Inspection Reports for
Carthage Center for Rehabilitation and Nursing

1045 West Street, Carthage, NY, 13619

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7 Reports · 1 Summary

2021–2024

Inspection Summary

8 inspections covered, June 2022 – September 2024.

Inspection Reports Summary


Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2024 with detailed deficiency and enforcement history.

Complaint Details
The state logged 97 complaints about this facility; 21 led to on-site inspections. Complaint surveys were conducted on multiple dates with citations issued.
Findings
Across 8 inspections, the facility received 74 citations including 33 standard health and 41 Life Safety Code citations. Most deficiencies were Level 2 with minor potential harm, but some Level 3 citations indicated actual harm; 3 enforcement actions with fines totaling $32,000 were recorded.

Citations (39)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents had isolated and pattern Level 2 deficiencies.
Standard Health Citation — quality of care: Dialysis had an isolated Level 2 deficiency.
Standard Health Citation — quality of care: Discharge Planning Process had an isolated Level 2 deficiency.
Standard Health Citation — quality of care: Food In Form To Meet Individual Needs had an isolated Level 2 deficiency.
Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary had a pattern Level 2 deficiency.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices had isolated and pattern Level 2 deficiencies.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility had an isolated Level 2 deficiency.
Standard Health Citation — quality of care: Medicaid/medicare Coverage/liability Notice had an isolated Level 2 deficiency.
Standard Health Citation — quality of care: Nutritive Value/appear, Palatable/prefer Temp had a pattern Level 2 deficiency.
Standard Health Citation — quality of care: Other Laws, Codes, Rules And Regulations had a Level 0 deficiency.
Standard Health Citation — quality of care: Quality Of Care had isolated Level 2 and Level 3 deficiencies.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment had pattern Level 2 deficiencies.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer had isolated Level 2 and Level 3 deficiencies.
Life Safety Code Citation — NFPA requirements: Cooking Facilities had pattern Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Discharge From Exits had isolated Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Doors With Self-closing Devices had pattern Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenanc had widespread Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste had widespread Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Emergency Lighting had pattern Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance had pattern Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Fire Drills had pattern and isolated Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General had isolated Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Policies/procedures For Sheltering In Place had pattern Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers had isolated Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Procedures For Tracking Of Staff And Patients had pattern Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation had pattern Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing had pattern and isolated Level 2 deficiencies.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie had pattern and isolated Level 2 deficiencies.
Standard Health Citation — quality of care: Preparation For Safe/orderly Transfer/dschrg had isolated Level 2 deficiencies.
Standard Health Citation — quality of care: License/comply W/ Fed/state/locl Law/prof Std had isolated Level 2 deficiencies.
Standard Health Citation — quality of care: Safe/functional/sanitary/comfortable Environ had pattern Level 2 deficiencies.
Standard Health Citation — quality of care: Bowel/bladder Incontinence, Catheter, Uti had isolated Level 2 deficiencies.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation had isolated Level 2 deficiencies.
Standard Health Citation — quality of care: Lab Srvcs Physician Order/notify Of Results had pattern Level 2 deficiencies.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation had isolated Level 2 deficiencies.
Standard Health Citation — quality of care: Notice Requirements Before Transfer/discharge had isolated Level 2 deficiencies.
Standard Health Citation — quality of care: Permitting Residents To Return To Facility had isolated Level 2 deficiencies.
Standard Health Citation — quality of care: Quality Of Care had isolated Level 3 deficiencies indicating actual harm.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer had isolated Level 3 deficiencies indicating actual harm.
Report Facts
Inspections on page: 8 Total violations/deficiencies cited: 74 Inspections with violations: 7 Inspections without violations: 1 Total complaints: 97 On-site complaint inspections: 21 Total enforcement actions: 3 Total fines: 32000 Citations from complaints: 19

Individual Reports

One document per inspection visit.

Inspection Report — Sep 26, 2024

Annual Inspection
Date: Sep 26, 2024

Visit Reason
The survey was a recertification and abbreviated survey conducted from 9/23/2024 to 9/26/2024 to assess compliance with regulatory requirements for the nursing home.

Findings
The facility had multiple deficiencies including failure to provide appropriate Medicare liability notices, maintain a safe and homelike environment, ensure discharge planning, provide adequate assistance with activities of daily living, maintain proper urinary catheter care, provide appropriate pressure ulcer care, apply recommended splints, ensure safe resident transfers, provide appropriate dialysis care, serve palatable and properly prepared food, and maintain food safety and sanitation standards.

Citations (12)
F 0582: The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage to a Medicare resident after discontinuation of Medicare Part A services.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment, with issues such as stained carpets, burned out lights, broken fixtures, missing tiles, and dirty floor mats in resident units.
F 0660: The facility failed to ensure discharge planning was conducted and communicated for a resident wishing to be discharged to an assisted living facility.
F 0677: The facility did not provide necessary assistance with activities of daily living for residents, including failure to assist with facial hair removal and proper grooming.
F 0684: The facility failed to provide treatment and care consistent with professional standards for a resident with an indwelling urinary catheter, as the catheter drainage bag was observed above bladder level.
F 0686: The facility did not ensure residents with pressure ulcers received appropriate treatment and services, including proper air mattress settings, turning and repositioning, and offloading of foot wounds.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for residents with hand contractures, as recommended splints and palm guards were not applied consistently.
F 0689: The facility did not ensure adequate supervision and safe transfer practices for a resident requiring mechanical lift assistance, transferring the resident without the required lift device.
F 0698: The facility failed to provide safe, appropriate dialysis care and oversight for a resident receiving hemodialysis, including inconsistent pre- and post-dialysis assessments and inaccurate documentation of access site.
F 0804: The facility did not ensure food was palatable, flavorful, and served at safe and appetizing temperatures during multiple meals and resident events.
F 0805: The facility failed to provide food prepared in a form designed to meet individual needs, serving thin liquids to a resident ordered nectar thick liquids.
F 0812: The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards, including improper cooling of foods, outdated food, unclean surfaces, and a malfunctioning dishwasher.
Report Facts
Deficiencies cited: 12 Temperature: 94 Temperature: 87 Temperature: 49.6 Temperature: 49.5 Temperature: 40 Temperature: 135 Temperature: 100 Temperature: 99 Temperature: 94 Weight: 123 Air mattress setting: 380 Air mattress setting: 230

Employees mentioned
NameTitleContext
Business Office Manager #16Named in relation to Medicare notice deficiency
Housekeeper #5Named in relation to environmental cleanliness deficiency
Licensed Practical Nurse #6Named in relation to personal care and hygiene deficiencies
Housekeeper #8Named in relation to environmental cleanliness deficiency
Maintenance Director #7Named in relation to environmental cleanliness deficiency
Physical Therapist #12Named in relation to discharge planning and transfer recommendations
Occupational Therapist #13Named in relation to discharge planning and splint recommendations
Director of Social WorkNamed in relation to discharge planning deficiency
Certified Nurse Aide #15Named in relation to personal care and transfer deficiencies
Licensed Practical Nurse #14Named in relation to personal care and catheter care deficiencies
Certified Nurse Aide #34Named in relation to personal care and hygiene deficiencies
Certified Nurse Aide #36Named in relation to personal care and hygiene deficiencies
Assistant Director of NursingNamed in relation to catheter care, air mattress, and transfer deficiencies
Certified Nurse Aide #41Named in relation to turning and repositioning deficiency
Licensed Practical Nurse #28Named in relation to dialysis and air mattress deficiencies
Registered Nurse #39Named in relation to wound care and dialysis
Licensed Practical Nurse #31Named in relation to offloading boot deficiency
Licensed Practical Nurse Unit Manager #22Named in relation to splint, transfer, dialysis, and air mattress deficiencies
Certified Nurse Aide #24Named in relation to transfer deficiency
Licensed Practical Nurse Manager #22Named in relation to transfer deficiency
Physical Therapist #23Named in relation to splint and transfer deficiencies
Director of NursingNamed in relation to splint, transfer, and dialysis deficiencies
Licensed Practical Nurse #14Named in relation to dialysis care deficiency
Food Service Director #33Named in relation to food service deficiencies
Activities Aide #42Named in relation to food service deficiencies
Physical Therapist #17Named in relation to diet consistency deficiency
Licensed Practical Nurse #6Named in relation to diet consistency deficiency
Licensed Practical Nurse Unit Manager #32Named in relation to diet consistency deficiency
Certified Nurse Aide #30Named in relation to diet consistency deficiency
Licensed Practical Nurse #28Named in relation to dialysis care deficiency
Assistant Director of Nursing #3Named in relation to dialysis care deficiency
Corporate Registered Dietitian #45Named in relation to food safety deficiency
[NAME] #44Named in relation to food safety deficiency

Inspection Report — Feb 23, 2024

Abbreviated Survey
Date: Feb 23, 2024

Visit Reason
The visit was an abbreviated survey to evaluate the facility's compliance with discharge planning requirements, specifically focusing on the preparation and orientation of residents for safe and orderly transfer or discharge.

Findings
The facility failed to provide and document sufficient discharge planning for Resident #6, who was discharged without a documented discharge plan. There was no evidence that necessary referrals, equipment orders, or follow-up appointments were established prior to discharge.

Citations (1)
10NYCRR415.11(d)(3) The facility did not provide or document sufficient preparation and orientation to ensure safe and orderly transfer or discharge for Resident #6. Discharge planning, referrals for post-discharge care, and equipment orders were not established prior to discharge.
Report Facts
Residents affected: 1 Pages faxed: 26

Employees mentioned
NameTitleContext
Director of TherapyInterviewed regarding walker use and discharge equipment
medical records staff #10Interviewed about discharge process and record handling for Resident #6
Director of NursingInterviewed about discharge planning process and social worker role
registered nurse #9Registered NurseSigned discharge instructions and transfer/discharge notice for Resident #6
social worker #8Social worker responsible for discharge coordination but was new and left position shortly after
physician #12PhysicianProvided orders and progress notes related to Resident #6's care and discharge
occupational therapist #7Occupational TherapistSigned discharge instructions recommending equipment for Resident #6

Inspection Report — Dec 8, 2023

Abbreviated Survey
Date: Dec 8, 2023

Visit Reason
The abbreviated survey was conducted due to a complaint regarding the heating system failure on the South Unit of the nursing home, which caused cold conditions for residents over several days in November 2023.

Complaint Details
The complaint was substantiated. Resident #1 reported the heat was off for 3 days on the South Unit and overheard staff say the heat would not be fixed until 11/27/2023. Interviews and record reviews confirmed the heating outage and inadequate response.
Findings
The facility failed to maintain a safe and comfortable environment on the South Unit when the heat stopped working from 11/22/2023 to 11/24/2023. The facility did not report the heating outage to the New York State Department of Health as required and did not consistently monitor temperatures or implement a plan to ensure resident comfort during the outage.

Citations (2)
F 0836: The facility did not operate in compliance with applicable laws and standards when the heat stopped working on the South Unit from 11/22/2023 to 11/24/2023 and the outage was not reported to the New York State Department of Health.
F 0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment during the heating outage on the South Unit from 11/22/2023 to 11/24/2023, with no routine temperature monitoring or consistent plan to maintain resident comfort.
Report Facts
Temperature range: 62.9 Temperature range: 66.8 Temperature monitoring hours: 7 Temperature monitoring hours: 8

Inspection Report — Apr 14, 2023

Abbreviated Survey
Date: Apr 14, 2023

Visit Reason
The abbreviated survey was conducted to investigate alleged violations related to abuse, neglect, and failure to provide appropriate care and timely laboratory result notification for residents.

Findings
The facility failed to thoroughly investigate injuries of unknown origin for one resident and failed to provide timely treatment and notification of abnormal laboratory results for multiple residents. Documentation and follow-up on incidents and lab results were inconsistent and incomplete.

Citations (3)
F 0610: The facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for Resident #6 who had bruising of unknown origin that was not properly investigated or reported immediately.
F 0690: The facility failed to ensure Resident #4, who was incontinent of bladder, received timely urinalysis and treatment for a urinary tract infection, with the urinalysis completed 9 days after the order date.
F 0773: The facility failed to promptly notify the ordering practitioner of abnormal laboratory results for Residents #2, 5, 6, and 7, resulting in delays in treatment and follow-up.
Report Facts
Residents reviewed: 7 Days delay for urinalysis: 9 Potassium level: 3.1 White blood cell count: 12.9

Employees mentioned
NameTitleContext
LPN Supervisor #16Licensed Practical Nurse SupervisorNamed in investigation of Resident #6's bruising incident.
Former DON #23Director of NursingDocumented assessment and investigation of Resident #6's injuries.
OT #31Occupational TherapistObserved bruising on Resident #6 and reported to DON.
LPN #7Licensed Practical NurseDocumented lab results and notifications for Resident #2.
NP #27Nurse PractitionerReviewed lab results and provided treatment orders for Resident #2.
LPN #17Licensed Practical NurseReviewed labs and documented orders for Residents #5 and #6.
LPN #21Licensed Practical NurseDocumented physician notification and orders for Resident #4.
Attending PhysicianExpected timely notification of abnormal lab results and reviewed Resident #4's case.

Inspection Report — Mar 16, 2023

Annual Inspection
Date: Mar 16, 2023

Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for nursing home care.

Findings
The facility failed to provide adequate assistance with activities of daily living (ADLs) for multiple residents due to insufficient staffing. Deficiencies included lack of timely personal hygiene care, improper supervision during meals, and failure to follow care plans for residents requiring assistance with transfers and diet consistency.

Citations (3)
F 0677: The facility failed to ensure residents unable to perform ADLs received necessary care, including hygiene, oral care, and assistance with dentures, resulting in residents being in bed during meals and poor personal care.
F 0689: The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents, including allowing a resident on nectar thick liquids to have thin liquids unsupervised and transferring a resident requiring two staff with only one.
F 0725: The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed or missed ADL care and residents waiting 3-4 hours for assistance.
Report Facts
Residents requiring 1-2 staff for dressing: 62 Residents requiring 1-2 staff for bathing: 69 Residents requiring 1-2 staff for transfers: 65 Residents requiring 1-2 staff for eating: 66 Residents requiring 1-2 staff for toileting: 62 Residents on thickened liquids: 3 Residents reviewed for ADL deficiencies: 3

Employees mentioned
NameTitleContext
CNA #19Certified Nurse AideNamed in findings related to inadequate resident care and supervision
LPN #22Licensed Practical NurseNamed in findings related to staffing and resident care
RN Unit Manager #5Registered Nurse Unit ManagerNamed in findings related to staffing and resident care
Director of NursingDirector of NursingProvided statements regarding staffing and care deficiencies
CNA #11Certified Nurse AideNamed in findings related to resident care and supervision
LPN #15Licensed Practical NurseNamed in staffing and care observations
Staffing Coordinator #18Staffing CoordinatorProvided information on staffing levels and challenges

Inspection Report — Mar 16, 2023

Annual Inspection
Date: Mar 16, 2023

Visit Reason
The survey was a recertification and abbreviated survey conducted to assess compliance with regulatory requirements for nursing home care.

Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, inadequate posting of survey results, unsafe and unclean environment, insufficient assistance with activities of daily living, inadequate supervision to prevent accidents, insufficient nursing staff, failure to provide nutritional supplements, serving food at unsafe temperatures, and non-functional or inaccessible call bell systems.

Citations (9)
F 0558: The facility failed to reasonably accommodate the needs and preferences of Resident #385 by not providing a longer bed despite multiple requests, resulting in pressure ulcers worsening due to heels pressing against the footboard.
F 0577: The facility failed to post the results and plan of correction for the most recent Life Safety Code Federal survey conducted on 6/24/21 in a place accessible to residents and families.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment with unclean and damaged floors, walls, windows, and doors in 33 resident rooms and 3 common areas.
F 0677: The facility failed to provide adequate assistance with activities of daily living for multiple residents, including failure to assist with incontinence care, oral care, showers, denture placement, and dressing, partly due to staffing shortages.
F 0689: The facility failed to ensure residents received adequate supervision to prevent accidents, including residents on aspiration precautions receiving thin liquids and unsupervised meals, and improper transfer of a resident requiring two-person assistance.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed or missed care, including residents waiting 3-4 hours for assistance with activities of daily living.
F 0800: The facility failed to provide a nourishing, palatable, well-balanced diet meeting residents' nutritional needs, specifically failing to provide Resident #19 with a nutritional supplement (Magic Cup) for two lunch meals as planned.
F 0804: The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures, with multiple observations of hot food served below 140°F and vegetables overcooked and mushy.
F 0919: The facility failed to ensure a working call system was available and within reach in resident rooms and bathing areas, with multiple call bell cords missing, too short, or not accessible to residents.
Report Facts
Residents affected: 1 Residents affected: 33 Residents affected: 2 Residents affected: 7 Residents affected: 2 Residents affected: 3 Residents affected: 1 Residents affected: 16 Residents affected: 13

Employees mentioned
NameTitleContext
RN #5Registered Nurse Unit ManagerNamed in findings related to bed extender request and ADL care
LPN #4Licensed Practical NurseNamed in findings related to bed extender request and aspiration precautions
CNA #3Certified Nursing AssistantNamed in findings related to bed extender request and ADL care
CNA #19Certified Nursing AssistantNamed in findings related to ADL care and nutritional supplement
Director of MaintenanceNamed in findings related to bed extender request and call bell maintenance
OT #7Occupational TherapistNamed in findings related to bed extender request
AdministratorNamed in findings related to bed extender request and staffing
DONDirector of NursingNamed in findings related to ADL care, nutritional supplements, staffing, and call bells
RD #26Registered DietitianNamed in findings related to nutritional supplements
Food Service DirectorNamed in findings related to food temperature and nutritional supplements
LPN #15Licensed Practical NurseNamed in staffing and ADL care findings
LPN #22Licensed Practical NurseNamed in findings related to ADL care, aspiration precautions, and call bells
CNA #11Certified Nursing AssistantNamed in findings related to aspiration precautions and ADL care
CNA #13Certified Nursing AssistantNamed in findings related to denture care and staffing
CNA #21Certified Nursing AssistantNamed in findings related to nutritional supplement and call bells
LPN Unit Manager #10Licensed Practical Nurse Unit ManagerNamed in findings related to call bells and aspiration precautions
Staffing Coordinator #18Named in findings related to staffing

Inspection Report — Jun 24, 2021

Annual Inspection
Date: Jun 24, 2021

Visit Reason
The survey was conducted as part of the recertification and abbreviated surveys for the nursing home to assess compliance with regulatory requirements.

Findings
The facility was found deficient in multiple areas including failure to ensure physician orders were in place at admission, inadequate assistance with activities of daily living, incomplete pressure ulcer care and prevention, failure to maintain resident mobility, improper catheter care, lack of provision of special eating equipment, and incomplete and inaccurate medical record documentation.

Citations (7)
F0635: The facility did not ensure physician orders for the resident's immediate care were in place on admission, resulting in delayed medication and dietary orders for one resident.
F0677: The facility failed to provide necessary assistance with activities of daily living including dressing, oral hygiene, nail care, and facial grooming for three residents.
F0686: The facility did not develop and implement a comprehensive care plan for pressure ulcer prevention and failed to reassess and re-evaluate interventions for one resident with skin impairments.
F0688: The facility did not ensure a resident with limited range of motion received appropriate services and assistance to maintain or improve mobility, and failed to implement a plan to maintain the resident's mobility.
F0690: The facility failed to provide necessary catheter care and treatment for a resident with an indwelling catheter, including lack of physician orders and failure to address frequent catheter leakage.
F0810: The facility did not provide special eating equipment and utensils, specifically a spouted cup, for a resident who needed them and appropriate assistance to use them during meals.
F0842: The facility did not maintain complete and accurate medical records for a resident, continuing to document use of an edema glove that was no longer required and was not removed from the plan of care.
Report Facts
Residents affected: 1 Residents affected: 3 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Edema glove use documented: 62

Employees mentioned
NameTitleContext
LPN #14Licensed Practical NurseInvolved in admission process and medication administration for Resident #279
DONDirector of NursingProvided statements regarding admission process and care plan implementation
CNA #13Certified Nurse AideProvided care and mouth hygiene for Resident #7
LPN Manager #6Licensed Practical Nurse ManagerProvided statements regarding resident care and admission processes
SLP #2Speech Language PathologistProvided evaluation and recommendations for Resident #329's swallowing and eating needs
OT #3Occupational TherapistProvided assistive device recommendations for Resident #329
Food Services DirectorResponsible for ordering and providing special eating equipment
Physician #33PhysicianProvided statements regarding catheter care and expectations

8 CMS Surveys

CMS Survey — Mar 16, 2023

Mar 16, 2023

CMS Survey — Apr 14, 2023

Apr 14, 2023

CMS Survey — Dec 8, 2023

Dec 8, 2023

CMS Survey — Feb 23, 2024

Feb 23, 2024

CMS Survey — Sep 26, 2024

Sep 26, 2024

CMS Survey — Jun 24, 2021

Jun 24, 2021

CMS Survey — Mar 16, 2023

Mar 16, 2023

CMS Survey — Sep 26, 2024

Sep 26, 2024

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