Rochester Manor

Based on interview and record review, it was determined that the facility failed to report an injury of unknown source to the State Survey Agency (SSA) for 1 of 1 residents reviewed for neglect. (Resident identifier is #1).Findings include:Review on 1/14/26 of Resident #1's progress note, dated 12/8/25 at 11:26 a.m., revealed a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left Upper Extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [Deep Vein Thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information, dated 12/8/25 at 11:02 a.m., revealed, You were seen today for: Closed fracture of radial head. elbow fracture. There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to thoroughly investigate an injury of unknown source for 1 of 1 resident reviewed for neglect. (Resident Identifier is #1). Findings include:Review on 1/14/26 of Resident #1's progress note, dated 12/8/25 at 11:26 a.m. revealed, a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left Upper Extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [Deep Vein Thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information, dated 12/8/25 at 11:02 a.m., revealed, You were seen today for: Closed fracture of radial head. elbow fracture. Interview on 1/14/26 at 12:30 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to provide notice to the resident or the resident representative(s) of transfer and bed hold for 1 of 2 residents reviewed for hospitalization (Resident identifier is #1).Findings include:Review on 1/14/26 of Resident #1's progress note dated 12/8/25 with an effective time of 11:26 a.m. revealed a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left upper extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [deep vein thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information from the local hospital, dated 12/8/25 at 11:02 a.m., revealed, You were seen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to ensure that resident medical records were complete and accurately documented for 1 of 4 medical records reviewed. (Resident Identifier is #1.)Findings Include:Review on 1/14/26 of Resident #1's progress note, dated 12/8/25 at 11:26 a.m., revealed a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left upper extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [deep vein thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information from the local hospital, dated 12/8/25 at 11:02 a.m., revealed, You were seen today for: Closed fracture of radial head. elbow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to follow it's grievance policy for tracking, investigating, and prompt resolution of grievances for 1 out of 1 resident reviewed for grievances (Resident identifiers is #4). Findings include: Interview on 6/4/25 at approximately 11:45 a.m. with Resident #4 revealed that Resident #23 wanders into their room frequently throughout the day and evening and has for some time now. Resident #4 stated they have voiced this concern to staff and nothing has been done to help keep Resident #23 out of their room. Interview on 6/6/25 at approximately 12:15 p.m. with Staff J (Infection Preventionist) stated that on 5/12/25 they spoke to Resident #4 and their roommate regarding Resident #23 wandering into their room. Staff J stated that this information was written up on a grievance form and brought to the managers morning meeting on 5/13/25. Interview on 6/6/25 at approximately 12:30 p.m. with Staff D (Administrator) revealed that the grievance from Resident #4 on 5/12/25 was not logged on the Grievance/Complaint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to thoroughly investigate after a resident's fall for 1 of 1 resident reviewed for falls in a final sample of 18 residents. (Resident Identifier is #82). Findings include: Review on 6/6/25 of the facility's policy titled Abuse Prohibition revised on 10/24/22 revealed, .The Center will implement an abuse prohibition program through the following: .Investigation of incidents and allegations; . Reporting of incidents, investigations, and Center response to the results of their investigations .10. At monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse, neglect, misappropriation of patient property, and exploitation that were reported to the state to: 10.1 Analyze occurrences to determine what changes are needed, if any, to prevent further occurrences; 10.2 Identify situations which a potential for risk; and 10.3 Determine what preventative measures will be implemented by staff. Review on 6/6/25 of Resident #82's Progress Note dated 4/24/25 at 5:22 p.m. and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, it was determined that the facility failed to revise a care plan for 1 resident in a final sample of 18 residents (Resident identifiers is #23). Findings include: Interview on 6/4/25 at approximately 11:45 a.m. with Resident #4 revealed that Resident #23 wanders into their room frequently in the evening and night for some time now. Interview on 6/6/25 at approximately 11:45 a.m. with Staff E (Licensed Practical Nurse) stated that Resident #23 will wander into Resident #4's room sometimes. Staff E said the staff will redirect Resident #23 when this occurs. Interview on 6/6/25 at approximately 11:55 a.m. with Staff F (Licensed Nursing Assistant) stated that Resident #23 will wander into Resident #4's room. Staff F said that staff will redirect Resident #23 with items to fidget with and will also try to engage her in activities. Review on 6/5/25 of Resident #23's progress notes revealed the following: On 4/11/25, Resident #23 required frequent redirection as he/she enters other resident's rooms and touches other resident's walkers; On 5/1/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 of 4 residents reviewed for medication administration in a final sample of 18 residents (Resident Identifiers is #77). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . [NAME], [NAME]; [NAME], [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to ensure that trauma survivors have interventions identified to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed for mood and behaviors in a final sample of 18 residents. (Resident identifier is #4). Findings include: Review on 6/5/25 of Resident #4's Psychiatric note, dated 5/13/25, revealed the following: .[Pronoun omitted] was referred for psychiatric medication management services for depression, anxiety, and PTSD [Post-Traumatic Stress Disorder] .[Name omitted] reports ongoing depressive and anxiety symptoms related to situational stressors .[Pronoun omitted] has also had a difficulty with several residents here and feels uncomfortable around them .[Name omitted] reports chronic nightmares and poor sleep related to childhood molestation .PTSD based symptoms nightmares .Chronic PTSD: chronic nightmares and flashbacks related to childhood sexual abuse perpetrated by her brother, [Name omitted]. Appears to have relational difficulties related to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and procedures for 1 of 1 resident observed for wound care in the final survey sample of 18 residents. (Resident identifier is #66). Findings include Observation on 6/4/25 at approximately 10:00 a.m. with Staff A (Licensed Practical Nurse) performing wound care for Resident #66 revealed the following: Staff A entered Resident #66's room and placed wound care supplies on a sterile field on the bedside table. Staff A pulled a pair of scissors out of his/her nursing scrub top pocket and placed it onto the bedside table without disinfecting/cleaning the scissors. Right great toe metatarsal wound care: Staff A donned gloves then proceeded to cut Resident #66's right foot dressing off with the unclean scissors and placed them back onto the bedside table with the wound care supplies. After removing the old dressing, Staff A cleaned the right great toe metatarsal wound with normal saline. Staff A used the unclean scissors to cut the new foam dressing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchen observed. Findings include: Review on 4/4/24 of the U.S. Food and Drug Administration Food Code dated 2017 retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: . On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to provide privacy of medical records on 1 of 4 units (Resident identifiers are #8 and #17). Findings include: Observations on 3/22/23 at 11:00 a.m., 12:00 p.m., and again at 2:00 p.m., revealed Resident #8's and Resident #17's Radiology Exam Order containing Resident #8's and Resident #17's name, date of birth , and image results stored face-up on the top counter of the nurse station viewable to unauthorized personnel on B-Wing. Observation on 3/22/23 at approximately 2:00 p.m., a document titled Rochester Manor Census List for B Wing Rooms 15-28 revealed full resident names, diet types and dietary notes stored face-up on the top counter of the nurse station viewable to unauthorized personnel. Interview on 3/22/23 at approximately 2:15 p.m. with Staff D (Licensed Practical Nurse) revealed staff utilize the counter for medical record documents due to lack of space. Interview on 3/22/23 at approximately 2:20 p.m. with Staff A (Director of Nursing) confirmed the observations. Review on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, it was determined that the facility 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 observed. Findings include: Review on 3/24/23 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and policy review, it was determined that the facility failed to implement an antibiotic stewardship program which included a system to track and monitor antibiotic use during 2 of 6 months reviewed. Findings include: Review on 3/24/23 of the facility's Infection Control Monthly Line Listing for January and February 2023 revealed tracking for the use of antibiotics for 14 residents. The line listings did not indicated clinical signs and symptoms to determine if the residents met the criteria for the use of antibiotics. For the month of January 2023 there were 5 residents receiving antibiotics (3-urinary tract infections (UTI), 1-osteomyelitis, and 1- hordeolum). For the month of February 2023 there were 9 residents receiving antibiotics (2-c-difficile, 3-pneumonia, 1-UTI, 1-surgical wound, 1- cellulitis, and 1-conjunctivitis). Interview on 3/24/23 at 9:10 a.m. with Staff B (Infection Preventionist) and Staff A (Director of Nursing) confirmed the line lists for January and February 2023 did not contain clinical signs and symptoms. Staff B stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.