Inspection visit

InspectionMarch 21, 2025

ROCHESTER RESIDENCE AND CARE CENTERCMS #39575129 citations on this visit

29 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 29 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for three of three residents (Resident R26, R37, and R56 ). Residents Affected - Some Findings include: Review of facility policy Call Lights: Accessibility and Timely Response last reviewed 1/7/25, indicated all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Process for responding to call lights: a. Turn off the signal light in the resident's room. b. Identify yourself and call the resident by name. c. Listen to the residents' request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. Inform the appropriate personnel of the resident's need. e. Do not promise something you cannot deliver. f. If assistance is needed with a procedure, summon help by using the call light. Stay with the resident until help (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 13 Event ID: 395751 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0558 arrives. Level of Harm - Minimal harm or potential for actual harm Resident R26 was admitted to the facility on [DATE]. Residents Affected - Some Reivew of Resident R26's MDS (minimum data set a periodic assessment of needs) indicated a diagnosis of heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), hypotension (condition where the force of blood pushing against the artery walls is too low), and diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high). During an observation on 3/17/25, at 10:34 a.m. Resident R26 call bell was observed being on for 18 minutes on the the facility call bell system. Resident R56 was admitted on [DATE]. Review of Resident R56 MDS indicated a diagnosis of congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and hypertension (when the force of blood flowing through your blood vessels is consistently too high). During an observation on 3/17/25, at 10:38 a.m. Resident R56 call bell was observed being on for one hour on the the facility call bell system. During an interview on 3/17/25, with Registered Nurse Employee E25 confirmed that Resident R26 waiting 18 minutes and Resident R56 waiting an one hour for call bell response exceed the time frame to answer a call bell timely, and that the facility failed to answer the call bells timely. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE]. Review of Resident R37's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of atrial fibrillation (abnormal heart rhythm), heart failure (heart doesn't pump the way it should), and hyperlipidemia (high fats in the blood) During an interview completed on 3/17/25, at 11:30 a.m. Resident R37 was in her bed. During this interview, Resident R37 stated, no one has come I've been pushing it constantly (referring to her call bell), I've been laying here waiting since breakfast, I'm not able to get my shower as we only had one nurse aid in the morning, some staff have come in since. During an observation on 3/17/25, at 11:31 a.m. the kiosk on the Hilltop hallway indicated that Resident R37's call light had been on for fifty minutes. During an interview completed on 3/17/25, at 11:31 a.m. Nurse Aid Employee E27 confirmed that the call bell for Resident R37 was on for fifty minutes. Nurse Aid Employee E27 also stated, I did speak with the resident earlier in the shift about her shower, she should have her shower today as more help has arrived. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code: 211.10(d) Resident care policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 2 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0558 28 Pa. Code: 211.12(d)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 3 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk, failed to re-evaluate residents for elopement risk, which resulted in an elopement for two of eleven residents (Residents R79 and R289) and transfer to a local hospital, then to a level one trauma center for one of eleven residents (Resident R289). This failure created an immediate jeopardy situation for two of 11 residents (Resident R79 and R289). Findings include: Review of the facility policy Elopements and Wandering Residents dated 1/7/25, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. Review of the admission record indicated Resident R79 was admitted on [DATE]. Review of Resident R79's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/29/24, indicated diagnoses of Alzheimer's (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), dementia (loss of cognitive functioning-thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and non-exudative age-related macular degeneration (AMD- common eye condition that primarily affects older adults, leading to a gradual loss of central vision). The residents Brief Interview for Mental Status (BIMS) assessment was 7, severely cognitively impaired. Review of an Elopement Risk Evaluation dated 12/28/24, indicated Resident R79 was a high elopement risk. Review of Resident R79's care plan dated 12/30/24, indicated Resident R79 was care planned for elopement. The care plan failed to include supervision as an intervention. Review of progress note dated 12/18/24, indicated Resident R79 was ambulating through hallway with walker attempting to figure out codes to exits to find her way out. Wander guard applied to the left wrist after verifying function. Resident R79 was attempting to obtain the codes to the exits and wanted to go home. Review of a progress note dated 2/6/25, at 5:01 p.m. revealed staff heard alarm sounding on the 4th floor at 3:05 p.m. Resident R79 was observed in the stairwell. Staff assisted Resident R79 back to the unit. An assessment was completed with no injuries observed. The resident's responsible party and certified registered nurse practitioner (CRNP) were notified. There were no new orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 4 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of information submitted to the Department of Health on 2/7/25, indicated on 2/6/25, Resident R79 eloped from the 4th floor at 3:05 p.m. It was indicated Resident R79 was in the stairwell. Staff assisted the resident back to the unit. The resident's wander guard (system designed to support the safety and independence of patients by monitoring their movements and gently preventing them from unintentionally leaving) was in place at the time of the event and was functioning appropriately. The Registered Nurse completed an assessment with no injuries observed. The resident was able to move extremities, and no pain or bruising was noted. The resident's responsible party and physician were notified. There were no new orders. It was indicated elopement assessments and care plans were updated. Review of Nurse Aide, Employee E14's witness statement dated 2/6/25, indicated at 3:05 p.m. an alarm was going off in the back stairwell. NA, Employee E14 opened the door and saw Resident R79 sitting on a step three floors down. NA, Employee E14 notified staff. Review of Nurse Aide, Employee E18's witness statement dated 2/6/25, indicated while giving report to NA, Employee E19, NA, Employee E14 came up to the nursing station and said a resident went down the stairwell. NA, Employee E18 and E19 looked at the call bell system and noticed Resident R79's call light was not on. NA, Employee E14, E18, and E19 ran down the hall to get the resident. Resident R79 made it about five flights of steps between the 3rd and 2nd floor. NA, Employee E18 took the resident back to the 4th floor using the elevator. The nurse and Director of Nursing were notified. Review of NA, Employee E19's witness statement dated 2/6/25, indicated at 3:05 p.m. NA, Employee E14 stated Resident R79 was observed past the third floor in the stairwell. NA, Employee E18 escorted Resident R79 to the third floor, and took the elevator back up to the fourth floor. During an interview on 3/18/25, at 10:15 a.m. Licensed Practical Nurse, Employee E31 was notified by staff on 2/6/25, Resident R79 was found in the stairwell. When LPN, Employee E31 went to assess Resident R79, Resident R79 was being brought back to the unit by a nurse aide. LPN, Employee E31 stated earlier that day Resident R79 was observed coming out of their room and seemed confused earlier in the day. Resident R79's room was located near the door at the end of the hallway. Resident R79 eloped during a change in shift. During an interview on 3/18/25, at 9:40 a.m. NA, Employee E18 stated Resident R79 eloped down the stairwell during shift change on 2/6/25. NA, Employee E18 indicated Resident R79 was observed down five flights of stairs. Resident R79 was throwing the walker down the steps. NA, Employee E18 indicated Resident R79 was tired after returning to the unit. NA, Employee E18 indicated the button on the stairwell was not working and maintenance was called to get it fixed. Resident R79's room was not changed. During an interview on 3/18/25, at 9:51 a.m. Director of Maintenance, Employee E32 indicated the door's egress (system used to provide a safe and accessible exit route in case of an emergency) and magnetic locks weren't working properly on 2/6/25. The facility had a company come the night Resident R79 eloped to take care of situation. The door got repaired around 1:00 a.m. on 2/7/25. During an interview on 3/18/25, at 10:39 a.m. Registered Nurse, Employee E34 stated on 2/6/25, it was reported that Resident R79 was found in the stairwell. Resident R79 had tossed the walker down the stairs. During an interview on 3/18/25, at 10:57 a.m. the Nursing Home Administrator (NHA) confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 5 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility failed to supervise Resident R79 and prevent an elopement on 2/6/25. The NHA confirmed the facility failed to update Resident R79's care plan for elopement. Resident R289 was admitted to the facility on [DATE], with the diagnoses of heart failure (heart doesn't pump blood as well as it should), UTI (urinary tract infection), non-Alzheimer's Dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), depression, and chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe). Review of Resident R289's MDS dated [DATE], indicated the diagnoses remained current. Section C indicated a BIMS score of 10 (Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment). A score of 8-12 indicates moderately impaired cognition. Section GG question Q - Does the resident use a wheelchair and/or scooter - Yes. Question R - Wheel 50 feet with two turns: once seated in wheelchair/scooter the ability to wheel at least 50 feet and make two turns indicated resident can do with supervision or touching assistance. Question S - Ability to wheel 150 feet once seated in wheelchair/scooter the ability to wheel at least 150 feet in a corridor or similar place indicated resident can do with supervision or touching assistance. Review of elopement risk evaluation dated 3/2/25, indicated Resident R289 was not at risk for elopement. Review of R289's clinical documentation progress notes indicated the following: - 3/1/25, 11:04 p.m. Resident stated that she was able to walk. Per report, husband stated that she could stand but was non-ambulatory. -3/2/25, at 1:40 a.m. Resident asked earlier when her husband was coming to get her. -3/3/25, at 2:23 a.m. Resident was alert and verbal with confusion, she continued to ask when her husband was coming to get her. Required frequent reminders regarding location and situation. -3/4/25, at 8:30 a.m. Resident was unable to verbalize reason for fall. Stated that she needed to go on down there. -3/4/25, at 1:13 p.m. Resident room changed to 353 B due to resident increase in falls and baseline confusion. -3/10/25, at 5:30 p.m. this nurse was alerted by Physical Therapist (PT) Employee E4 that resident had fallen down emergency exit steps. She was assessed and assisted into her wheelchair and carried up ten stairs with maximum assistance. Orders received and implemented to send her to the emergency room (ER) for further evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 6 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few -3/10/25, at 9:44 p.m. spoke with ER nurse at local hospital, resident being transferred to a level one trauma center for further evaluation at that time. Review of facility provided witness statements indicated the following: PT Employee E4 indicated she was in the gym charting with the doors closed due to it being the end of the day. She heard some loud thuds and bangs nearby and went to check where the noise came from. She looked through the window to the stairwell by the gym and saw Resident R289 lying down the stairs on the landing on her right side with her wheelchair down by her feet. PT Employee E4 ran to get a nurse. Licensed Practical Nurse (LPN) Employee E5 indicated she was alerted by PT that a resident fell down the stairs in her wheelchair. Found resident lying at the bottom of stairs in stairwell. Resident was out of her wheelchair lying on her right side. A little diaphoretic (sweaty) and somewhat incoherent. EMS (emergency medical services) called. Nurse Aide (NA) Employee E6 indicated at 5:20 p.m. she was passing trays and noticed Resident R289 was not by the nurse's station where she was a few minutes prior. The alarm was going off so she and NA Employee E7 started checking doors, arrived at the Pub's door and resident was in stairwell with the nurses. NA Employee E7 indicated at the end of passing the second cart they heard an alarm go off and she and NA Employee E6 went to stair wells and didn't see anyone. A nurse was putting food in the fridge over in the café end of the floor and stated Resident R289 fell down the steps. During a telephonic interview on 3/17/25, at 1:51 p.m. PT Employee E4 indicated I heard a bunch of noise. I was in the therapy room with the door shut. It was around dinner time and the aides were passing trays. Something was crashing or falling nearby, I looked for where the noise was and there was a glass window I glanced down because there was nothing in hall. Resident R289 was on the landing on the floor below. She was on the landing, fell down ten steps and the wheelchair was with her. I ran to get a nurse. The first noise I heard was a banging crash, the first nurse I grabbed (LPN Employee E5) ran with me and stayed with the resident. She was not her nurse, so I ran a second time to get the patients nurse (Registered Nurse, RN Employee E8). The wheelchair was on its side on top of her legs, she was on her side on the landing and the wheelchair was on its side. I've seen Resident R289 in the lobby area, I did work with her for physical therapy. I saw her that day and she was due for a report. I reviewed her goals, resident stated I'm glad I'm making progress because I want to go. Telephonic interview attempted with LPN Employee E5 on 3/21/25, at 11:52 a.m. unsuccessfully and voice mail was full. During an interview on 3/18/25, at 9:42 a.m. NA Employee E6 indicated Resident R289 said she wanted to go home. She's been saying that ever since she got here. She did not have a wanderguard. At the time we were picking up a second food cart and Resident R289 was out front at the desk. I was taking the cart back around the corner and Resident R289 said I want to go home. I told her let's eat dinner first and then we'll talk about it. When I came back Resident R289 was gone. At that time, I didn't tell the nurse because she wasn't in the hallway then I would have to find her which would take how long. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 7 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 3/18/25, at 11:31 a.m. NA Employee E7 indicated the type of residents they've been bringing in here are more confused residents, and it was dinner time. Resident R289 was saying she wanted to go home the same week she came. Said we were keeping her hostage, and she was saying she wanted to leave. Everyone was noticing Resident R289 was saying that. She was starting to show it in the hallway roaming. Resident R289 was at the nurses desk by her room, but more by the desk. We just got the second cart, and we were passing it. We heard the alarm. I ran to one stairwell and NA Employee E6 ran to the other steps. That's when therapy found her at the other stairway down the steps. During a telephonic interview on 3/17/25, at 2:28 p.m. RN Employee E8 indicated I was passing my meds as RN Supervisor; I think therapy put her in her chair and Resident R289 was asking about dinner to some staff. I said what's wrong, Ms. Resident R289 She said I'm not talking to you. The therapist came to get me and said she fell down the steps. I went straight to the stairwell. I saw her lying down ten steps on the landing with her wheelchair. There were other nurses there when I arrived. Resident was laying on her side/belly and she was alert. I did text the Assistant Director of Nursing (ADON) Employee E9 because one of the aides expressed concern for her needing a wander guard. Before I knew it, she was at the bottom of the steps, maybe within ten minutes of me texting the ADON. During an interview on 3/17/25, at 12:22 p.m. Assistant Director of Nursing (ADON) Employee E9 indicated RN Employee E8 called me ten minutes prior to the incident asking where the wander guards were kept because Resident R289 was acting agitated and asking about the elevators which was new for her. RN Employee E8 called me back about ten minutes later and stated Resident R289 went to the Pub, opened the door in her wheelchair. The magnetic lock has a fire safety mechanism that if pushed on long enough will open up as a fire safety rule. Someone in therapy heard a noise and found Resident R289 at bottom of stairs. During an interview on 3/18/25, at 1:55 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that Resident R289 was in the hallway, pressed the doorway to release the fire alarm on the doorway, wheeled self through doorway and went down the stairs in her wheelchair and the facility failed to identify elopement risk behaviors timely. The DON and NHA were made aware that an Immediate Jeopardy situation existed for residents on 3/18/25, at 1:55 p.m. and an immediate action plan was requested. On 3/18/25, at 1:55 p.m. the Immediate Jeopardy template was provided to the facility administration. On 3/18/25, at 4:32 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R79 was returned safely to her room by staff and assessed by RN. No injuries observed and no pain voiced by resident. Elopement risk evaluation updated, and care plan updated to include resident preferences and any triggers for exit seeking behavior. Care plan also updated to include remaining safe on my unit and free of elopements through next review. Cited Resident R289 dated 3/10/25 is no longer in facility and no longer expected to return. Family collected personal belongings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 8 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Root cause analysis identified as staff did not report exit seeking behavior timely and facility failed to provide appropriate supervision. Residents: All residents will have updated elopement risk evaluations completed by DON or designee by 3/19/25. Residents Affected - Few Care plan interventions for residents identified for elopement risk will be implemented by ensuring staff are provided with person centered interventions. This will be completed by DON or designee by 3/19/25. Care plan goals for residents who are identified for elopement risk updated to include remaining safe on the unit through staff supervision and free of elopements through next review. This will be completed by DON or designee by 3/19/25. System Correction: Whole house education on elopement risks and assessments, supervision, and care plans of residents. This education includes agency staff and staff will be educated prior to their next scheduled shift. This will be completed by NHA or designee by 3/20/25. Review and update the elopement policy as needed by end of day 3/19/25. Monitoring: Audits of new exit seeking behaviors will be conducted by DON or designee daily x 2 weeks, weekly x 2 weeks, then monthly x 2 months to ensure evaluations and care plans are up to date. Findings of audits will include updated elopement evaluations and care plan goals/interventions. Ongoing results will be submitted to QA. Immediate Jeopardy was lifted on 3/19/15, at 1:53 p.m. and the abatement plan was verified as follows: -88/88 Residents were assessed for risk of elopement on 3/18/25. Two residents were newly admitted after IJ was called and the facility completed an elopement assessment. The residents were not identified as a risk. Total of 90/90 residents were assessed for elopement risk. -12/12 Residents identified as an elopement risk through assessment. 12/12 Resident care plans were updated on 3/18/25, with interventions to prevent elopement, including supervision of the resident. Review of assessments identified one resident was newly identified as an elopement risk from entrance. The resident was added to elopement binders. -12/12 Resident care plan goals were updated to I will remain safe on the unit through staff supervision and free of elopements through next review. -106/138 in-house staff were educated on elopement risks and assessments, supervision, and care plans of residents. The facility utilizes two agency companies. 24/24 agency staff were educated. 36/36 in-person interviews were completed and confirmed staff were educated. 7/7 telephonic interviews conducted revealed staff received education. Staff were educated on the importance of supervision of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 9 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0689 Level of Harm - Immediate jeopardy to resident health or safety residents, exit-seeking behaviors as well as when to reevaluate residents for an elopement risk. All staff must verify education prior to the start of their next shift. -Elopement and Wandering Residents policy was reviewed and revised on 3/18/25. It was indicated care plan goals will include remaining free of elopements by supervision. Adequate supervision will be provided to help prevent accidents or elopements. Residents Affected - Few -An audit of residents with newly identified exit seeking behaviors was completed on 3/18/25, and 3/19/25. No residents were observed with exit seeking behaviors. -The facility's next scheduled QA meeting is 3/26/25. During an exit interview on 3/21/25, at 2:45 p.m. information was disseminated to the Director of Nursing (DON), Nursing Home Administrator (NHA), and the Corporate [NAME] President of Operations Employee E26 that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk, failed to re-evaluate residents for elopement risk, which resulted in an elopement for two of eleven residents (Residents R79 and R289) and transfer to a local hospital, then to a level one trauma center for one of eleven residents (Resident R289) and this failure created in an immediate jeopardy situation potentially placing residents at risk of harm or injury for two of 11 residents (Resident R79 and R289). 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 10 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident observations, and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five days (3/10/25, 3/17/25, and 3/18/25). Findings Include: Review of the facility policy Nursing Services and Sufficient Staff dated 1/7/25, indicated it is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the admission record indicated Resident R80 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/28/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), End Stage Renal Disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and high blood pressure. Review of Resident R80's physician order dated 2/24/25, indicated dialysis every Monday, Wednesday, and Friday. Review of Resident R80's current care plan indicated resident requires hemodialysis related to renal failure. Encourage resident to go for scheduled dialysis appointments. Observation on 3/17/25, at 9:26 a.m. Resident R80 was in the wheelchair in the hallway. Interview with Nurse Aide (NA) Employee E33 on 3/17/25, at 9:30 a.m. indicated Resident R80 missed his ride because he wasn't up on time. NA Employee E33 indicated he was agency, this was his first day, and he passed the breakfast trays. It was only himself and one other nurse aide to start the daylight shift this morning. We have like 45 residents on the floor. Interview on 3/17/25, at 9:40 a.m. Registered Nurse (RN) Employee E20 confirmed Resident R80 missed his transportation to dialysis today and that medic rescue could not come to transport him today. RN Employee E20 indicated they started the shift with only two aides this morning and NA Employee E33 thought it more important that the residents get their breakfast trays passed and did not get Resident R80 out of bed in time for his transportation because he was still passing trays. Resident R289 was admitted to the facility on [DATE], with the diagnoses of heart failure (heart doesn't pump blood as well as it should), UTI (urinary tract infection), non-Alzheimer's Dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), depression, and chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe). Review of Resident R289's MDS dated [DATE], indicated the diagnoses remained current. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 11 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R289's progress note dated 3/10/25, at 5:30 p.m. indicated nurse was alerted by Physical Therapist (PT) Employee E4 that resident had fallen down emergency exit steps. She was assessed and assisted into her wheelchair and carried up ten stairs with maximum assistance. Orders received and implemented to send her to the emergency room (ER) for further evaluation. Telephonic interview on 3/17/25, at 2:28 p.m. RN Employee E8 indicated I was passing my meds as RN Supervisor, on 3/10/25, I did text the Assistant Director of Nursing (ADON) Employee E9 because one of the aides expressed concern for Resident R289 needing a wander guard. Before I knew it, she was at the bottom of the steps, maybe within ten minutes of me texting the ADON. It's hard to be Supervisor and have a medication cart at the same time. Observation on 3/18/25, at 9:44 a.m. indicated RN Employee E8 was in hallway working with a medication cart. Interview on 3/18/25, at 9:44 a.m. RN Employee E8 indicated, That I know of nobody stayed with Resident R289 when I was trying to get the wanderguard information from the ADON. They were passing trays and I'm pretty sure there were only three aides that night. I was on the medication cart that night and Supervisor of the facility at the same time, as always, as I am again today. Interview on 3/18/25, at 9:42 a.m. Nurse Aide (NA) Employee E6 indicated at on 3/10/25, at 5:20 p.m. she was passing trays and noticed Resident R289 was not by the nurse's station where she was a few minutes prior. There were three aides. We all three work together, it's not enough help to get to everything. Resident R289 said she wanted to go home. She's said that since she got here. You can't watch them, if they are determined to get out, they're going to do it. I was picking up a second cart to pass trays, Resident 289 said she wanted to go home, and I responded let's eat dinner first and then we'll talk about it. When I got back, she was gone. I did not stay with the resident or tell the nurse because she wasn't in the hallway, then I'd have to go looking for her which would take me how long. During tray pass with only three aides, there's just no time to waste. Interview on 3/18/25, at 11:31 a.m. NA Employee E7 indicated there were three aides on 3/10/25, for evening shift, and recalled that the RN supervisor was on the medication cart and House Supervisor. It's not enough staff for the type of residents they've been bringing in here. The residents are more confused. Trays take a long time to pass because the aides have to put all the drinks on the trays individually. Interview with the Nursing Home Administrator on 3/18/25, at 10:57 a.m. confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five days (3/10/25, 3/17/25, and 3/18/25). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(7) Personnel policies and procedures. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 12 of 13 Printed: 05/15/2026 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 395751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rochester Residence and Care Center 174 Virginia Avenue Rochester, PA 15074 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's policy, plan of correction for previous incident, resident records and staff interview it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed concerns identified during an elopement (2/6/25). Residents Affected - Few Findings include: The facility Quality assessment and assurance committee policy last reviewed on 1/7/25, indicated that the facility will maintain a QA committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies. Review of the facility policy Elopements and Wandering Residents dated 1/7/25, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Review of Resident R79's progress note dated 2/6/25, at 5:01 p.m. indicated the staff heard alarm sounding on the 4th floor at 3:05 p.m. and the resident was observed off the unit on the emergency stairwell, staff assisted the resident back to the unit. Review of Quality assurance meeting documentation on 2/6/25, indicated that the QA committee met on 2/6/25 and put correct concerns in place to prevent future elopements down the emergency stairway. Review of R289's clinical progress notes indicated that on 3/10/25, at 5:30 p.m. staff was alerted by Physical Therapist (PT) Employee E4 that Resident R289 had eloped and fallen down emergency exit steps. The incident on 3/10/25 was the second elopement in an emergency stairway by a resident. During an interview on 3/21/25, at 12:21 p.m. the Nursing Home Administrator (NHA) information was disseminated that the facility failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed concerns identified during an elopement on 2/6/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395751 If continuation sheet Page 13 of 13

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

29 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0565GeneralS&S Epotential for harm
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0610GeneralS&S Dpotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
0679GeneralS&S Epotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0688GeneralS&S Dpotential for harm
F688 - Mobility
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.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0744GeneralS&S Dpotential for harm
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Epotential for harm
F758 - Medication Errors
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.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0770GeneralS&S Dpotential for harm
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0558GeneralS&S Epotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0689SeriousS&S Jimmediate jeopardy
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0725GeneralS&S Epotential for harm
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
0865GeneralS&S Dpotential for harm
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
0911GeneralS&S Epotential for harm
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.

FAQ · About this visit

Common questions about this visit

What happened during the March 21, 2025 survey of ROCHESTER RESIDENCE AND CARE CENTER?

This was a inspection survey of ROCHESTER RESIDENCE AND CARE CENTER on March 21, 2025. The surveyor cited 29 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ROCHESTER RESIDENCE AND CARE CENTER on March 21, 2025?

Yes, 29 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 21, 2025