Rochester Manor

In the surveyor’s words

From the most serious findings on record at Rochester Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 24, 2023

  Based on interview and record review, it was determined that the facility failed to ensure that a resident had adequate devices to prevent a fall, resulting in a fracture, for 1 of 3 residents reviewed for accident hazards in a final sample of 29 residents (Resident identifier is #86). Finding include: Interview on 3/22/23 at 11:03 a.m. with Resident #86 revealed Resident #86 was admitted to the facility for skilled nursing services on 3/2/23. Resident #86 stated that upon admission, he/she was asked if he/she needed bed rails. Resident #86 stated Absolutely, I'm weak and have a history of falls. Further interview with Resident #86 revealed that bed rails were never installed on their bed. […]

• No harm, potential for more than minimal, isolatedF656Jun 11, 2026

  Based on record review and interview, the facility failed to implement a comprehensive care plan for 1 resident in a final sample of 19 residents (Resident identifier is #55).Findings Include: Review on 6/11/26 of the facility's policy Skin integrity and Wound Management, review date 6/15/25, revealed . The plan of care will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition.Resident #55Review on 6/11/26 of Resident #55;'s care plan revealed an intervention of Weekly wound assessment to include measurements and description of wound status, dated 8/21/25 within the focus area of risk for skin… […]

• No harm, potential for more than minimal, isolatedF684Jun 11, 2026

  Based on observation, interview, and record review, the facility failed to facilitate ordered services from an outside provider for 1 of 3 residents reviewed for Urinary catheter/UTI (Urinary Tract Infection) in a final sample of 19 residents. (Resident identifier is #36.)Findings include:Interview on 6/8/26 at approximately 10:34 a.m. with Resident #36 revealed that they were waiting for an appointment that was very important to them. Review 6/8/26 of Resident #36's Physician's orders revealed an order dated 5/26/26, please arrange for urgent follow up with urology. to consider prophylactic abx (antibiotics) given repeated hospitalizations with urosepsis and chronic indwelling foley.Interview on 6/11/26 at approximately 1:18 p.m. […]

• No harm, potential for more than minimal, isolatedF609Jan 14, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF610Jan 14, 2026

  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. […]