Rochester Residence And Care Center
ROCHESTER RESIDENCE AND CARE CENTER in ROCHESTER, PA — inspection on January 31, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Allow residents to self-administer drugs if determined clinically appropriate.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R1).Findings include:
Review of the facility policy Resident Self-Administration of Medications dated 12/11/25, indicated the facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.
Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of resident R1's Minimum Data Set (MDS-a periodic assessment of care needs) dated 11/3/25, indicated the diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and dementia (a group of symptoms that affect memory, thinking and interferes with daily life).
Resident R1's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aids in detecting cognitive impairment).
The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment.
Resident R1's BIMS score was a 10 indicating Resident R1 was moderately impaired.During an observation on 1/31/26, at 11:05 a.m.
Resident R1 was lying in bed. On the bedside table included a clear medication cup with four pills inside.
Medication included: one white pill, one brown pill, one peach pill, and one black pill. No nurse was observed in the room at this time.
During an interview on 1/31/26, at 11:07 a.m.
Registered Nurse (RN) Employee E4 stated, It was a terrible oversight. I should have stayed in the room.
During an interview on 1/31/26, at 11:08 a.m. RN Employee E4 confirmed the medication cup of pills sitting on Resident R1's bedside table.Review of Resident R1's physician orders failed to include an order for self-administration of medications.Review of Resident R1's care plan failed to address self-administration of medications.During a review of Resident R1's clinical record on 1/31/26, at 11:33 a.m. failed to reveal that a self-administration of medication assessment was completed.
During an interview on 1/31/26, at 1:15 p.m. the Director of Nursing confirmed the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R1).28 Pa.
Code 201.18(b)(1)(3) Management28 Pa.
Code: 211.12(d)(1)(5) Nursing services
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/31/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Rochester Residence and Care Center
174 Virginia Avenue Rochester, PA 15074
SUMMARY STATEMENT OF DEFICIENCIES
Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on three of four medication carts (Vineyard, Rosewood, and Rosewood 2).
Findings include:Review of facility policy HIPAA Security Measures dated 12/11/25, indicated it's the facilities policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and records that are in electronic format.During an observation on 1/29/26, at 10:45 a.m. the Vineyard Medication Cart and the Rosewood Medication Cart were observed sitting in the hallway, beside each other, and was left unattended with the computer screen open with identifiable information and any passerby could see resident personal and confidential information.
During an interview on 1/29/26, at 10:47 a.m.
Licensed Practical Nurse (LPN) Employee E1 confirmed the Vineyard Medication Cart computer screen was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information.
During an interview on 1/29/26, at 10:49 a.m.
Registered Nurse (RN) Employee E2 confirmed the Rosewood Medication Cart computer screen was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information.During an observation on 1/31/26, at 10:31 a.m. the Rosewood 2 Medication Cart was observed sitting in the hallway and was left unattended with the computer screen open with identifiable information and any passerby could see resident personal and confidential information.
During an interview on 1/31/26, at 10:33 a.m. RN Employee E3 stated, I was in a room, and confirmed that the Rosewood 2 Medication Cart was left unattended with the computer screen open with identifiable information and any passerby could see resident personal and confidential information.
During an interview on 1/31/26, at 12:04 p.m.
Nursing Home Administrator confirmed that the facility failed to maintain the confidentiality of residents' medical information on three of four medication carts (Vineyard, Rosewood, and Rosewood 2), as required.28 Pa.
Code: 201.14(a) Responsibility of licensee.28 Pa.
Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b)(1)(2) Medical records.28 Pa.
Code: 211.12(d)(1)(3) Nursing services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/31/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Rochester Residence and Care Center
174 Virginia Avenue Rochester, PA 15074
SUMMARY STATEMENT OF DEFICIENCIES
clothes.
Watch for shivering, swelling, decrease responsiveness, decrease temperatures.
Try to warm up but not too quickly.
During an interview on 1/31/26, at 10:53 a.m.
Nurse Aide (NA) Employee E8 stated, Residents are now requesting to take blankets off. If they were cold, I would offer them blankets.
They may be confused.
Give them warm drinks.
Report low temperatures of residents to the nurse. I thought the education was helpful. It's a nice reminder.
During an interview on 1/31/26, at 11:20 a.m.
Nurse Aide (NA) Employee E7 stated, I was educated on hypothermia and temps of rooms. I would check temperatures, bundle residents up with blankets, and wear extra clothing.
Keep them hydrated. I think the education was good.
Helpful.
During an interview on 1/31/26, at 11:32 a.m.
Nurse Aide (NA) Employee E9 stated, They went over signs and symptoms of hypothermia.
Watch for them complaining of cold, puffy faces, loss of consciousness, low temperatures. I learned to observe signs and symptoms of hypothermia. I thought the education was good and informative.
During an interview on 1/31/26, Resident R2 stated, I feel a difference in the temperatures. It's warmer.
They put plastic on the windows.
During an interview on 1/31/26, Resident R9 stated, I'm warm. A few days ago, it was cooler but its warmer now.
During an interview on 1/31/26, Resident R1 stated, Its warmer now.
They put plastic up at the windows. I only need one blanket now.
During an interview on 1/31/26, Resident R10 stated, Its much nicer than the other day. I don't need to use the blankets as much.Verification of the facility's Corrective Action Plan revealed all elements of plan were met.
The Immediate Jeopardy was lifted on 1/31/26, at 1:15 p.m. NHA was made aware.During an interview on 1/29/26, at 2:30 p.m. the NHA confirmed that the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents.
This failure created an immediate jeopardy situation by potentially putting residents at risk of harm or injury.28 Pa.
Code: 201.18(b)(3) Management
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/31/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Rochester Residence and Care Center
174 Virginia Avenue Rochester, PA 15074
SUMMARY STATEMENT OF DEFICIENCIES
Based on facility policy, observations, and staff interviews, the facility failed to ensure the outside environment was free of potential accidental hazards, failed to evaluate the snow hazard, and failed to implement a plan for snow removal for two of two parking lot areas, walkways and surrounding grounds three days after a snowstorm (Front Parking and Rear Parking Area).Findings include:During an observation on 1/28/26, at 3:00 p.m. when the State Agency (SA) arrived at the facility, the front parking lot used to maintain a flow of vehicles for visitors, transport, and ambulances was impassable.
Only one entrance way was plowed, which would cause emergency vehicles to have a difficult time turning around and exit the parking lot in case of an emergency.
The exit to leave the parking lot was not plowed and snow was impeding the ability to leave quickly.
Additionally, sidewalks leading to the building were not shoveled.
The second parking area was covered with snow and not plowed, and vehicles were stuck in lot.
During a review of a family member's concern dated 1/28/26, at 11:59 a.m. revealed the following: - It is an absolute disaster down there with snow you can't get in you can't get out.
During an interview on 1/28/26, at 3:10 p.m. the Nursing Home Administrator (NHA) stated, stated the company that was contracted for snow removal never arrived on January 11 (during the snowstorm) or anytime after to maintain the grounds around the building. As of 1/28/26, the NHA stated that they are in the process of finding a contractor to remove the snow and clear the remainder parking lot and entrance. NHA stated that they did have the local road crew clear an area of the lot.
During an observation on 1/28/26, at 6:10 p.m. the walkway to the Virgina Ave emergency exit and the Courtyard emergency exit were not shoveled.
Both doors did open but the area was not clear to walk.
During an interview on 1/28/26, at 6:22 p.m. the NHA confirmed that the facility failed to ensure the outside environment was free of potential hazards and failed to evaluate the hazard and failed to implement a plan for snow removal for two of two parking lot areas and failed to clear the walkways for two of three exits three days after a snowstorm ended.28 Pa.
Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1) Management28 Pa.
Code 201.18(e)(1) Management28 Pa.
Code 211.10(d) Resident care policies28 Pa.
Code 211.12(d)(1) Nursing services28 Pa.
Code 211.12(d)(5) Nursing services
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/31/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Rochester Residence and Care Center
174 Virginia Avenue Rochester, PA 15074
SUMMARY STATEMENT OF DEFICIENCIES
Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart while not in use for three of four medication carts (Vineyard, Rosewood, and Rosewood 2).Findings include:Review of facility policy Medication Storage dated 12/11/25, indicated all drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, and medication rooms).
During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication cart.During an observation on 1/29/26, at 10:45 a.m. the Vineyard Medication Cart and the Rosewood Medication Cart were observed sitting in the hallway, beside each other, with the cart unlocked and unattended.
During an interview on 1/29/26, at 10:47 a.m.
Licensed Practical Nurse (LPN) Employee E1 confirmed the Vineyard Medication Cart was unlocked, unattended, and that the facility failed to properly secure a medication cart while not in use.
During an interview on 1/29/26, at 10:49 a.m.
Registered Nurse (RN) Employee E2 confirmed the Rosewood Medication Cart was unlocked, unattended, and that the facility failed to properly secure a medication cart while not in use.During an observation on 1/31/26, at 10:31 a.m. the Rosewood 2 Medication Cart was observed sitting in the hallway with the cart unlocked and unattended.During an interview on 1/31/26, at 10:33 a.m. RN Employee E3 stated, I was in a room, and confirmed that the Rosewood 2 Medication Cart was unlocked, unattended, and that the facility failed to properly secure a medication cart while not in use.
During an interview on 1/31/26, at 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to properly secure a medication cart while not in use for three of four medication carts (Vineyard, Rosewood, and Rosewood 2), as required.28 Pa.
Code: 201.14(a) Responsibility of licensee.28 Pa.
Code: 211.9(a)(1)(k) Pharmacy services.28 Pa.
Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/31/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Rochester Residence and Care Center
174 Virginia Avenue Rochester, PA 15074
SUMMARY STATEMENT OF DEFICIENCIES
Based on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in outside dumpsters to prevent the potential for rodent and insect infestation.Findings include:Review of facility policy Disposal of Garbage and Refuse, dated 12/11/25, indicates that the facility shall dispose of kitchen garbage and refuse.
There shall be sufficient numbers of receptacles to hold refuse where refuse is discarded.
Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.
Garbage should not accumulate or be left outside the dumpster.During an observation on 1/29/26, at 5:38 p.m. the outdoor trash compactor had two shopping carts, an oversized chair, many empty cardboard boxes, and an uncountable amount of filled garbage bags sitting around the dumpster.
During an interview on 1/29/26, at 6:00 p.m. the Nursing Home Administrator confirmed that that there were trash and debris collecting in the disposal area, and that the facility failed to properly contain and dispose of garbage in the outside dumpster area to prevent potential rodent and insect infestation.28 Pa.
Code 201.18(b)(3) Management.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/31/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Rochester Residence and Care Center
174 Virginia Avenue Rochester, PA 15074
SUMMARY STATEMENT OF DEFICIENCIES
Based on review of job descriptions, clinical records, observations, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents.Findings include:The job description for the Nursing Home Administrator dated 12/19/24, indicated the NHA leads, guides, and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents.
Plans, develop, organize, implement, evaluate, and direct the overall operation of the facility.
Performs rounds to observe residents and ensure overall needs are met.
Participates in safety and emergency drills.
Fulfills responsibilities as assigned during implementation or activation of the facility's emergency plan.The job description for the Director of Nursing dated 10/16/25, indicated the DON is to plan, organize, develop, and direct the overall operations of the nursing service department.
Establish facility policies and procedures and provide appropriate care and services to the residents.
Plans, develops, organizes, implements, evaluates, and directs the overall operations of the nursing services department.
Performs rounds to observe residents and ensure nursing needs are being met.
Fulfills responsibilities as assigned during implementation or activation of the facility's emergency plan.Based on findings identified, the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents.
The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.
During an interview on 1/29/26, at 2:30 p.m. the NHA was notified that they failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents.28 Pa.
Code 201.14(a) Responsibility of licensee.28 Pa.
Code 201.18(b)(1)(3)(e)(1) Management.28 Pa.
Code 211.12(d)(1)(2)(3)(5) Nursing services.
Facility ID: