Rochester Residence: Wrong Food Served, Kitchen Unreachable - PA
The tray was for a resident the inspection report identifies as Resident R2. She had a physician's order for a regular diet, in place since November 2024. What arrived at lunch on August 12 was minced and pureed food. Nurse Aide Employee E2 turned to the unit clerk and said, "They gave Resident R2 minced and pureed food, and she is on a regular diet. They do this all the time."
The unit clerk, Employee E3, picked up the phone and called the dietary department to get it corrected. The call went to a recording: "The person at this extension is unavailable." There was no option to leave a message.
Resident R2 confirmed at lunch that she had received the wrong food. "This happens all the time," she said, "where they are giving me things I won't eat."
The inspection was a complaint investigation, conducted at Rochester Residence and Care Center on August 12, 2025. Inspectors were present when the tray arrived, when the call to dietary went unanswered, and when staff on two separate nursing units, The Gardens and Scenic Heights, described the same problem from different floors of the same building.
Employee E3, the unit clerk who made the unanswered call, told inspectors that getting through to the kitchen was a routine ordeal. "This happens all the time," she said. "You have to call three and four times. It can take an hour or two to get someone what they want." On the Scenic Heights unit, a licensed practical nurse, Employee E4, said she also could not reach the dietary department by phone. "I don't think the phone is working or it is off the hook."
A second resident, Resident R3, was interviewed that afternoon at Scenic Heights. "I didn't get my salad again," she said. "I never get what I ask for."
The facility's own registered dietitian, Employee E5, confirmed both failures to inspectors. She acknowledged that Resident R2 should not have received pureed or minced food, and that the kitchen's phone system had made it impossible for staff on either unit to request food items or corrections for residents. Her explanation of how the process was supposed to work made the breakdown plain: if a resident wanted a different menu item or something additional, a staff member or the resident was expected to call the kitchen and leave a message. On August 12, that was not possible.
The citation covers both nursing units and is classified as affecting many residents. The facility is disputing it.
What the inspection captured was not a single bad lunch. It was a nurse aide who recognized the wrong tray on sight and knew exactly what to say about it. A unit clerk who made a call that went nowhere and described that as normal. A nurse on a different floor who had given up on the phone entirely. Two residents who used the same phrase, in separate interviews, hours apart: this always happens, I never get what I ask for.
The registered dietitian confirmed the diet order error and confirmed the phone problem. She did not dispute either finding. The facility, in its response to the citation, does.
Resident R2 ate lunch on August 12 with food she had not ordered, could not correct, and said she had been receiving in error before that day. Whether her tray was eventually replaced, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rochester Residence and Care Center from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
ROCHESTER RESIDENCE AND CARE CENTER in ROCHESTER, PA was cited for violations during a health inspection on August 12, 2025.
The tray was for a resident the inspection report identifies as Resident R2.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.