LPN 20 | Licensed Practical Nurse | Observed medication storage deficiencies |
| Dietary Aide 19 | Dietary Aide | Tested sanitation solution; unaware of expired test strips |
| Dietary Manager | Dietary Manager | Provided sanitation and chemical storage policies |
| Maintenance Director | Maintenance Director | Responsible for environmental maintenance and repairs |
| Payroll Personnel | Payroll Personnel | Provided information on employee physicals and references |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00394946 completed on December 20, 2022.
Complaint Details
Complaint IN00394946 was investigated and found to be in compliance as of the review date February 13, 2023.
Findings
Life Care Center of Rochester was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 2
Date: Dec 20, 2022
Visit Reason
This visit was for the investigation of complaint IN00394946, which was substantiated with federal deficiencies cited related to the allegations.
Complaint Details
Complaint IN00394946 was substantiated with federal deficiencies cited at F803 related to menu and food preference issues.
Findings
The facility failed to ensure resident menus and individual food plans met resident preferences, with complaints about lack of variety and no posted menus. Additionally, the facility failed to store foods in a sanitary manner, including undated and expired food items in the walk-in cooler and freezer, and poor cleanliness of food storage areas.
Deficiencies (2)
Menus did not meet resident needs or were not prepared in advance or followed, resulting in lack of variety and no posted menus.
Food procurement, storage, preparation, and serving were not sanitary; undated and expired food items were found and food storage areas were unclean.
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 5
Medicaid Census: 45
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00381314 and IN00373942.
Complaint Details
Complaint IN00381314 - Substantiated with no deficiencies cited. Complaint IN00373942 - Substantiated with no deficiencies cited.
Findings
Both complaints were substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 4
Medicaid census: 43
Other census: 9
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