Inspection visit
Inspection
45 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 45 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy, review of facility documents, and resident records, resident council group interview, review of
resident representative concern, observation and staff interview, it was determined that the facility failed to
ensure that care was provided in a manner which maintained resident dignity for two of two residents
(Resident R18 and R51), failed to assist a resident to eat in a timely manner and failed to ensure that food
was provided in a manner which maintained resident dignity for one of four residents (Resident R67), and
failed to provide a dignified dining experience for all residents for three out of six months (July, August, and
September 2025).
Findings include:
Review of facility policy Catheter Care dated 1/7/25, indicated privacy bags will be available and catheter
drainage bags will be covered at all times while in use.
Review of facility policy “Activities of Daily Living (ADLs)” dated 1/7/25, indicated the facility
will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and
services will be provided for the following ADLs:
- Bathing, dressing, grooming, and oral care
- Transfer and ambulation
- Toileting
- Eating to include meals and snacks
Review of the clinical record indicated Resident R18 was admitted to the facility on [DATE].
Review of Resident R18's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25,
indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged
periods of time), chronic pain, and atrial fibrillation (irregular heart rhythm).
Review of Resident R18's physician order dated 6/5/25, indicated foley catheter related to neuromuscular
dysfunction of bladder.
During an observation on 9/15/25, at 10:37 a.m. Resident R18's catheter draining bag was observed
hanging on bed frame without a dignity/privacy bag.
(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
09/19/2025
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 0550
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 9/15/25, at 10:40 a.m. Licensed Practical Nurse Employee E7 confirmed Resident
R18's catheter draining bag did not have a privacy cover and that the facility failed to ensure that care was
provided in a manner in which maintained Resident R18's dignity.
Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE].
Residents Affected - Many
Review of Resident R51's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and
neurogenic bladder (a condition where the nerves that control bladder function are damaged or impaired,
leading to abnormal bladder control). Section H- Bladder and Bowel H0100 Appliances A- Indwelling
catheter is coded.
Review of Resident R51's physician order dated 1/15/25, indicated foley catheter related to neuromuscular
dysfunction of bladder.
Review of Resident R51's physician order dated 2/26/25, indicated keep foley drainage bag covered at all
times.
During an observation on 9/15/25, at 11:35 a.m. Resident R51's catheter draining bag was observed
hanging on bed frame without a dignity/privacy bag.
During an interview on 9/15/25, at 11:37 a.m. Registered Nurse Employee E2 confirmed Resident R51's
catheter draining bag did not have a privacy cover and that the facility failed to ensure that care was
provided in a manner in which maintained Resident R51's dignity.
Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE].
Review of Resident R67's MDS dated [DATE], indicated diagnoses of depression, dementia (a group of
symptoms that affects memory, thinking and interferes with daily life), and heart failure (a progressive heart
disease that affects pumping action of the heart muscles). Section GG-Functional Abilities A-Eating is
coded as a “1”, indicating dependent – helper does all of the work.
Review of Resident R67's physician order dated 9/3/25, indicated Assist to Dine.
During an observation on 9/17/25, at 1:40 p.m. Resident R67 was sitting at the nurse's station in his chair
and his lunch was sitting on top of the nurse's station, not served.
During an interview on 9/17/25, at 1:45 p.m. Registered Nurse (RN) Employee E2 stated, “Oh, I'll
feed him now” and proceeded to set up and feed Resident R67. When asked, “Is his food still
hot?” RN Employee E2 felt the bottom of the plate and stated it was still warm. Then SA (State
Agency) felt the bottom of the plate at the same time and the plate felt cold to touch.
During an interview of 9/17/25, at 1:58 p.m. RN Employee E2 confirmed that Resident R67 was given cold
food for lunch and the facility failed to assist a resident to eat in a timely manner and failed to ensure that
food was provided in a manner which maintained resident dignity for one of four residents (Resident R67).
Review of Resident Council Meeting Minutes dated 7/2/25, stated Foods are served on foam plates. Would
like to have soup in a different container. Not Styrofoam.
(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
09/19/2025
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Review of a Resident Representative concern dated 9/8/25, stated All silverware is plastic. No plates,
Styrofoam container.
During a Group interview on 9/16/25, at 1:30 p.m. five out of five residents stated that they receive food on
Styrofoam and plastic silverware on a regular basis.
Residents Affected - Many
During an Interview on 9/18/25, at 10:54 a.m. Dietary Manager Employee E22 stated that the facility has
been experiencing a shortage of plates, bowls, plate warmers, and silverware since she started at the
facility in August 2025.
During an interview on 9/18/25, at 2:30 a.m. the Nursing Home administrator confirmed that the facility
failed to provide a dignified dining experience for three of six months by serving on disposable dinnerware.
28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.
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
09/19/2025
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, observations, and staff interviews, it was determined that the facility failed to
accommodate the proper linen needs for two of two units (third and fourth floors) and provide a clean, safe,
comfortable and homelike environment on one of two nursing units (Third Floor).Findings include: A review
of facility policy Safe and Homelike Environment dated 1/7/25, indicated in accordance with residents '
rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring
that the residents can receive care and services safely. The facility will provide and maintain bed and bath
linens that are clean and in good condition. During a tour of the facility on 9/15/25, at 9:20 a.m. the following
was observed:-The clean linen rack on the fourth floor outside room [ROOM NUMBER], failed to have linen
that was in good condition. Observation revealed that eight pieces of towel were ripped in pieces to create
washcloths. Also noted were ripped bath blankets, four sheets and two bath blankets. No towels or
pillowcases were present.-The main linen rack outside of room [ROOM NUMBER] had zero towels and
zero washcloths.-The linen rack outside of room [ROOM NUMBER] had three towels, four pillowcases, and
three washcloths.-The linen rack outside of room [ROOM NUMBER] had seven torn washcloths made from
towels or blankets, no towels, and six bath blankets. During an interview and tour with Licensed Practical
Nurse (LPN) Employee E7 the lack of adequate linens in good condition was confirmed. Interview with
Nurse Aide (NA) Employee E15 on 9/15/25, at 9:25 a.m. indicated it's gotten pretty bad with the linens. We
can't give care in the morning without linens. We do the best we can. Interview with NA Employee E16 on
9/15/25, at 9:29 a.m. indicated we have some wipes, but we'll use whatever we have to for morning care.
Interview with NA Employee E17 on 9/15/25, at 10:02 a.m. indicated there's not enough linen, morning care
is rough. They'll bring more linen up by lunch. NA continued to explain that torn washcloths were better than
nothing.
Observation on 9/15/25, at 10:05 a.m. Resident R45's privacy curtain was soiled with a substance on the
lower half of the curtain. Interview with Registered Nurse (RN) Employee E10 on 9/15/25, at 10:15 a.m.
indicated the facility is not providing the supplies we need. There is never enough linen, sometimes no toilet
paper and there is no hand sanitizer, it has been backed up on orders since June. RN also confirmed
appearance of Resident R45's privacy curtain being soiled.
Observation on 9/15/25, at 10:35 a.m. Resident R4's family member was emptying the trash can that was
full of soiled briefs. Interview on 9/15/25, at 10:38 a.m. Resident R87 indicated they have no washcloths
here. The staff have washed me with pillowcases, bath blankets, or whatever they can find.
During an interview on 9/15/25, at 12:32 p.m. NA Employee E1 stated, We've been having a problem for a
while now. Weeks, at least a month. We don't have enough towels, wash cloths, fitted sheets. We 100%
have not been able to give baths or showers because we don't have enough staff or supplies. We have to
pick and choose who gets a bath because we don't have enough supplies to give them.During an interview
on 9/15/25, at 12:34 p.m. NA Employee E1 stated, The resident in room [ROOM NUMBER] passed away
over the weekend. That room has been cleaned and is ready for a new admission, but there is still a dirty
urinal in the bathroom.
During an observation on 9/15/25, at 12:35 p.m. a disposable urinal with dark amber colored stains was
observed sitting on the toilet in the bathroom of room [ROOM NUMBER].During an observation on 9/15/25,
at 12:50 p.m. of the Third Floor Shower Room revealed the following:- Two mechanical lifts, one empty linen
cart, a shower chair, and a bedside commode were observed in the whirlpool tub room.- A broken tile was
observed on the wall of the shower stall adjacent to the whirlpool tub room.(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
09/19/2025
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Debris was noted on the floor of two of three of the shower stalls.- Yellow discoloration was noted on all
three of the shower stall floors.- Rust was noted on the ceiling of the shower stall located adjacent to the
whirlpool tube room.- One of three shower stalls had visible peeling on the ceiling in two separate locations.
Peeling was noted around the light fixture in the ceiling and additional peeling reveal a small hole in the
ceiling. Light could be seen coming from the floor above through the hole in the ceiling. - An open bottle of
white distilled vinegar was noted on the floor of the main room of the shower room. The cap was sitting on
the floor next to the bottle. A piece of white tape had been placed on the bottle with handwriting that stated,
Opened 4/4.During an interview on 9/15/25, at 1:54 p.m. the Nursing Home Administrator (NHA) confirmed
that the facility failed to provide a clean, safe, homelike environment in room [ROOM NUMBER] and the
Third Floor Shower Room.
Interview on 9/15/25, at 3:00 p.m. the NHA confirmed that the facility failed to accommodate the proper
linen needs for two of two units (third and fourth floors) and provide a clean, safe, comfortable and homelike
environment.
28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa.
Code: 211.12(d)(1)(5) Nursing services.
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
09/19/2025
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy and documentation, staff and resident interviews it was determined that the facility
failed to protect residents from neglect and verbal abuse for three of three residents (Resident R13, R26,
and R32). Findings include:
Review of facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated
1/7/25, indicated: Neglect is the failure of the home, its employees, or service providers to provide goods
and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional
distress. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully
include disparaging and derogatory terms to residents.
Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a
Brief Interview for Mental Status (“BIMS”) is a screening test that aides in detecting cognitive
impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact8-12: moderately impaired0-7: severe impairment
Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE].
Review of Resident R13's MDS (Minimum Data Set, periodic assessment of resident care needs) dated
6/25/25, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and
difficulty swallowing. Question C0500 BIMS Summary Score indicated the resident scored a 15, cognitively
intact. Question H0300 Urinary Continence indicated the resident was coded 3 always incontinent (no
episodes of continent voiding).
Review of a facility submitted document dated 7/19/25, indicated the following: Resident R13 reported that
she had not been changed at all on the previous shift. Resident reports that prior to the daylight nurse aide
providing care on 7/19/25, she had not been changed for incontinence since seven or eight p.m. the
previous night.
Review of Resident R13's witness statement dated 7/19/25, indicated that the last time she was changed
for incontinence was around 7:00- 8:00 p.m. on 7/18/25. Resident reported that she slept on and off
throughout the night but was never woken to be changed by staff. Resident reports that she woke up this
morning at around 7:20 a.m. when a staff member came in to provide her with fresh ice water.
Review of a written witness statement from Licensed Practical Nurse Employee E30 dated 7/19/25,
indicated that Resident R13 informed nurse that she was not changed by the aide last night, and that
resident stated she was wet until the daylight aides came in to change them.
During an interview on 9/16/25, at 11:12 a.m. Resident R13 confirmed the above incident and added I was
soaked, went 12hours without being checked.
During an interview on 9/18/25, at 2:17 p.m. the Director of Nursing confirmed that staff should have
checked on Resident R13, and that If residents are asleep, you still have to change them. That should not
have happened., and that the facility failed to prevent an incident of neglect for Resident R13.
(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
09/19/2025
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 0600
Review of the clinical record indicated Resident R26 was admitted to the facility on [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Review of resident R26's MDS dated [DATE], indicated the diagnoses of diabetes (a long-term condition in
which the body has trouble controlling blood sugar and using it for energy), stroke (damage to the brain
from an interruption of blood supply), and high blood pressure.
Residents Affected - Some
Review of Resident R26's progress note dated 9/10/25, at 11:45 a.m. indicated resident told this nurse that
on 11-7 shift the night before, the Nurse Aide (NA) whom resident could not remember the name of double
briefed the resident and resident ended up leaking urine out the side as the NA did not have the briefs on
right and then the NA preceded to the resident they are not getting any more water for the night.
Administrator, Director of Nursing, and unit manager notified. Skin assessment done. Moisture areas noted
to bottom of buttocks. Cream applied.
Review of facility provided documentation dated 9/8/25, indicated Resident R26 reported to staff on
9/10/25, two nights before (9/8/25) a staff member put two briefs on the resident and told the resident they
were not getting any more water for the night. Resident's skin assessed and a moisture associated area
was identified on the left gluteal fold (horizontal skin crease on the lower part of the buttocks that separates
them from the posterior upper thigh).
Review of Nurse Aide (NA) Employee E18's witness statement dated 9/12/25, indicated NA did care for the
resident, removed the brief and washed and changed the resident. At no time did the NA see or apply two
briefs. NA also denied telling the resident they could not have any water.
Review of Resident R26's Skin Alteration evaluation dated 9/10/25, indicated left gluteal fold, new moisture
areas noted to bottom of buttocks RE: double briefing from 11-7 shift the night before.
Interview on 9/17/25, at 9:00 a.m. Resident R26 indicated NA Employee E18 did double brief the resident,
and the resident indicated that it was not allowed, and resident knew it was not allowed to deny the resident
water.
Interview on 9/17/25, at 12:57 p.m. [NAME] President of Operations Employee E11 confirmed that the
facility failed to protect residents from neglect and verbal abuse for one of three residents (Resident R26).
Review of the clinical record indicated Resident R32 was admitted to the facility on [DATE].
Review of Resident R32's MDS dated [DATE], indicated diagnoses of high blood pressure, need for
assistance with personal care, and muscle weakness. Question C0500 BIMS Summary Score indicated the
resident scored a 15, cognitively intact. Question H0300 Urinary Continence indicated the resident was
coded 2 frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of
continent voiding).
Review of a facility submitted document dated 9/16/25, indicated the following: Resident R32 reported that
on 9/16/25 an aide grabbed her blankets and said you have to stop this, you're old enough to know to not
wet these blankets.
Review of Resident R32's witness statement indicated the resident stated, I don't know her name, but
someone said it was NA Employee E4. She came in and grabbed my blankets and said, you have to stop
this, you're old enough to know not to wet all these blankets. I apologized to her and today she
(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
09/19/2025
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
was very nice. I don't want to report anyone, and I don't want to get anyone in trouble, but I don't want
anyone to be treated the way I was treated.
Review of a witness statement dated 9/16/25, indicated Occupational Therapist (OT) Employee E8 stated,
When therapist arrived initially, first time, NA Employee E4 just finished attending to resident [Resident
R32]. NA Employee E4 reported she just finished stripping resident's bed. Therapist seen resident later in
morning. Resident asked therapist the CNA (Certified Nurse Aide) name who was present this morning
stripping bed. Resident was upset how staff treated her this morning. Resident reported that she was never
treated that way before. Therapist followed up with nursing manager.
Review of a witness statement dated 9/19/25, completed by NA Employee E4 stated, I did not say that to
her. All I said to her was [NAME] you gotta be laying here freezing, why didn't you ring and let them know or
ask for the bed pan she said she didn't know she could do that I told her that she is allowed to ring any time
she wants. As I was changing the bed OT Employee E8 came in the room to tell me she did an ADL
(activities of daily living) on one of the residents. I had all the wet linens on the floor, and she asked me if
she wet the bed, I said yes and OT Employee E8 told her that she is capable of ringing for the bed
pan.During an interview on 9/19/25, at 9:29 a.m. the Nursing Home Administrator confirmed that the facility
failed to protect Resident R32 from verbal abuse.
28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code:
211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.
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
09/19/2025
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.
Based on review of facility policy, resident observations, resident 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 on four of five days (9/15/25,
9/16/25, 9/17/25, and 9/18/25).Findings include:
Review of facility policy Nursing Services Sufficient Staff dated 1/7/25, indicated the facility will 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, as determined by
resident assessments and individual plans of care.
During an interview on 9/15/25, at 12:32 p.m. Nurse Aide (NA) Employee E1 stated, We've been having a
problem for a while now. Weeks, at least a month. We don't have enough towels, wash cloths, fitted sheets.
We 100% have not been able to give baths or showers because we don't have enough staff or supplies. We
have to pick and choose who gets a bath because we don't have enough supplies to give them.During an
interview on 9/15/25, at 12:45 p.m. NA Employee E14 stated, There were a lot of call offs yesterday, they
had to pull and aide from upstairs, there were only two nurses. We couldn't give proper care because we
didn't have enough staff.
During an interview on 9/15/25, at 12:46 p.m. NA Employee E4 stated, Our residents are in peed over beds
because we don't have enough staff to do care.
Observation on 9/15/25, at 1:04 p.m. staff on the fourth floor were passing lunch trays to the residents'
rooms.
Interview on 9/15/25, at 1:05 p.m. Nurse Aide (NA) Employee E32 indicated We haven't had the dining
room in a long while. It's because you need one NA in the dining room which would leave only three of us
on the floor.
Interview on 9/15/25, at 1:15 p.m. Registered Nurse (RN) Employee E10 confirmed the fourth-floor dining
room is not used to her knowledge and RN had been at facility approximately seven months.
Observation on 9/16/25, at 9:15 a.m. Licensed Practical Nurse (LPN) Employee E7 was observed at the
medication cart on the fourth floor.
Interview on 9/16/25, at 9:16 a.m. LPN Employee E7 indicated I'm the only nurse on the floor, which means
I have all three carts. It'll probably take me until noon to pass my morning medications. We have 49
residents up here.
Observation on 9/16/25, at 12:45 p.m. the dining room on the fourth floor was being utilized for lunch.
Interview on 9/16/25, at 12:46 p.m. an unidentified visitor indicated this is the first time they've had lunch in
here. Normally it's only used for holidays or special celebrations.
Interview on 9/16/25, at 9:30 a.m. the Director of Nursing confirmed that the other nurse for the fourth floor
who was scheduled to start at 7:00 a.m. wasn't coming in until 11:00 a.m. and confirmed
(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
09/19/2025
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
LPN Employee E7 was the only nurse on the floor.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 9/17/25, at 12:00 p.m. fourth floor staff indicated they had four NA's on the floor and one NA
was sitting one on one with a resident, which left only three for the floor. If they were to do the dining room
for lunch it would only leave two NA's on the floor.
Residents Affected - Some
Interview on 9/17/25, at 12:15 p.m. LPN Employee E7 confirmed there were only four NA's on the floor.
Interview on 9/18/25, at 12:20 p.m. fourth floor staff indicated they had four NA's on the floor and one NA
was sitting one on one with a resident, which left only three for the floor. If they were to do the dining room
for lunch it would only leave two NA's on the floor.
Interview on 9/18/25, at 12:30 p.m. Registered Nurse (RN) Employee E10 confirmed there were only four
NA's on the floor.
Interview on 9/18/25, at 1:30 p.m. the Director of Nursing confirmed 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 on four of five days (9/15/25, 9/16/25, 9/17/25, and 9/18/25).
28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(6) Management.28 Pa.
Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(4)(5)(f.1)(i) 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
09/19/2025
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy, clinical record review, facility documents, observation, and staff interview, it was determined
that the facility failed to ensure proper hand hygiene, failed to prevent cross contamination during a
dressing change for one of three residents (Resident R74), and failed to implement an infection control
program that included a system of surveillance to identify possible communicable diseases or infections,
identify floor mapping for three of five months (July, August, and September 2025) and failed to implement
Covid outbreak response timely for one of three residents (Resident R72). Finding include:
Residents Affected - Many
Review of facility policy Hand Hygiene dated 1/7/25, indicated that all staff will perform proper hand hygiene
procedures to prevent the spread of infection to other personnel, residents, and visitors. Alcohol-based
hand rub with 60 to 95% alcohol is the preferred method of cleaning hands in most clinical situations. All
staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel,
residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves,
perform hand hygiene prior to putting gloves on, and immediately after removing gloves.
Review of the facility policy Clean Dressing Change reviewed 1/7/25, indicated the facility will provide
wound care in a manner to decrease potential for infection and cross-contamination. Physician's orders will
specify type of dressing and frequency of changes.
Review of facility policy Infection Prevention and Control Program dated 1/7/25, indicated an infection
prevention and control program is established to maintain and provide a safe, sanitary and comfortable
environment and to help prevent the development and transmission of communicable diseases and
infections. Surveillance tools are used for identifying the occurrence of infections, recording their numbers
and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to
infection prevention and control practices, and detecting unusual pathogens with infection control
implications.
Review of a resident representative concern dated 9/2/25, stated that The hand sanitizer stations are
empty.
During an observation on 9/15/25, from 1:00 p.m. to 1:05 p.m. seven out of seven hand sanitizer stations
were found to be empty through the Third and Fourth floors.
During an interview on 9/15/25, at 1:05 p.m. Registered Nurse Employee E31 confirmed that the hand
sanitizer dispensers are empty and added That's been going on for weeks.
During an interview on 9/15/25, the Nursing Home Administrator (NHA) confirmed that the facility has not
had hand sanitizers, as the brand that was being used was recalled by the manufacturer and they had to be
removed, but will refill the dispensers with another product.
During an observation on 9/16/25, at 10:07 a.m. hand sanitizer stations remained empty.
During an interview on 9/16/25, at 10:20 a.m. the NHA confirmed that the facility failed to ensure proper
hand hygiene was being completed due to not having hand sanitizer readily available.
(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
09/19/2025
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 0880
Review of Resident R74's clinical record indicated resident was admitted to the facility on [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident R74's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a
metabolic disorder in which the body has high sugar levels for prolonged periods of time), and venous
insufficiency (a condition in which the veins enlarge due to malfunction of their valves causing improper flow
of blood, and pooling). Section M- Skin conditions coded as “4”- total number of venous
ulcers present.
Residents Affected - Many
Review of Residents R74's physician orders dated 7/10/25, indicate to cleanse with soap and water lightly
scrubbing legs, apply triamcinolone cream (a steroid cream used to reduce inflammation) in a thin layer,
then ammonium lactate (lotion used to treat dry scaly skin conditions) cream, then Adaptic (a non-adherent
wound dressing) over open areas. Secure with Kerlix (cotton gauze bandage rolls) every three days.
During an observation on 9/18/25 at 10:52 a.m. Licensed Practical Nurse (LPN) Employee E7 entered
Resident R74's room to complete a dressing change. LPN Employee E7 placed a barrier for supplies. Then
placed a towel under Resident R74's leg. LPN Employee E7 unwrapped bandage off residents' leg and
changed gloves. She failed to wash her hands. New gloves put on. LPN Employee washed leg per order,
took gloves off, and failed to wash hands. New gloves put on. Medication applied. Gloves taken off, failed to
wash hands between medications. New gloves put on. LPN Employee E7 removed scissors from her pocket
and failed to clean them prior to use. Scissors were put back into pocket. Dressing secured with Kerlix. Date
and initials added to dressing appropriately. Gloves taken off, failed to wash hands.
Upon leaving the room, SA (State Agency) reminded LPN Employee to wash hands prior to leaving the
room.
During an interview on 9/18/25, at 11:15 a.m. LPN Employee E7 confirmed that no hand washing was
completed during the dressing change or afterwards, failed to clean scissors prior to use, and failed to
prevent cross contamination during a dressing change for one of three residents (Resident R74).
- Asymptomatic residents with close contact with someone with SARS-CoV-2 infection should have a series
of three viral test for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24
hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative again 48
hours after the second negative test. This will typically be at day one (whereby day of exposure is day zero),
day three, and day five.
Review of the facility's monthly tracking of surveillance on 9/18/25, failed to include a system of surveillance
to identify possible communicable diseases or infections, and identify floor mapping for three of six months
(July, August, and September 2025).
Interview on 9/18/25, at 12:09 p.m. the Director of Nursing confirmed the facility failed to implement an
effective infection control plan as required for the months of July, August, and September 2025, and was
unable to produce the documents with surveillance including floor mapping.
Interview on 9/16/25, at 9:44 a.m. the Director of Nursing (DON) indicated the facility had one resident test
positive for Covid at 5:00 a.m. (Resident R72).
(continued on next page)
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
09/19/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
-Registered Nurse (RN) Employee E33 tested positive on Saturday, 9/12/25, and didn't inform the facility
until Sunday, 9/13/25 via email.
-DON indicated RN Employee E33 was swabbed in the parking lot outside the facility on 9/13/25, and the
positive test was confirmed.
Residents Affected - Many
-DON indicated the facility did not conduct contact tracing or test any residents or staff who may have been
exposed during the transmission time of RN Employee E33 last working day in the facility which was
9/11/25, who didn't feel well at work that day.
-DON indicated the facility finally tested all residents on the third floor, where the exposure would have
occurred from the positive nurse, on the 11:00 p.m. to 7:00 a.m. shift on 9/15/25, into early morning of
9/16/25.
Observation by Survey agency (SA) on 9/16/25, at 11:00 a.m. Resident R72 was in the room with two staff
members who had masks on. Nurse Aide (NA) Employee E4 indicated Resident R72 had covid. The other
staff member who was masked was unaware of the positive resident status. Neither staff member had eye
protection in place at the time. SA was unaware of the positive Covid status prior to entering the room as
there failed to be proper signage to alert staff/visitors of the precautions required. Resident R72's
roommates' privacy curtain was not pulled, and the roommate was not wearing any source control for
protection from exposure from Resident R72.
Interview on 9/16/25, at 1:00 p.m. the Director of Nursing confirmed the facility failed to implement an
infection control program that included a system of surveillance to identify possible communicable diseases
or infections, identify floor mapping for three of five months (July, August, and September 2025) and failed
to implement Covid outbreak response timely for one of three residents (Resident R72).
28 Pa. code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa.
Code: 211.10(a)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.
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.
Back to topCitations
45 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.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
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.
F575 - The facility must post, in a form and manner accessible and understandable
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F620 - Admissions policy
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
F628 - Documentation
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
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.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
F942 - Training Requirements
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
F945 - Infection control
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
F946 - Compliance and ethics
Provide training in compliance and ethics.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F949 - Training Requirements
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F584 - Safe Environment
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.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0131GeneralS&S Epotential for harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0347GeneralS&S Dpotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
FAQ · About this visit
Common questions about this visit
What happened during the September 19, 2025 survey of ROCHESTER RESIDENCE AND CARE CENTER?
This was a inspection survey of ROCHESTER RESIDENCE AND CARE CENTER on September 19, 2025. The surveyor cited 45 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ROCHESTER RESIDENCE AND CARE CENTER on September 19, 2025?
Yes, 45 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."
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 . If you believe any information is inaccurate, report it here.