Inspection Reports for
Alice Hyde Medical Center
45 Sixth Street, Malone, NY, 12953
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Inspection Report — Mar 6, 2026
Complaint Investigation State
Date: Mar 6, 2026
Visit Reason
State-compiled facility profile showing 11 inspections from June 2022 to May 2026 with deficiency and enforcement history.
Complaint Details
The state logged 199 complaints about this facility; 11 led to on-site inspections. The facility received 168.1 complaints per 100 beds versus a statewide rate of 57.4, resulting in 17 citations from complaints.
Findings
Across 11 inspections, 7 resulted in citations totaling 44 deficiencies including standard health and life safety code violations. The facility had 2 enforcement actions with fines totaling $18,000 and a high complaint volume with 199 complaints recorded.
Citations (27)
Free From Abuse And Neglect: Standard Health Citation — quality of care with actual harm noted in isolated cases.
Inappropriate Discharge: Standard Health Citation — quality of care with minor potential harm in isolated cases.
Activities Meet Interest/needs Each Resident: Standard Health Citation — quality of care with minor potential harm in a pattern.
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care with minor potential harm in a pattern.
Free From Abuse And Neglect: Standard Health Citation — quality of care with minor potential harm in a pattern.
Other Laws, Codes, Rules And Regulations: Standard Health Citation — quality of care with no harm potential.
Residents Are Free Of Significant Med Errors: Standard Health Citation — quality of care with minor potential harm in isolated cases.
Right To Be Free From Physical Restraints: Standard Health Citation — quality of care with minor potential harm in isolated cases.
Development Of Communication Plan: Life Safety Code Citation — NFPA requirements with minor potential harm widespread.
Discharge From Exits: Life Safety Code Citation — NFPA requirements with minor potential harm in a pattern.
Electrical Systems - Essential Electric System: Life Safety Code Citation — NFPA requirements with minor potential harm widespread or pattern.
Ep Training Program: Life Safety Code Citation — NFPA requirements with minor potential harm widespread.
Fire Drills: Life Safety Code Citation — NFPA requirements with minor potential harm widespread.
Gas Equipment - Qualifications And Training: Life Safety Code Citation — NFPA requirements with minor potential harm in a pattern.
Illumination Of Means Of Egress: Life Safety Code Citation — NFPA requirements with minor potential harm widespread.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with minor potential harm in a pattern.
Free From Abuse And Neglect: Standard Health Citation — quality of care with minor potential harm in isolated cases.
Reporting Of Alleged Violations: Standard Health Citation — quality of care with minor potential harm in isolated cases.
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care with minor potential harm in a pattern.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with minor potential harm in isolated cases.
Free From Abuse And Neglect: Standard Health Citation — quality of care with minor potential harm in isolated cases.
Investigate/prevent/correct Alleged Violation: Standard Health Citation — quality of care with minor potential harm in a pattern.
Reporting Of Alleged Violations: Standard Health Citation — quality of care with minor potential harm in a pattern.
Residents Are Free Of Significant Med Errors: Standard Health Citation — quality of care with minor potential harm in a pattern.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with minor potential harm in a pattern.
Medicaid/medicare Coverage/liability Notice: Standard Health Citation — quality of care with minor potential harm in a pattern.
Electrical Systems - Essential Electric System: Life Safety Code Citation — NFPA requirements with minor potential harm widespread.
Report Facts
Inspections on page: 11
Total violations/deficiencies cited: 44
Inspections with violations: 7
Inspections without violations: 4
Total complaints: 199
On-site complaint inspections: 11
Citations issued from complaints: 17
Enforcement actions: 2
Total fines: 18000
Inspection Report — Dec 19, 2025
Abbreviated Survey CMS
Date: Dec 19, 2025
Visit Reason
The facility underwent an abbreviated survey to assess compliance with care plan adherence, abuse prevention, and medication administration safety.
Findings
The survey found the facility failed to ensure residents were free from neglect and significant medication errors. Three residents experienced falls due to care plan violations, and one resident received medications intended for another resident.
Citations (2)
F 0600: The facility did not ensure residents were free from neglect for three residents. Staff failed to perform toileting every two hours, use two-person assist for transfers, and activate bed alarms as care planned, resulting in falls.
F 0760: The facility did not ensure residents were free from significant medication errors. One resident was administered seven medications ordered for another resident due to failure to verify the correct resident and follow medication administration protocols.
Report Facts
Residents reviewed for neglect: 7
Residents affected by neglect: 3
Medications administered in error: 7
Residents reviewed for medication errors: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #5 | Named in toileting neglect finding for Resident #7 | |
| Director of Nursing #1 | Director of Nursing | Oversaw investigation and education related to toileting and medication errors |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Administered wrong medications to Resident #46 and was terminated |
| Registered Nurse #2 | Registered Nurse | Reported medication error and completed incident reports |
Inspection Report — Feb 10, 2025
Abbreviated Survey CMS
Date: Feb 10, 2025
Visit Reason
The visit was an abbreviated survey to investigate allegations of verbal abuse by staff towards a resident.
Findings
The facility failed to protect Resident #1 from verbal abuse by Licensed Practical Nurse #1, who was witnessed speaking aggressively and yelling at the resident. The Licensed Practical Nurse was placed on administrative leave and subsequently terminated for unprofessional behavior.
Citations (1)
F 0600: Protect each resident from all types of abuse including verbal abuse. Resident #1 was subjected to verbal abuse by Licensed Practical Nurse #1 who spoke aggressively and yelled at the resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in verbal abuse finding and subsequent termination. | |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding the incident and actions taken. |
Inspection Report — Jun 11, 2024
Abbreviated Survey CMS
Date: Jun 11, 2024
Visit Reason
The abbreviated survey was conducted to review compliance with timely reporting of suspected abuse, neglect, or theft and the results of investigations to proper authorities.
Findings
The facility failed to ensure that all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source, were immediately reported to the State Agency for one resident. Specifically, Resident #20 was left unattended, fell, sustained injury, and the incident was not reported to the Department of Health until the following day.
Citations (1)
F 0609: The facility did not timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities. Resident #20 was left unattended on 2/29/2024, fell, and sustained injury, but the incident was reported to the Department of Health on 3/01/2024.
Report Facts
Residents reviewed for abuse: 4
Date of fall incident: Feb 29, 2024
Date of report to Department of Health: Mar 1, 2024
Inspection Report — Apr 15, 2024
Abbreviated Survey CMS
Date: Apr 15, 2024
Visit Reason
The visit was an abbreviated survey conducted from 3/18/2024 through 3/29/2024 to assess compliance with care plan implementation and accident prevention for residents.
Findings
The facility failed to implement comprehensive person-centered care plans for 5 of 25 residents reviewed, including failure to complete required 15-minute safety checks and ensure bed alarms and appropriate footwear were used. Additionally, the facility did not ensure the environment was free from accident hazards for one resident who experienced a fall with unsafe conditions.
Citations (2)
F 0656: The facility did not implement comprehensive person-centered care plans for 5 residents, including failure to complete 15-minute safety checks and use bed alarms and appropriate footwear as required.
F 0689: The facility did not ensure the environment was free from accident hazards for Resident #15, who was found on the floor with the bed not in a low position, call light out of reach, and no socks on.
Report Facts
Residents reviewed for comprehensive care plans: 25
Residents with deficient care plans: 5
Residents reviewed for accidents: 5
Residents affected by accident hazard deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Certified Nurse Aide | Named in fall incident and care plan violation for Resident #15 |
| Certified Nurse Aide #7 | Certified Nurse Aide | Interviewed regarding 15-minute safety check sheet completion |
| Human Resource Director #1 | Human Resource Director | Confirmed employment and education of Certified Nurse Aide #2 |
| Clinical Educator #1 | Clinical Educator | Described counseling and education process for falls and care plan compliance |
Inspection Report — May 25, 2023
Abbreviated Survey CMS
Date: May 25, 2023
Visit Reason
The visit was an abbreviated survey to investigate allegations of neglect, abuse, medication errors, and compliance with reporting and investigation requirements at Alice Hyde Medical Center.
Findings
The facility failed to ensure residents were free from neglect and abuse, timely reporting of abuse allegations, thorough investigations of abuse and neglect incidents, and prevention of significant medication errors for multiple residents. Several medication administration errors and failure to follow care plans were documented.
Citations (4)
F 0600: The facility did not ensure Resident #6 was free from neglect when staff failed to apply a required lap buddy, resulting in a fall causing a fractured nose and bruising.
F 0609: The facility failed to timely report allegations of abuse to the Department of Health for 5 residents, with delays ranging from 4 to 5 hours or no reports made.
F 0610: The facility did not ensure thorough investigations of alleged abuse and neglect for 4 residents, with missing or incomplete investigation summaries.
F 0760: The facility failed to prevent significant medication errors for 3 residents, including administering medications on hold, incorrect dosages, and underdosing.
Report Facts
Residents reviewed for neglect: 7
Residents reviewed for abuse: 7
Residents reviewed for medication errors: 4
Medication administration errors: 3
Delay in abuse reporting: 4
Delay in abuse reporting: 5
Medication error dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | RNS | Witnessed Resident #6 without lap buddy and responded to fall. |
| Director of Nursing | DON | Acknowledged failure to follow care plan and incomplete investigations. |
| Administrator | Provided statements on abuse reporting requirements and investigations. | |
| Licensed Practical Nurse #2 | LPN | Administered medications in error to Residents #9, #10, and #11. |
| Registered Nurse Manager #1 | RNM | Discussed medication error remediation and dose changes. |
| Registered Nurse Educator | RNE | Discussed nursing competencies and follow-up on medication errors. |
Inspection Report — Aug 18, 2022
Annual Inspection CMS
Date: Aug 18, 2022
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with Medicare and Medicaid regulations and facility standards.
Findings
The facility failed to provide timely notification to residents regarding Medicare service termination and did not maintain food preparation and kitchen equipment according to professional standards, including calibration of thermometers and cleanliness of kitchen areas.
Citations (2)
F 0582: The facility did not ensure residents receiving Medicare Part A were given timely 2-day notification of service termination using the required Notice of Medicare Non-Coverage form.
F 0812: The facility did not ensure food was prepared and served in accordance with professional standards, including an uncalibrated food thermometer, a malfunctioning dishwashing machine thermometer display, and soiled refrigerators and floors in multiple kitchens.
Report Facts
Residents reviewed: 3
Country Kitchens inspected: 3
Activities Kitchens inspected: 6
Inspection Report — Jan 31, 2020
Annual Inspection CMS
Date: Jan 31, 2020
Visit Reason
The survey was a recertification annual inspection to assess compliance with regulatory requirements and investigate specific complaints and incidents.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of psychotropic medication changes, inadequate investigation of abuse allegations, insufficient supervision to prevent resident elopement, lack of a complete medication regimen review policy, incomplete facility-wide staffing assessment, and deficiencies in infection prevention and control practices.
Citations (6)
F 0580: The facility did not ensure the resident representative was notified of psychotropic medication changes for Resident #108 with cognitive impairment.
F 0610: The facility failed to thoroughly investigate an allegation of rough care by a staff member for Resident #25, and did not document RN assessments after the incident.
F 0689: The facility did not provide adequate supervision to prevent elopement of Resident #105, who was found outside the building undetected.
F 0756: The facility lacked a policy with established time frames for steps in the monthly Medication Regimen Review process.
F 0838: The facility assessment did not include evaluation of staff needed to ensure sufficient qualified staff to meet residents' needs.
F 0880: The facility failed to maintain infection prevention and control practices including improper dressing change technique, cross-contamination of wound care supplies, and unsafe intravenous medication administration.
Report Facts
Deficiencies cited: 6
Wound measurement: 11.1
Wound measurement: 13.5
Wound measurement: 0.1
Wound measurement: 11.2
Wound measurement: 12.2
Wound measurement: 3
Medication dosage: 0.5
Medication dosage: 12.5
Medication dosage: 250
Medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in infection control deficiencies related to improper dressing change and IV medication administration. |
| RN #5 | Registered Nurse | Named in infection control deficiency for carrying wound care supplies between resident rooms without proper precautions. |
| RNUM #2 | Registered Nurse Unit Manager | Interviewed regarding failure to notify resident representative and abuse investigation. |
| DON | Director of Nursing | Interviewed regarding notification policies, abuse investigation, infection control, and facility assessment. |
| Administrator | Facility Administrator | Interviewed regarding abuse investigation and elopement incident. |
| Infection Control Nurse/Staff Education Nurse #2 | Infection Control Nurse | Interviewed regarding lack of dressing change in-service and infection control education. |
| Infection Control Coordinator #3 | Infection Control Coordinator | Interviewed regarding pseudomonas infections and wound care education. |
| Nurse Manager for Quality Assurance #7 | Nurse Manager | Interviewed regarding wound care practices and infection control. |
Inspection Report — Nov 30, 2018
Annual Inspection CMS
Date: Nov 30, 2018
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of transfers and bed hold policies to residents and representatives, incomplete implementation of comprehensive care plans, inadequate supervision to prevent accidents, improper medication management including pain medication monitoring and antibiotic stewardship, food safety violations in kitchen operations, and lack of policy on safe food handling for foods brought in by visitors.
Citations (9)
F 0623: The facility did not ensure timely written notification to residents and representatives of transfer/discharge reasons in a language they understand for two residents.
F 0625: The facility did not provide written notice specifying the duration of the bed hold policy to residents and representatives at the time of transfer for two residents.
F 0656: The facility failed to develop and implement complete care plans with measurable objectives for three residents, including failure to implement 15-minute checks, dysphagia interventions, and skin issue care plans.
F 0689: The facility did not ensure adequate supervision to prevent accidents for two residents, including failure to provide 1:1 supervision during unsafe behaviors and failure to provide plasticware as care planned.
F 0756: The facility policy for monthly drug regimen review did not include steps for pharmacist action when urgent irregularities are identified.
F 0757: The facility did not ensure residents received pain medications with adequate monitoring or prevent unnecessary drug use, including inadequate pain scale documentation and antibiotic dose duplication.
F 0758: The facility did not ensure comprehensive gradual dose reductions for psychotropic medications were completed for one resident over a one-year period.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, including improper sanitizer concentration, uncalibrated thermometers, and unsanitary kitchen conditions.
F 0813: The facility policy on foods brought by visitors did not include information on safe food handling, storage, or reheating practices.
Report Facts
Medication administrations: 35
Medication administrations: 29
Medication doses: 20
Sanitizer concentration: 0
Sanitizer concentration: 150
Food thermometer readings: 25
Food thermometer readings: 27
Food thermometer readings: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #2 | Social Worker | Named in findings related to transfer/discharge notification and gradual dose reduction documentation |
| Director of Nursing | Director of Nursing | Named in findings related to transfer/discharge notification, bed hold policy, medication management, and gradual dose reduction process |
| Registered Nurse #2 | MDS Coordinator | Named in findings related to transfer/discharge notification and bed hold policy |
| Certified Nursing Assistant #4 | CNA | Named in findings related to failure to implement 15-minute checks and dysphagia care plan |
| Certified Nursing Assistant #5 | CNA | Named in findings related to failure to implement 15-minute checks and dysphagia care plan |
| Licensed Practical Nurse #4 | LPN | Named in findings related to dysphagia care plan |
| Registered Nurse #8 | RN | Named in findings related to skin care plan and accident supervision |
| Certified Nursing Assistant #7 | CNA | Named in findings related to accident supervision and unsafe behaviors |
| Nurse Manager #3 | Nurse Manager | Named in findings related to pain medication documentation |
| Pharmacist | Pharmacist | Named in findings related to drug regimen review and gradual dose reduction process |
| Nurse Practitioner | Nurse Practitioner | Named in findings related to antibiotic stewardship and gradual dose reduction process |
| Director of Support Services | Director of Support Services | Named in findings related to food service safety and visitor food policy |
| Social Worker #1 | Social Worker | Named in findings related to visitor food policy |
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