Pennsylvania Department of Health
 ROCHESTER RESIDENCE AND CARE CENTER
Building Inspection Results

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ROCHESTER RESIDENCE AND CARE CENTER
Inspection Results For:

There are  43 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ROCHESTER RESIDENCE AND CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on June 11, 2024, at Rochester Residence and Care Center it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID # 180902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2024, it was determined that Rochester Residence and Care Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Doors with Self-Closing Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices in three instances, affecting two of ten smoke compartments within the component.

Findings include:

1. Observation on June 11, 2024, revealed the following door deficiencies:

a) 10:00 a.m., the door to the old morgue failed to latch when tested;
b) 10:43 a.m., the doors to the receiving dock failed to latch when tested;
c) 11:20 a.m., the door to the restroom on the fourth floor failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the door deficiencies.



 Plan of Correction - To be completed: 08/06/2024

1. Repairs on self-closing doors were complete for the storage room (referenced as 'old morgue door'), receiving dock door, and fourth floor restroom door.
2. Maintenance Department will be educated by the NHA on the regulatory requirements of latching doors.
3. Audits to be completed weekly x4 weeks and monthly x3 months on 10% of facility doors.

NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review, observation, and interview, it was determined the facility failed to perform the twelve monthly kitchen fire suppression system inspections, affecting one of ten smoke compartments.

Findings include:

1. Document review and observation on June 11, 2024, at 11:55 a.m., revealed the monthly inspections for the kitchen fire suppression system in the kitchen were not completed.

Interview with the Facility Administrator and Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the facility lacked documentation for the monthly kitchen fire suppression system inspections.






 Plan of Correction - To be completed: 08/06/2024

1. Monthly kitchen fire suppression system inspection was completed for June 2024. 2. Monthly suppression system inspections tasks have been entered into the preventative maintenance system TELS for compliance tracking.
3. Maintenance Department will be educated by the NHA on the regulatory requirements of monthly suppression system inspections.
4. Audits to be completed monthly x3 months. Results of audits will be submitted to facility QAPI committee.

NFPA 101 STANDARD Sprinkler System - Installation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351


Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system installation requirements in one instance, affecting one out of ten smoke compartments.

Findings include:

1. Observation on June 11, 2024, at 11:30 a.m., revealed there was no sprinkler coverage in a storage room, near the Employees Entrance/Exit. The sprinkler head is located above a drop ceiling that was missing several ceiling tiles. There would be no sprinkler coverage with the ceiling tiles in place.

Interview with the Facility Administrator and Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the lack of sprinkler protection.


 Plan of Correction - To be completed: 08/06/2024

1. The facility has contacted local Fire companies to obtain quotes for sprinkler installation in the storage room by the employee entrance. Sprinklers will be installed and tiles will be replaced.
2. Maintenance Department will be educated by the NHA on the regulatory requirements of having sprinklers in all site smoke compartments.
3. Audits to be completed weekly x4 weeks and monthly x3 months on facility smoke compartments.
4. Audits will be submitted to QAPI committee for further recommendations.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting three of ten smoke compartments.

Findings include:

1. Observation on June 11, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:05 a.m., there was a gap greater than 1/8 of an inch in a ceiling tile above a pull station, in the Event Room;
b) 10:10 a.m., there were multiple missing ceiling tiles in the Central Supply Room, and a smaller adjacent storeroom was missing a ceiling tile;
c) 10:15 a.m. the ceiling above the firewall near Central Supply was missing a ceiling tile;
d) 11:30 a.m., there was a wire attached to the sprinkler line above the smoke doors, near Room 343.


Interview with the Facility Administrator and Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the above listed sprinkler deficiencies.



 Plan of Correction - To be completed: 08/06/2024

1. The gap in the ceiling tile above the pull station in the event room was repaired on 6/26/24. Missing ceiling tiles were replaced in the central room, adjacent storeroom and the firewall near central supply on 6/26/24. The wire attached to the sprinkler line above the ceiling tile in front of room 343 was detached on 6/28/24.
2. Maintenance Department will be educated by the NHA on the requirements of ceiling tiles, and sprinkler line inspection, testing, and maintenance.
3. Audits to be completed weekly x4 weeks and monthly x3 months on facility sprinkler lines and 25% of facility ceiling tiles.
4. Audits will be submitted to QAPI committee for further recommendations

NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355


Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of ten smoke compartments.

Findings include:

1. Observation on June 11, 2024, at 10:52 a.m., revealed the facility failed to perform the required annual inspection on the fire extinguisher in the basement storage room.

Interview with the Facility Administrator and Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the above portable fire extinguisher deficiency.




 Plan of Correction - To be completed: 08/06/2024

1. The fire extinguisher was inspected.

2. Maintenance Department will be educated by the NHA on the requirements of fire extinguisher inspections.

3. Audits to be completed monthly x3 months on fire extinguisher inspections.

4. Audits will be submitted to QAPI committee for further recommendations.
NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, in one of ten smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101 (2012).

Findings include:

1. Observation on June 11, 2024, at 9:57 a.m., revealed an open electrical junction box located in the ceiling above the smoke doors, near room 343.

Interview with the Facility Administrator and Maintenance Director on June 11, 2024,
at 2:00 p.m., confirmed the electrical system deficiency.



 Plan of Correction - To be completed: 08/06/2024

1. The electrical junction box will be closed.

2. Maintenance Department will be educated by the NHA on the requirements of closed electrical junction boxes.

3. Audits to be completed monthly x3 months on electrical junction boxes.

4. Audits will be submitted to QAPI committee for further recommendations.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918


Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on June 11, 2024, at 8:40 a.m., revealed the facility failed to perform the following required emergency generator testing:

a) The monthly 30 minute load tests;
b) The monthly conductance testing.

Interview with the Facility Administrator and Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the missing generator testing documentation.




 Plan of Correction - To be completed: 08/06/2024

1. The required testing was scheduled.

2. Maintenance Department will be educated by the NHA on the requirements of generator testing requirements.

3. Audits to be completed monthly x3 months on generator testing.

4. Audits will be submitted to QAPI committee for further recommendations.
NFPA 101 STANDARD Electrical Equipment - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in one instance, affecting one of ten smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1

Findings include:

1. Observation on June 11, 2024, at 9:34 a.m., revealed that there were laundry carts blocking access to an electrical panel in the laundry room.

Interview with the Facility Administrator and the Maintenance Director on June 11, 2024, at 2:00 p.m. confirmed the electrical equipment deficiency.



 Plan of Correction - To be completed: 08/06/2024

1. The laundry carts were moved.

2. Maintenance and EVS depts will be educated by the NHA on the requirements of keeping access to electrical panels clear.

3. Audits to be completed weekly x4 weeks then monthly x3 months on maintaining electrical equipment.

4. Audits will be submitted to QAPI committee for further recommendations.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID # 180902
Component 02
Annex Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2024, it was determined that Rochester Residence and Care Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the building construction requirements, affecting five of five floors within the component.

Findings include:

1. Observation on June 11, 2024, at 10:30 a.m., revealed the building is a three-story, unprotected noncombustible structure, which is fully sprinklered. This type of construction is not permitted to be greater than two stories in height.

Interview with the Facility Administrator and Facility Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the construction type was not permitted.





 Plan of Correction - To be completed: 08/06/2024

The facility is having a Fire Safety Evaluation System (FSES) completed and is requesting a Time-Limited Waiver.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on June 11, 2024, at 8:40 a.m., revealed the facility failed to perform the following required emergency generator testing:

a) The monthly 30 minute load tests;
b) The monthly conductance testing.

Interview with the Facility Administrator and Maintenance Director on June 11, 2024, at 2:00 p.m., confirmed the missing generator testing documentation.




 Plan of Correction - To be completed: 08/06/2024

1. The required testing was scheduled.

2. Maintenance Department will be educated by the NHA on the requirements of generator testing requirements.

3. Audits to be completed monthly x3 months on generator testing.

4. Audits will be submitted to QAPI committee for further recommendations.

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