Inspection Reports for
Absolut Center for Nursing and Rehabilitation at Three Rivers, LLC
101 Creekside Drive, Painted Post, NY, 14870
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Inspection Report — Feb 28, 2025
Complaint Investigation State
Date: Feb 28, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2025 with citation and complaint history.
Complaint Details
The state logged 63 complaints about this facility; 12 led to on-site inspections. No citations resulted from those complaints during the reporting period.
Findings
Across 4 inspections in the reporting period, 16 citations were issued, including 9 standard health and 7 Life Safety Code citations. The facility had 63 complaints with 12 on-site inspections, but no formal enforcement actions were taken.
Citations (16)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was cited for deficiencies.
Standard Health Citation — quality of care: Dialysis procedures were found deficient.
Standard Health Citation — quality of care: Infection Control practices were deficient.
Standard Health Citation — quality of care: Infection Prevention & Control protocols were deficient.
Standard Health Citation — quality of care: Quality Of Care was found deficient.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenance was deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance was deficient.
Life Safety Code Citation — NFPA requirements: Fire Drills were deficient.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress was deficient.
Standard Health Citation — quality of care: Bowel/bladder Incontinence, Catheter, Uti care was deficient.
Standard Health Citation — quality of care: Treatment/devices To Maintain Hearing/vision were deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extensions were deficient.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Systems were deficient.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barriers were deficient.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was deficient and not yet corrected.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 16
Inspections with violations: 3
Inspections without violations: 1
Total complaints: 63
On-site complaint inspections: 12
Enforcement actions: 0
Inspection Report — Feb 28, 2025
Annual Inspection CMS
Date: Feb 28, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 02/24/2025 to 02/28/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to report alleged abuse, inadequate assistance with personal hygiene, failure to provide ordered treatments such as ace wraps, inconsistent dialysis care and monitoring, and deficiencies in infection prevention and control practices including improper use of precautions and lack of annual policy review.
Citations (5)
F 0609: The facility failed to timely report suspected abuse involving a resident falling out of bed during care that was not provided according to the care plan requiring two staff.
F 0677: The facility did not ensure residents dependent on staff received necessary grooming and personal hygiene services, specifically inconsistent nail care for a resident.
F 0684: The facility failed to provide treatment and care according to orders for a resident with edema, specifically not applying ace wraps as ordered and lacking documentation of refusals.
F 0698: The facility did not provide safe, appropriate dialysis care, failing to monitor a resident's tunneled dialysis catheter and fluid restriction, and not following vascular physician recommendations.
F 0880: The facility failed to maintain an infection prevention and control program, including improper use of personal protective equipment, incorrect or missing precaution signage, and failure to review infection control policies annually.
Report Facts
Residents reviewed: 7
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in abuse reporting deficiency related to Resident #66 fall incident |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Named in abuse reporting deficiency related to Resident #66 fall incident |
| Licensed Practical Nurse Manager #2 | Licensed Practical Nurse Manager | Interviewed regarding abuse reporting, nail care, dialysis care, and fluid intake documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting, nail care, dialysis care, and infection control practices |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed regarding nail care and ace wrap application |
| Dialysis Clinical Coordinator | Registered Nurse | Interviewed regarding dialysis care and tunneled catheter monitoring |
| Registered Nurse Educator | Infection Preventionist | Interviewed regarding infection prevention and control program deficiencies |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed not wearing PPE near Resident #45 with Covid-19 |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed and interviewed regarding PPE use with Resident #100 |
Inspection Report — Jan 13, 2023
Annual Inspection CMS
Date: Jan 13, 2023
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to ensure that a resident with glaucoma received proper vision care and that a resident with a Foley catheter had appropriate medical justification, care planning, and catheter management to prevent urinary tract infections.
Citations (2)
F0685: The facility did not ensure that Resident #46 with glaucoma received eye examinations since admission on 4/21/21 to maintain adequate vision.
F0690: The facility did not ensure Resident #361 had a valid medical justification for a continuing Foley catheter, proper catheter care, or an updated care plan, and catheter tubing was observed on the floor increasing infection risk.
Report Facts
Residents reviewed for vision and hearing: 2
Residents reviewed for catheters: 1
Date of admission for Resident #46: Apr 21, 2021
Date of catheter insertion for Resident #361: Oct 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/RCC #1 | Registered Nurse/Resident Care Coordinator | Named in findings related to lack of documentation and catheter care for Resident #361. |
| LPN/RCC #1 | Licensed Practical Nurse/Resident Care Coordinator | Interviewed regarding Optometrist scheduling and Resident #46 care. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding lack of documentation for Resident #361's Foley catheter. |
| PA | Physician Assistant | Provided orders for catheter insertion and discussed follow-up care for Resident #361. |
| MD | Medical Doctor | Interviewed about documentation expectations for Foley catheter use and follow-up. |
| Director of Nursing | Director of Nursing | Interviewed about expectations for documentation and care planning. |
| Medical Records Director | Medical Records Director | Interviewed about Optometrist scheduling. |
| Regional Quality Assurance Nurse | Regional Quality Assurance Nurse | Interviewed with Director of Nursing about documentation expectations. |
Inspection Report — May 3, 2021
Annual Inspection CMS
Date: May 3, 2021
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, failure to provide timely written notification of transfers and bed hold policies, inadequate assistance with activities of daily living such as nail care, and failure to provide food and drink that was palatable and served at safe temperatures.
Citations (5)
F 0585: The facility did not make prompt efforts to resolve a grievance from Resident #7 regarding treatment by a staff member, as concerns were not documented, investigated, or resolved timely.
F 0623: The facility failed to ensure that Residents #40 and #87 or their representatives were notified in writing of transfers to the hospital and the reasons for the move.
F 0625: The facility did not provide written notice of the bed hold policy to Residents #40 and #87 or their representatives at the time of hospital transfer.
F 0677: Resident #31 was not assisted with proper nail care, resulting in untrimmed, jagged fingernails with debris, despite requiring extensive assistance for personal hygiene.
F 0804: The facility did not provide food and drink that was palatable or served at safe and appetizing temperatures for Residents #34, #7, #83, and #48, and equipment to keep food warm was not repaired or replaced.
Report Facts
Residents reviewed for dignity: 4
Residents involved in transfer notification deficiency: 2
Residents involved in bed hold policy deficiency: 2
Residents reviewed for ADL assistance: 3
Residents reviewed for food and drink quality: 4
Food truck unit size: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Reported Resident #7's grievance but did not escalate to Nurse Manager or Director of Nursing. | |
| Licensed Practical Nurse (LPN) #2 | Named in Resident #7's grievance regarding abrupt behavior. | |
| Certified Nursing Assistant (CNA) | Received Resident #7's complaint but did not report it. | |
| Director of Social Work | Reported no knowledge of Resident #7's grievance. | |
| Director of Nursing (DON) | Stated that Resident #7's grievance should have been reported and investigated. | |
| Business Office Manager | Stated that written transfer notices were provided after hospital transfers. | |
| Administrator | Stated facility did not have a bed hold policy and residents are returned as a courtesy. | |
| Admissions Director | Stated no longer bed holds per Medicaid regulations but beds held as courtesy. | |
| Certified Nursing Assistant (CNA) | Admitted not performing nail care for Resident #31. | |
| Nurse Manager | Expected staff to perform nail care on shower days and assist with hand hygiene. | |
| Director of Food Service (DFS) | Reported equipment failures affecting food temperature and quality. | |
| Nurse Manager (NM) | Assisted with passing trays due to staffing shortages. |
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