Inspection·June 17, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to the notify resident representative of a change in condition or care for one of three residents (Resident R1). Findings include: Review of facility policy Notification of Changes: dated 1/7/25, indicated that the facility will promptly inform the resident, and notifies the resident's representative when there is a change requiring notification which include circumstances that require a need to alter treatment. This may include new treatment or discontinuation of treatment. For competent individuals the facility must still notify the resident's representative, if known. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/18/25, included diagnoses of high blood pressure, sepsis (a life-threatening reaction to an infection), and muscle weakness. Review of Resident R1's demographic profile indicated that resident had two emergency contacts. Review of Resident R1's progress note dated 6/11/25, at 10:35 a.m. indicated that Nurse was informed at this time that there is presence of live lice, as well as a significant amount of nits present. This nurse assessed resident and, per resident, she was unaware that they were present. Review of Resident R1's progress note dated 6/11/25, at 14:15 p.m. indicated that RN )Registered Nurse) Supervisor spoke to Nurse Practitioner regarding resident's head lice. Orders received and implemented for one time only lice shampoo. Order faxed to pharmacy. Coconut oil and shower cap was placed on resident's hair until lice shampoo arrives. This was well tolerated. Review of clinical record did not reveal documentation that Resident R1's family/emergency contact were notified of the presence of lice and need to add treatment. During an interview on 6/17/25, at 2:24 p.m. the Director of Nursing confirmed the facility failed to provide documentation that the facility notified a resident representative of a change in condition or care for one of three residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. (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 2 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 06/17/2025 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)