Rochester Residence and Care Center: Staffing Failures - PA
That's not an estimate. That's what the facility's own Director of Nursing confirmed to inspectors on September 18, 2025.
The inspection, a complaint survey completed September 19, found that Rochester Residence failed to maintain sufficient nursing staff on September 15, 16, 17, and 18. Four of five days. The Director of Nursing acknowledged the failure directly, telling inspectors the facility had not provided enough nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents across those four days.
The numbers inspectors documented were stark. The fourth floor had four nursing assistants on duty. One of those four was assigned to sit one-on-one with a single resident, a continuous supervision assignment that pulled that aide entirely out of general floor coverage. That left three aides for the rest of the floor. When lunchtime came and staff moved into the dining room to assist residents with meals, the number dropped to two.
Two aides. One floor.
Inspectors confirmed this pattern on back-to-back days. On September 17 at noon, fourth floor staff described the situation themselves. At 12:15 p.m., LPN Employee E7, who was the only nurse on the floor, confirmed the count: four aides, one of them pulled for one-on-one supervision. The same conversation happened again the following day. At 12:20 p.m. on September 18, fourth floor staff described the identical conditions. Ten minutes later, Registered Nurse Employee E10 confirmed it.
The facility had one licensed practical nurse covering the floor. One nurse.
What the inspection report does not describe is what those two aides were doing during lunch, or which residents were waiting, or how long call lights went unanswered. The report does not name residents or describe specific incidents of harm. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected.
But the staffing picture the report draws is not a snapshot of one bad shift. Four days in a row, the fourth floor of Rochester Residence operated this way. The one-on-one supervision assignment, whatever its necessity for the resident receiving it, effectively reduced an already thin crew by 25 percent every day it was in place. And every day that crew moved into the dining room for lunch, the floor coverage was cut in half again.
Nursing assistants in long-term care facilities handle the work that defines daily life for residents: bathing, dressing, toileting, repositioning, feeding, responding to falls. When a resident calls for help and no one comes quickly, the consequences range from wet clothing and missed meals to falls and pressure injuries. The inspection report does not document those outcomes here. It documents the conditions that make them more likely.
The Director of Nursing's confirmation on September 18 was an acknowledgment that the problem was not a surprise to facility leadership. By that point, three of the four deficient days had already passed. The fourth was still underway.
Rochester Residence and Care Center is located at 174 Virginia Avenue in Rochester, Pennsylvania. The complaint inspection was conducted by the Pennsylvania Department of Health on behalf of the Centers for Medicare and Medicaid Services.
The Director of Nursing confirmed the staffing failure. The floor had two aides at lunch. The nurse was alone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rochester Residence and Care Center from 2025-09-19 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: June 27, 2026 · Our methodology
ROCHESTER RESIDENCE AND CARE CENTER in ROCHESTER, PA was cited for violations during a health inspection on September 19, 2025.
That's what the facility's own Director of Nursing confirmed to inspectors on September 18, 2025.
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.