Inspection Report — Mar 7, 2025
Complaint Investigation
Capacity: 380
Citations: 10
Date: Mar 7, 2025
Visit Reason
The inspection was conducted as a Recertification/Complaint Survey from 03/02/2025 to 03/07/2025 to investigate complaints and assess compliance with regulatory requirements.
Complaint Details
The visit was complaint-related, triggered by allegations including residents' rights violations, environmental concerns, medication errors, and staffing shortages. The complaint intake summary dated 12/18/2024 noted leaks in ceilings needing patching.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to refuse room transfers, inadequate maintenance of a clean and homelike environment, inaccurate resident assessments, incomplete baseline care plans, medication administration errors, inadequate treatment for limited range of motion, insufficient nursing staff to meet resident needs, failure to act on pharmacy recommendations, and improper medication storage.
Citations (10)
Failure to ensure a resident had the right to refuse a room transfer without consent.
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple rooms showing water damage and stains.
Minimum Data Set assessments did not accurately reflect residents' status, including bowel/bladder continence and diagnosis coding.
Failure to provide resident and/or representative with a written summary of the baseline care plan within 48 hours of admission.
Resident did not receive prescribed Cyanocobalamin Injection as ordered; medication order contained conflicting routes and was not clarified.
Resident with limited range of motion did not receive appropriate treatment; hand roll device was frequently not applied as ordered.
Insufficient nursing staff provided to meet residents' needs, especially on weekends, evenings, and nights, resulting in delays in care and response.
Attending physician did not document review or action on pharmacy recommendation to correct medication order.
Medication error rate exceeded 5% due to failure to administer three prescribed medications to a resident because medications were unavailable.
Drugs and biologicals were not labeled or stored according to professional standards; insulin pens were undated and expired insulin was not discarded.
Report Facts
Residents sampled: 38
Bed capacity: 380
Medication error rate: 11.11
Hand roll non-application: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Social Worker | Responsible for informing Resident #125 of room change and obtaining consent; stated no consent was documented |
| Director of Social Services | Stated resident must agree to room change unless medically necessary; unsure of reason for Resident #125's room change | |
| Regional Director of Social Services | Stated Resident #125 requested room change but no documentation supports this | |
| Registered Nurse #5 | Registered Nurse | Interviewed about Resident #98's care needs and continence status |
| Minimum Data Set Coordinator #1 | MDS Coordinator | Responsible for completing MDS for Resident #98; acknowledged errors in bowel/bladder coding |
| Minimum Data Set Coordinator #2 | MDS Coordinator | Completed MDS for Resident #125; acknowledged failure to code Bipolar Disorder diagnosis |
| Minimum Data Set Coordinator #3 | MDS Department Overseer | Oversaw MDS department; stated no review of accuracy of assessments |
| Registered Nurse #1 | Unit Manager | Observed medication administration; aware of medication order error for Resident #19 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Administered medications; unaware of injection order for Resident #19; involved in medication error |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding staffing, medication errors, and care plan processes |
| Medical Doctor #1 | Physician | Attending physician for Resident #19; acknowledged medication order error and missed pharmacy recommendation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported no hand rolls available for Resident #56 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Acknowledged failure to apply hand roll for Resident #56 |
| Registered Nurse #3 | Registered Nurse | Reviewed treatment administration records for hand roll application |
| Staffing Coordinator | Staffing Coordinator | Discussed staffing challenges and recruitment efforts |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported staffing shortages and impact on resident care |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Reported staffing shortages and impact on treatments |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Reported staffing shortages and impact on medication and treatment administration |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Reported staffing shortages on weekends and impact on resident care |
| Registered Nurse #2 | Staff Educator | Discussed medication storage training and unlabelled insulin pens |
| Pharmacy Consultant | Pharmacy Consultant | Performed drug regimen reviews; reported pharmacy recommendations not acted upon |
Inspection Report — Mar 7, 2025
Citations: 30
Date: Mar 7, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The facility received 113 complaints with 12 on-site inspections resulting in 3 citations from complaints during the reporting period.
Findings
Across 9 inspections, 7 had no citations while 2 inspections resulted in 30 citations total, including 16 standard health and 14 Life Safety Code citations. The facility had 113 complaints with 12 on-site inspections and no formal enforcement actions.
Citations (30)
Standard Health Citation — quality of care: Accuracy Of Assessments found deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Baseline Care Plan deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Drug Regimen Review, Report Irregular, Act On deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Free Of Medication Error Rts 5 Prcnt Or More deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Quality Of Care deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Right To Refuse Certain Transfers deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Sufficient Nursing Staff deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Discharge From Exits deficient with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Accuracy Of Assessments deficient with pattern potential for minimal harm.
Standard Health Citation — quality of care: Care Plan Timing And Revision deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary deficient with widespread minor potential harm.
Standard Health Citation — quality of care: Free From Abuse And Neglect deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Pain Management deficient with isolated minor potential harm.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficient with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Alcohol Based Hand Rub Dispenser (abhr) deficient with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Corridor - Doors deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Corridors - Construction Of Walls deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Physical Environment deficient with no harm potential.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers deficient with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Soiled Linen And Trash Containers deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation deficient with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures deficient with pattern minor potential harm.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Compar deficient with widespread minor potential harm.
Report Facts
Inspections on page: 9
Total violations/deficiencies cited: 30
Inspections with violations: 2
Inspections without violations: 7
Total complaints: 113
On-site complaint inspections: 12
Citations from complaints: 3
Total enforcement actions: 0
Inspection Report — Apr 12, 2023
Complaint Investigation
Citations: 2
Date: Apr 12, 2023
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey from 4/3/23 to 4/12/23, triggered by allegations of abuse involving Resident #13 and a review of care plan compliance for Resident #230 related to elopement risk.
Complaint Details
The complaint investigation involved Resident #13 who reported being hit by CNA #4 on 12/8/22. The facility's Accident/Incident Report and multiple interviews with Resident #13, staff, and other residents substantiated the abuse. CNA #4 was terminated and local law enforcement was involved.
Findings
The facility failed to protect Resident #13 from abuse by a Certified Nursing Assistant (CNA #4) who hit the resident after being asked to leave the room. The investigation substantiated the abuse allegation. Additionally, the facility did not ensure Resident #230's Comprehensive Care Plan related to elopement risk was reviewed and revised quarterly as required.
Citations (2)
Failure to protect Resident #13 from abuse by CNA #4 who hit the resident on the left temple.
Failure to review and revise Resident #230's Comprehensive Care Plan related to elopement risk after each assessment.
Report Facts
Residents investigated for abuse: 5
Residents affected: 1
Residents investigated for accidents: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Named in abuse finding for hitting Resident #13 |
| Assistant Director of Nursing | ADON | Interviewed regarding abuse investigation and care plan compliance |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding Resident #230's elopement risk and monitoring |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding Resident #230's elopement behavior |
| Registered Nurse #4 | RN | Interviewed regarding care plan updates for Resident #230 |
Inspection Report — Apr 12, 2023
Annual Inspection
Citations: 5
Date: Apr 12, 2023
Visit Reason
The inspection was conducted as a Recertification Survey from 04/03/2023 to 04/12/2023 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in timely reporting of suspected abuse, accuracy of Minimum Data Set (MDS) assessments, comprehensive care plan reviews, pain management, and food storage practices. Specific issues included failure to report an unwitnessed fall with injury within 2 hours, inaccurate MDS documentation for multiple residents, failure to update care plans quarterly, inadequate pain medication administration, and storage of expired food items.
Citations (5)
Failure to timely report suspected abuse or injuries of unknown source to the New York State Department of Health within 2 hours, specifically for Resident #26's unwitnessed fall with a laceration.
Inaccurate Minimum Data Set (MDS) assessments for 4 residents, including failure to document continuous oxygen use, incorrect diagnosis of schizophrenia, failure to document vision impairment, and failure to document use of wander alert device.
Failure to review and revise Resident #230's Comprehensive Care Plan related to elopement risk upon each quarterly assessment.
Failure to provide pain management as ordered for Resident #217, including not administering pain medications despite resident complaints and physician orders.
Food safety violations including storage of expired half and half creamers and expired saltine crackers in the kitchen and dry storage room.
Report Facts
Residents reviewed for Falls: 3
Residents sampled for MDS accuracy: 35
Residents investigated for Accidents: 5
Residents reviewed for pain management: 9
Expired food items observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #2 | Interviewed regarding Resident #26's fall and reporting procedures. | |
| Director of Nursing (DON) | Interviewed regarding reporting decisions and pain management policies. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding reporting procedures and MDS oversight. | |
| Administrator | Interviewed regarding video review and incident conclusions for Resident #26. | |
| MDS Coordinator | Interviewed regarding MDS scheduling and accuracy oversight. | |
| MDS Assessor (MDSA) | Interviewed regarding MDS assessment errors and diagnosis documentation. | |
| Certified Nursing Assistant (CNA) #5 | Interviewed regarding Resident #230's behavior and monitoring. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding pain medication administration for Resident #217. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding pain medication administration and Resident #230's wanderguard. | |
| Registered Nurse (RN) #1 | Interviewed regarding pain assessment and medication administration. | |
| Dietary Aide | Interviewed regarding expired food items in dry storage. | |
| Dietary Supervisor (DS) #1 | Interviewed regarding food storage and expiration checks. | |
| Dietary Supervisor (DS) #2 | Interviewed regarding food storage rounds and expired items. | |
| Food Service Director (FSD) | Interviewed regarding food storage oversight and expired items. | |
| Physician Assistant (PA) | Interviewed regarding Resident #45's mental health diagnoses. | |
| Medical Doctor (MD) | Interviewed regarding Resident #45's diagnoses and pain management. | |
| Psychologist | Interviewed regarding Resident #45's mental health status. |
Inspection Report — Mar 6, 2020
Annual Inspection
Citations: 1
Date: Mar 6, 2020
Visit Reason
The inspection was conducted as a Recertification survey to assess the facility's compliance with infection prevention and control practices.
Findings
The facility failed to ensure proper infection control practices, specifically a Certified Nursing Assistant (CNA) was observed not performing hand hygiene after contact with a trash bin and after exiting the soiled utility room before interacting with residents. Interviews with staff confirmed expectations and training on hand hygiene.
Citations (1)
Failure to provide and implement an infection prevention and control program, specifically inadequate hand hygiene by a Certified Nursing Assistant.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | CNA | Observed failing to perform hand hygiene after contact with trash bin and soiled utility room. |
| Registered Nurse | RN | Interviewed regarding hand hygiene expectations for staff. |
| Assistant Director of Nursing Services | ADNS / Facility Infection Control Representative | Interviewed regarding hand hygiene policies and education. |
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