Rochester Residence and Care Center

In the surveyor’s words

From the most serious findings on record at Rochester Residence and Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584Jan 31, 2026

  Based on observations, facility policy, resident interviews, and staff interview, it was determined 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. Findings Include:Review of the facility policy Safe and Homelike Environment dated 12/11/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. This includes ensuring that the residents can receive care and services safely. […]

• Immediate jeopardy, patternF689Mar 30, 2023

  Based on facility policy review, clinical and facility record review, facility provided documents, hospital records, and staff interviews, it was determined that the facility failed to provide adequate supervision for two residents resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for 10 of 10 residents (Residents R1, R2, R4, R5, R6, R7, R8, R9, R10 and R11) and allowing two of those residents to elope from the 4th floor (Resident R1 and R2). […]

• Immediate jeopardy, isolatedF689Feb 13, 2026

  Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of seventeen residents (Resident R77) identified as having a high risk for wandering.Findings include: Review of the facility policy Elopements and Wandering Residents last reviewed 12/11/25, indicated the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-entered plan… […]

• Immediate jeopardy, isolatedF726May 15, 2025

  Based on facility policy, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with an insulin pump (wearable device that delivers insulin continuously to people with diabetes), and placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted. Findings include: Interview on 4/29/25, at 9:35 a.m. […]

• Immediate jeopardy, isolatedF689Mar 21, 2025

  Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk, failed to re-evaluate residents for elopement risk, which resulted in an elopement for two of eleven residents (Residents R79 and R289) and transfer to a local hospital, then to a level one trauma center for one of eleven residents (Resident R289). This failure created an immediate jeopardy situation for two of 11 residents (Resident R79 and R289). […]