Inspection Reports for
Carthage Center for Rehabilitation and Nursing
1045 West Street, Carthage, NY, 13619
Back to Facility ProfileCitations (last 4 years)
Citations (over 4 years)
16.5 citations/year
Citations are regulatory findings recorded during state inspections.
224% worse than New York average
New York average: 5.1 citations/yearCitations per year
40
30
20
10
0
Inspection Report
Annual Inspection
Citations: 12
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
| Name | Title | Context |
|---|---|---|
| Business Office Manager #16 | Named in relation to Medicare notice deficiency | |
| Housekeeper #5 | Named in relation to environmental cleanliness deficiency | |
| Licensed Practical Nurse #6 | Named in relation to personal care and hygiene deficiencies | |
| Housekeeper #8 | Named in relation to environmental cleanliness deficiency | |
| Maintenance Director #7 | Named in relation to environmental cleanliness deficiency | |
| Physical Therapist #12 | Named in relation to discharge planning and transfer recommendations | |
| Occupational Therapist #13 | Named in relation to discharge planning and splint recommendations | |
| Director of Social Work | Named in relation to discharge planning deficiency | |
| Certified Nurse Aide #15 | Named in relation to personal care and transfer deficiencies | |
| Licensed Practical Nurse #14 | Named in relation to personal care and catheter care deficiencies | |
| Certified Nurse Aide #34 | Named in relation to personal care and hygiene deficiencies | |
| Certified Nurse Aide #36 | Named in relation to personal care and hygiene deficiencies | |
| Assistant Director of Nursing | Named in relation to catheter care, air mattress, and transfer deficiencies | |
| Certified Nurse Aide #41 | Named in relation to turning and repositioning deficiency | |
| Licensed Practical Nurse #28 | Named in relation to dialysis and air mattress deficiencies | |
| Registered Nurse #39 | Named in relation to wound care and dialysis | |
| Licensed Practical Nurse #31 | Named in relation to offloading boot deficiency | |
| Licensed Practical Nurse Unit Manager #22 | Named in relation to splint, transfer, dialysis, and air mattress deficiencies | |
| Certified Nurse Aide #24 | Named in relation to transfer deficiency | |
| Licensed Practical Nurse Manager #22 | Named in relation to transfer deficiency | |
| Physical Therapist #23 | Named in relation to splint and transfer deficiencies | |
| Director of Nursing | Named in relation to splint, transfer, and dialysis deficiencies | |
| Licensed Practical Nurse #14 | Named in relation to dialysis care deficiency | |
| Food Service Director #33 | Named in relation to food service deficiencies | |
| Activities Aide #42 | Named in relation to food service deficiencies | |
| Physical Therapist #17 | Named in relation to diet consistency deficiency | |
| Licensed Practical Nurse #6 | Named in relation to diet consistency deficiency | |
| Licensed Practical Nurse Unit Manager #32 | Named in relation to diet consistency deficiency | |
| Certified Nurse Aide #30 | Named in relation to diet consistency deficiency | |
| Licensed Practical Nurse #28 | Named in relation to dialysis care deficiency | |
| Assistant Director of Nursing #3 | Named in relation to dialysis care deficiency | |
| Corporate Registered Dietitian #45 | Named in relation to food safety deficiency | |
| [NAME] #44 | Named in relation to food safety deficiency |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Feb 23, 2024
Visit Reason
One isolated Level 2 deficiency related to preparation for safe/orderly transfer/discharge, corrected by March 20, 2024.
Findings
One isolated Level 2 deficiency related to preparation for safe/orderly transfer/discharge, corrected by March 20, 2024.
Citations (1)
Preparation for safe/orderly transfer/dschrg
Inspection Report
Abbreviated Survey
Citations: 1
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
| Name | Title | Context |
|---|---|---|
| Director of Therapy | Interviewed regarding walker use and discharge equipment | |
| medical records staff #10 | Interviewed about discharge process and record handling for Resident #6 | |
| Director of Nursing | Interviewed about discharge planning process and social worker role | |
| registered nurse #9 | Registered Nurse | Signed discharge instructions and transfer/discharge notice for Resident #6 |
| social worker #8 | Social worker responsible for discharge coordination but was new and left position shortly after | |
| physician #12 | Physician | Provided orders and progress notes related to Resident #6's care and discharge |
| occupational therapist #7 | Occupational Therapist | Signed discharge instructions recommending equipment for Resident #6 |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 2
Date: Dec 8, 2023
Visit Reason
Two isolated Level 2 deficiencies related to licensing compliance and safe/functional environment, both corrected by January 3, 2024.
Findings
Two isolated Level 2 deficiencies related to licensing compliance and safe/functional environment, both corrected by January 3, 2024.
Citations (2)
License/comply w/ fed/state/locl law/prof std
Safe/functional/sanitary/comfortable environ
Inspection Report
Abbreviated Survey
Citations: 2
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
Complaint Investigation
Capacity: 60
Citations: 3
Date: Apr 14, 2023
Visit Reason
Three Level 2 deficiencies including bowel/bladder incontinence, investigation of alleged violations, and lab services notification, with some deficiencies showing pattern scope, all corrected by May 3, 2023.
Findings
Three Level 2 deficiencies including bowel/bladder incontinence, investigation of alleged violations, and lab services notification, with some deficiencies showing pattern scope, all corrected by May 3, 2023.
Citations (3)
Bowel/bladder incontinence, catheter, uti
Investigate/prevent/correct alleged violation
Lab srvcs physician order/notify of results
Inspection Report
Abbreviated Survey
Citations: 3
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
| Name | Title | Context |
|---|---|---|
| LPN Supervisor #16 | Licensed Practical Nurse Supervisor | Named in investigation of Resident #6's bruising incident. |
| Former DON #23 | Director of Nursing | Documented assessment and investigation of Resident #6's injuries. |
| OT #31 | Occupational Therapist | Observed bruising on Resident #6 and reported to DON. |
| LPN #7 | Licensed Practical Nurse | Documented lab results and notifications for Resident #2. |
| NP #27 | Nurse Practitioner | Reviewed lab results and provided treatment orders for Resident #2. |
| LPN #17 | Licensed Practical Nurse | Reviewed labs and documented orders for Residents #5 and #6. |
| LPN #21 | Licensed Practical Nurse | Documented physician notification and orders for Resident #4. |
| Attending Physician | Expected timely notification of abnormal lab results and reviewed Resident #4's case. |
Inspection Report
Annual Inspection
Census: 88
Capacity: 90
Citations: 3
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
Facility census: 88
Total capacity: 90
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
| Name | Title | Context |
|---|---|---|
| CNA #19 | Certified Nurse Aide | Named in findings related to inadequate resident care and supervision |
| LPN #22 | Licensed Practical Nurse | Named in findings related to staffing and resident care |
| RN Unit Manager #5 | Registered Nurse Unit Manager | Named in findings related to staffing and resident care |
| Director of Nursing | Director of Nursing | Provided statements regarding staffing and care deficiencies |
| CNA #11 | Certified Nurse Aide | Named in findings related to resident care and supervision |
| LPN #15 | Licensed Practical Nurse | Named in staffing and care observations |
| Staffing Coordinator #18 | Staffing Coordinator | Provided information on staffing levels and challenges |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 18
Date: Mar 16, 2023
Visit Reason
Multiple Level 2 deficiencies in quality of care and life safety code, including ADL care, accident hazards, nutrition, diet, resident call system, environment, nursing staff sufficiency, corridor doors, electrical equipment, fire drills, gas equipment, fire extinguishers, smoking regulations, sprinkler system, and smoke barriers. Most deficiencies corrected by May 1, 2023.
Findings
Multiple Level 2 deficiencies in quality of care and life safety code, including ADL care, accident hazards, nutrition, diet, resident call system, environment, nursing staff sufficiency, corridor doors, electrical equipment, fire drills, gas equipment, fire extinguishers, smoking regulations, sprinkler system, and smoke barriers. Most deficiencies corrected by May 1, 2023.
Citations (18)
ADL care provided for dependent residents
Free of accident hazards/supervision/devices
Nutritive value/appear, palatable/prefer temp
Provided diet meets needs of each resident
Reasonable accommodations needs/preferences
Resident call system
Right to survey results/advocate agency info
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Corridor - doors
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Fire drills
Gas equipment - cylinder and container storag
Portable fire extinguishers
Smoking regulations
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Citations: 9
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
Facility census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse Unit Manager | Named in findings related to bed extender request and ADL care |
| LPN #4 | Licensed Practical Nurse | Named in findings related to bed extender request and aspiration precautions |
| CNA #3 | Certified Nursing Assistant | Named in findings related to bed extender request and ADL care |
| CNA #19 | Certified Nursing Assistant | Named in findings related to ADL care and nutritional supplement |
| Director of Maintenance | Named in findings related to bed extender request and call bell maintenance | |
| OT #7 | Occupational Therapist | Named in findings related to bed extender request |
| Administrator | Named in findings related to bed extender request and staffing | |
| DON | Director of Nursing | Named in findings related to ADL care, nutritional supplements, staffing, and call bells |
| RD #26 | Registered Dietitian | Named in findings related to nutritional supplements |
| Food Service Director | Named in findings related to food temperature and nutritional supplements | |
| LPN #15 | Licensed Practical Nurse | Named in staffing and ADL care findings |
| LPN #22 | Licensed Practical Nurse | Named in findings related to ADL care, aspiration precautions, and call bells |
| CNA #11 | Certified Nursing Assistant | Named in findings related to aspiration precautions and ADL care |
| CNA #13 | Certified Nursing Assistant | Named in findings related to denture care and staffing |
| CNA #21 | Certified Nursing Assistant | Named in findings related to nutritional supplement and call bells |
| LPN Unit Manager #10 | Licensed Practical Nurse Unit Manager | Named in findings related to call bells and aspiration precautions |
| Staffing Coordinator #18 | Named in findings related to staffing |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Nov 30, 2022
Visit Reason
One isolated Level 2 deficiency related to investigation/prevention/correction of alleged violation, corrected by January 12, 2023.
Findings
One isolated Level 2 deficiency related to investigation/prevention/correction of alleged violation, corrected by January 12, 2023.
Citations (1)
Investigate/prevent/correct alleged violation
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 4
Date: Jul 27, 2022
Visit Reason
Four deficiencies including notice requirements before transfer/discharge, permitting residents to return, quality of care, and treatment to prevent/heal pressure ulcers. Two were Level 3 indicating actual harm, others Level 2. All corrected by August 31, 2022.
Findings
Four deficiencies including notice requirements before transfer/discharge, permitting residents to return, quality of care, and treatment to prevent/heal pressure ulcers. Two were Level 3 indicating actual harm, others Level 2. All corrected by August 31, 2022.
Citations (4)
Notice requirements before transfer/discharge
Permitting residents to return to facility
Quality of care
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Annual Inspection
Citations: 7
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
| Name | Title | Context |
|---|---|---|
| LPN #14 | Licensed Practical Nurse | Involved in admission process and medication administration for Resident #279 |
| DON | Director of Nursing | Provided statements regarding admission process and care plan implementation |
| CNA #13 | Certified Nurse Aide | Provided care and mouth hygiene for Resident #7 |
| LPN Manager #6 | Licensed Practical Nurse Manager | Provided statements regarding resident care and admission processes |
| SLP #2 | Speech Language Pathologist | Provided evaluation and recommendations for Resident #329's swallowing and eating needs |
| OT #3 | Occupational Therapist | Provided assistive device recommendations for Resident #329 |
| Food Services Director | Responsible for ordering and providing special eating equipment | |
| Physician #33 | Physician | Provided statements regarding catheter care and expectations |
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