4 Reports
Inspection Report — Jun 6, 2025
Complaint Investigation
Date: Jun 6, 2025
Visit Reason
The inspection was conducted to investigate complaints related to grievance handling, fall investigation, care plan revisions, medication administration, trauma-informed care, and infection control at Rochester Manor.
Complaint Details
The complaint investigation revealed failures in grievance handling, fall investigation, care plan revision, medication administration timing, trauma-informed care, and infection control practices.
Findings
The facility failed to follow its grievance policy, thoroughly investigate a resident's fall, revise a care plan for wandering behavior, follow physician orders for medication administration timing, provide trauma-informed care interventions, and implement proper infection control procedures during wound care.
Deficiencies (6)
Failed to follow grievance policy for tracking, investigating, and prompt resolution of grievances for 1 resident.
Failed to thoroughly investigate after a resident's fall for 1 resident.
Failed to revise a care plan for wandering behavior for 1 resident.
Failed to follow physician orders for medication administration timing for 1 resident.
Failed to ensure trauma survivors have interventions to eliminate or mitigate triggers for 1 resident.
Failed to implement infection control policies and procedures during wound care for 1 resident.
Report Facts
Residents reviewed: 18
Residents affected: 1
Medication late administration instances: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Infection Preventionist | Interviewed regarding grievance from Resident #4. |
| Staff D | Administrator | Interviewed regarding grievance handling and fall investigation. |
| Staff C | Registered Nurse | Provided details about Resident #82's fall and investigation. |
| Staff B | Director of Nursing | Interviewed about fall investigation and medication administration timing. |
| Staff E | Licensed Practical Nurse | Interviewed about Resident #23 wandering behavior and trauma awareness. |
| Staff F | Licensed Nursing Assistant | Interviewed about Resident #23 wandering behavior and trauma awareness. |
| Staff G | Director of Social Services | Interviewed about trauma history and care plan for Resident #4. |
| Staff A | Licensed Practical Nurse | Observed performing wound care with infection control deficiencies. |
Inspection Report — Apr 3, 2024
Routine
Date: Apr 3, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with professional standards for food safety, specifically focusing on proper storage, preparation, distribution, and serving of food to prevent foodborne illness.
Findings
The facility failed to store food in accordance with professional standards, as evidenced by multiple food items in the walk-in refrigerator lacking proper date markings and some items showing signs of spoilage. This included unmarked Ready Care Chocolate Shakes, meat sauce, mashed sweet potatoes, cooked ham, and sliced white cheese, as well as spoiled produce.
Deficiencies (8)
Seventeen soft moist green peppers with white and black spots in the walk-in refrigerator.
Fifteen soft moist celery stalks with brown spots in a bin with no lid.
Three bags of hearts of romaine lettuce with brown spots on outer leaves.
Twenty-eight 4-ounce cartons of Ready Care Chocolate Shakes with no thawed date or use by date.
One clear plastic container of meat sauce with no prepared date or use by date.
One large metal tray of mashed sweet potatoes with no prepared date or use by date.
One gallon size zip lock bag of cooked ham with no prepared date or use by date.
Three individually wrapped packages of sliced white cheese with no opened date or use by date.
Report Facts
Soft moist green peppers: 17
Soft moist celery stalks: 15
Bags of hearts of romaine lettuce: 3
4-ounce cartons of Ready Care Chocolate Shakes: 28
Large metal tray of mashed sweet potatoes: 1
Gallon size zip lock bag of cooked ham: 1
Individually wrapped packages of sliced white cheese: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Culinary Manager | Confirmed findings of improperly stored and unlabeled food items during interview |
Inspection Report — Mar 24, 2023
Complaint Investigation
Date: Mar 24, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure a resident had adequate devices to prevent a fall, which resulted in injury.
Complaint Details
The investigation was complaint-related, focusing on whether the facility provided adequate fall prevention devices to Resident #86. The complaint was substantiated as the resident fell and sustained injuries due to delayed installation of bed rails.
Findings
The facility failed to timely install bed rails for Resident #86 despite assessment, consent, and physician orders, resulting in the resident falling out of bed and sustaining multiple rib fractures and other injuries. The facility acknowledged the failure and implemented a Quality Assurance Plan to address the issue.
Deficiencies (1)
Failure to ensure a resident had adequate devices to prevent a fall, resulting in a fracture for Resident #86.
Report Facts
Residents reviewed for accident hazards: 3
Resident weight: 340
Bed rails ordered: 2
Work order number: 5538
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Entered progress notes regarding Resident #86's admission, bed rail evaluation, and fall incident |
| Staff H | Registered Nurse | Interviewed regarding Resident #86's refusal to get out of bed for side rail installation |
| Staff C | Maintenance Supervisor | Interviewed regarding cancellation of work order for side rails |
| Staff G | Administrator | Interviewed regarding documentation and facility's Quality Assurance Plan implementation |
Inspection Report — Mar 22, 2023
Annual Inspection
Date: Mar 22, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident privacy, accident hazards prevention, food safety, and antibiotic stewardship at Rochester Manor nursing home.
Findings
The facility was found deficient in maintaining privacy of medical records, ensuring timely installation of bed rails to prevent falls, storing food safely according to professional standards, and implementing an effective antibiotic stewardship program with proper tracking and monitoring.
Deficiencies (4)
Failed to provide privacy of medical records on 1 of 4 units, with resident information visible to unauthorized personnel.
Failed to ensure a resident had adequate devices to prevent a fall, resulting in multiple rib fractures for 1 of 3 residents reviewed.
Failed to store food according to acceptable standards for food safety to prevent foodborne illness in the main kitchen and 1 of 2 unit kitchenettes.
Failed to implement an antibiotic stewardship program which included a system to track and monitor antibiotic use during 2 of 6 months reviewed.
Report Facts
Residents receiving antibiotics: 5
Residents receiving antibiotics: 9
Packages of hot dog rolls expired: 2
Packages of long grinder rolls expired: 6
Loaves of white bread without use by date: 3
Packages of round sandwich rolls without use by date: 2
Soft moist green peppers with black spots: 26
Soft moist celery stalks with brown spots: 12
Six packs of hard boiled eggs without label or use by date: 2
Packages of English muffins without use by date: 2
Packages of round sandwich rolls without use by date: 2
Package of small dinner rolls without use by date: 1
Package of white bread without use by date: 1
Bed rails ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Confirmed observations of medical record privacy breach and antibiotic stewardship program deficiencies |
| Staff B | Infection Preventionist | Confirmed antibiotic stewardship program deficiencies |
| Staff C | Maintenance Supervisor | Provided information about cancellation of bed rail work order |
| Staff D | Licensed Practical Nurse | Interviewed regarding use of nurse station counter for medical records |
| Staff E | Culinary Director | Confirmed expired and unlabeled food items |
| Staff F | Licensed Practical Nurse | Entered progress notes and bed rail evaluation for Resident #86 |
| Staff G | Administrator | Interviewed about bed rail installation failure and quality assurance plan |
| Staff H | Registered Nurse | Interviewed about Resident #86's refusal to get out of bed for side rail installation |
5 CMS Surveys
CMS Survey — Mar 24, 2023
Mar 24, 2023
CMS Survey — Jun 6, 2025
Jun 6, 2025
CMS Survey — Mar 24, 2023
Mar 24, 2023
CMS Survey — Apr 3, 2024
Apr 3, 2024
CMS Survey — Jun 6, 2025
Jun 6, 2025
Loading inspection reports...
