6 Reports
Inspection Report — Jan 24, 2025
Annual Inspection CMS
Date: Jan 24, 2025
Visit Reason
The survey was a recertification and abbreviated survey conducted from 1/16/2025 to 1/24/2025 to assess compliance with state and federal regulations for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to respond to resident council concerns, inadequate investigation of abuse allegations, lack of physician orders on admission, failure to coordinate mental health screenings, inadequate discharge planning, medication errors including administration of expired medications and late insulin doses, improper diet consistency served leading to choking, incomplete dialysis communication, and unsafe food handling practices in the kitchen.
Citations (10)
F 0565: The facility failed to ensure resident council concerns were addressed or responded to with rationale for 10 of 10 residents at meetings from 8/2024 to 12/2024.
F 0610: The facility did not thoroughly investigate an alleged care plan violation involving a one-person transfer of Resident #371 resulting in skin tears and bruising without assessment by a qualified professional.
F 0635: The facility did not ensure Resident #473 had physician orders for immediate care consistent with physical status on admission due to conflicting hospital discharge orders and summary.
F 0644: The facility failed to refer Resident #66 for a new Level II Preadmission Screening and Resident Review after significant change in mental condition and medication intervention for schizophrenia.
F 0660: The facility did not ensure discharge planning addressed Resident #105's goal to return to prior living situation and failed to involve the resident or document discharge planning meetings.
F 0684: Resident #49 was administered 14 doses of expired levetiracetam from 1/10/2025 to 1/17/2025 without physician notification or documented seizure activity.
F 0689: Resident #171 was served and fed ground vegetables instead of a pureed diet, causing choking and hospital transfer; staff education on safe dining was delayed, resulting in immediate jeopardy.
F 0698: Resident #65's dialysis communication sheets were incomplete for 25 of 34 sessions and the facility failed to ensure follow-up communication and documentation between dialysis center and facility.
F 0759: Resident #27 received 5 medications late including insulin given after breakfast and insulin pen not primed; Resident #110 received 4 medications by mouth instead of gastrostomy tube and late without physician approval; medication error rate was 37.04%.
F 0812: The facility failed to ensure food was stored, prepared, and cooled properly in the kitchen; a pan of crab cake mix was held at 48°F exceeding safe cooling times, and kitchen drain was clogged with foul odor.
Report Facts
Medication doses administered expired: 14
Dialysis sessions with incomplete documentation: 25
Medication error rate: 37.04
Medication doses administered late: 5
Staff suspension days: 3
Crab cake mix temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #31 | Administered expired levetiracetam to Resident #49 | |
| Certified Nurse Aide #3 | Fed Resident #171 wrong diet consistency leading to choking incident | |
| Licensed Practical Nurse #24 | Administered insulin late and did not prime insulin pen for Resident #27 | |
| Licensed Practical Nurse #10 | Administered medications late and gave medications by mouth instead of gastrostomy tube for Resident #110 | |
| Registered Nurse Educator #14 | Provided education on medication administration and meal ticket verification | |
| Director of Nursing | Oversaw investigations and provided statements on multiple deficiencies | |
| Administrator | Provided statements on discharge planning and resident council follow-up |
Inspection Report — Jan 24, 2025
Certification/complaint State
Date: Jan 24, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2023 to 2025 with detailed deficiency and enforcement history.
Complaint Details
The state logged 91 complaints about this facility; 9 led to on-site inspections. Complaint surveys issued 8 citations in total.
Findings
Across 16 inspections in the reporting period, 58 citations were issued including 39 standard health and 19 life safety code citations. The facility had 91 complaints with 9 on-site inspections and 7 enforcement actions totaling $60,000 in fines.
Citations (40)
Admission Physician Orders For Immediate Care: Standard Health Citation for quality of care with isolated minor potential harm.
Coordination Of Pasarr And Assessments: Standard Health Citation for quality of care with isolated minor potential harm.
Dialysis: Standard Health Citation for quality of care with isolated minor potential harm.
Discharge Planning Process: Standard Health Citation for quality of care with isolated minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation for quality of care with isolated minor potential harm.
Free Of Accident Hazards/supervision/devices: Standard Health Citation for quality of care with isolated immediate jeopardy.
Free Of Medication Error Rts 5 Prcnt Or More: Standard Health Citation for quality of care with isolated minor potential harm.
Investigate/prevent/correct Alleged Violation: Standard Health Citation for quality of care with isolated minor potential harm.
Quality Of Care: Standard Health Citation for quality of care with pattern minor potential harm.
Resident/family Group And Response: Standard Health Citation for quality of care with isolated minor potential harm.
Cooking Facilities: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Corridor - Doors: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Exit Signage: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Hazardous Areas - Enclosure: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Sprinkler System - Installation: Life Safety Code Citation for NFPA requirements with pattern minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Utilities - Gas And Electric: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Reporting - National Health Safety Network: Standard Health Citation for quality of care with widespread minor potential harm not yet corrected.
Therapeutic Diet Prescribed By Physician: Standard Health Citation for quality of care with isolated minor potential harm.
Activities Meet Interest/needs Each Resident: Standard Health Citation for quality of care with isolated minor potential harm.
ADL Care Provided For Dependent Residents: Standard Health Citation for quality of care with isolated minor potential harm.
Department Criminal History Review: Standard Health Citation for quality of care with scope level 0.
Develop/implement Comprehensive Care Plan: Standard Health Citation for quality of care with isolated minor potential harm.
Free From Abuse And Neglect: Standard Health Citation for quality of care with pattern minor potential harm.
Grievances: Standard Health Citation for quality of care with isolated minor potential harm.
Infection Prevention & Control: Standard Health Citation for quality of care with isolated minor potential harm.
Influenza And Pneumococcal Immunizations: Standard Health Citation for quality of care with pattern minor potential harm.
Nutrition/hydration Status Maintenance: Standard Health Citation for quality of care with isolated minor potential harm.
Resident Call System: Standard Health Citation for quality of care with isolated minor potential harm.
Respiratory/tracheostomy Care And Suctioning: Standard Health Citation for quality of care with isolated minor potential harm.
Right To Participate In Planning Care: Standard Health Citation for quality of care with isolated minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation for quality of care with pattern minor potential harm.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation for NFPA requirements with pattern minor potential harm.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation for NFPA requirements with widespread minor potential harm.
Fire Alarm System - Testing And Maintenance: Life Safety Code Citation for NFPA requirements with pattern minor potential harm.
Means Of Egress - General: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Multiple Occupancies - Construction Type: Life Safety Code Citation for NFPA requirements with pattern minor potential harm.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Vertical Openings - Enclosure: Life Safety Code Citation for NFPA requirements with isolated minor potential harm.
Report Facts
Total inspections: 16
Total citations: 58
Standard Health citations: 39
Life Safety Code citations: 19
Complaints: 91
On-site complaint inspections: 9
Enforcement actions: 7
Total fines: 60000
Citations from complaints: 8
Inspection Report — Oct 18, 2023
Abbreviated Survey CMS
Date: Oct 18, 2023
Visit Reason
The abbreviated survey was conducted to evaluate compliance with therapeutic diet orders and resident safety related to diet prescriptions following a reported incident of choking and vomiting in a resident with a history of esophageal obstruction.
Findings
The facility failed to ensure that residents were provided therapeutic diets prescribed by a physician. Specifically, Resident #1 did not have a physician-ordered diet upon admission, which contributed to an episode of choking and vomiting requiring hospitalization for esophageal food obstruction removal.
Citations (1)
F 0808: The facility did not ensure therapeutic diets were prescribed by the attending physician as required. Resident #1 lacked a documented diet order upon admission, leading to an incident of choking and vomiting with subsequent hospitalization.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Documented resident vomiting and observed choking incident |
| LPN #9 | Licensed Practical Nurse | Documented resident continued dysphagia and vomiting |
| SLP #7 | Speech Language Pathologist | Conducted swallow evaluation and recommended emergency transfer |
| NP #6 | Nurse Practitioner | Completed visit for coughing and vomiting, arranged hospital transfer |
| Dietetic Technician #9 | Dietetic Technician | Noted absence of diet order and discussed with nursing to add order |
| Physician #1 | Physician | Stated admission orders should include diet order |
| LPN #5 | Licensed Practical Nurse | Described process of transcribing admission orders including diet |
Inspection Report — Jun 8, 2023
Annual Inspection CMS
Date: Jun 8, 2023
Visit Reason
The survey was a recertification survey conducted from 6/1/23 to 6/8/23 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility had multiple deficiencies including failure to ensure resident participation in care planning, unsafe and unclean environment, unresolved resident grievances, incomplete care plans, inadequate assistance with activities of daily living, insufficient activity programming, inadequate supervision to prevent falls, failure to maintain nutritional status, improper respiratory care, food safety violations, incomplete infection control program, lack of immunization offers and documentation, and inadequate call system accommodations for residents.
Citations (13)
F 0553: The facility did not ensure residents or their representatives were invited to or included in the development and implementation of person-centered care plans for 1 resident.
F 0584: The facility had unclean and damaged floors, walls, ceilings, and window hardware in multiple resident units, creating potential hazards.
F 0585: The facility failed to promptly resolve a grievance regarding missing resident clothing for 1 resident.
F 0656: The facility did not develop and implement comprehensive person-centered care plans addressing anticoagulant monitoring and dementia care for 2 residents.
F 0677: The facility failed to provide necessary assistance with toileting and dressing for 2 residents, resulting in unmet care needs.
F 0679: The facility did not provide meaningful activities tailored to resident interests for 2 residents, limiting their engagement and well-being.
F 0689: The facility failed to ensure adequate supervision and use of assistive devices to prevent falls for 1 resident with a history of multiple falls.
F 0692: The facility failed to maintain acceptable nutritional status for 1 resident with significant weight loss that was not addressed or reassessed.
F 0695: The facility did not provide oxygen therapy as ordered for 1 resident, resulting in lack of oxygen administration for multiple days.
F 0812: The facility had inaccessible hand wash sinks, non-working paper towel dispensers, improper glove use, and failure to perform hand hygiene in food service areas.
F 0880: The facility did not maintain an infection prevention and control program by failing to review the Legionella risk assessment annually.
F 0883: The facility failed to offer or document influenza and pneumococcal immunizations or education for multiple residents and staff.
F 0919: The facility did not ensure a working call system accessible to a resident with disabilities who could not use the provided call bell.
Report Facts
Weight loss percentage: 17
Weight loss percentage: 15.7
Weight loss percentage: 14.6
Weight loss percentage: 9
Weight loss percentage: 6.7
Weight loss percentage: 5.6
Weight loss percentage: 10
Oxygen flow rate: 2
Oxygen flow rate: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #10 | Licensed Practical Nurse | Named in influenza vaccine declination and oxygen administration findings. |
| Dietary Aide #43 | Dietary Aide | Observed improper hand hygiene during meal service. |
| Dietary Aide #47 | Dietary Aide | Observed improper glove use and hand hygiene. |
| CNA #7 | Certified Nursing Assistant | Named in failure to assist resident with toileting and dressing. |
| CNA #9 | Certified Nursing Assistant | Named in call bell accessibility and oxygen tank findings. |
| RN Unit Manager #13 | Registered Nurse Unit Manager | Named in oxygen administration and call bell accessibility findings. |
| Director of Nursing | Director of Nursing | Named in multiple findings including oxygen administration, immunization, and call bell accessibility. |
| Director of Facilities | Director of Facilities | Named in Legionella risk assessment and environmental maintenance findings. |
| Food Service Director | Food Service Director | Named in food service hand hygiene and sink accessibility findings. |
| Occupational Therapist #12 | Occupational Therapist | Named in call bell accessibility evaluation. |
| RN Infection Preventionist #29 | Registered Nurse Infection Preventionist | Named in immunization program findings. |
| Certified Nurse Aide #21 | Certified Nurse Aide | Named in nutritional intake and activity findings. |
| Nurse Practitioner #25 | Nurse Practitioner | Named in immunization and anticoagulant care plan findings. |
Inspection Report — May 26, 2023
Abbreviated Survey CMS
Date: May 26, 2023
Visit Reason
The abbreviated survey was conducted to evaluate compliance with resident abuse protections and investigation procedures following multiple incidents of resident-to-resident sexual abuse and mistreatment.
Findings
The facility failed to ensure residents were free from abuse, specifically resident-to-resident sexual abuse involving Resident #1 and others. The facility also failed to thoroughly investigate alleged violations, implement timely investigations, and report incidents to the New York State Department of Health as required.
Citations (2)
F 0600: The facility did not ensure residents had the right to be free from abuse, including sexual abuse, for 3 of 4 residents reviewed. Resident #1 exhibited sexually inappropriate behaviors and the facility failed to develop and implement an effective plan to prevent further incidents.
F 0610: The facility did not respond appropriately to all alleged violations. Investigations were not timely or thorough, and required reports to the New York State Department of Health were not made within mandated timeframes for multiple incidents involving residents.
Report Facts
Residents reviewed: 4
Incidents documented: 5
15-minute checks duration: 3
1:1 monitoring duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Reported Resident #1 reaching for Resident #3's torso during an incident. |
| CNA #5 | Certified Nurse Aide | Observed Resident #1 rubbing Resident #2's upper chest and reported incidents involving Resident #1. |
| Linen Supervisor #3 | Linen Supervisor | Observed Resident #1 fondling Resident #2 and reported the incident. |
| DON | Director of Nursing | Provided statements regarding investigation procedures and monitoring of residents. |
| Administrator | Facility Administrator | Interviewed regarding notification and investigation of incidents and resident puncture wounds. |
| SW #20 | Social Worker | Interviewed Resident #1 and residents involved in incidents. |
Inspection Report — Jul 30, 2021
Annual Inspection CMS
Date: Jul 30, 2021
Visit Reason
The survey was a recertification and abbreviated survey conducted from 7/27/21 to 7/30/21 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs, failure to maintain a homelike environment, inadequate investigation and reporting of alleged abuse, failure to maintain proper food temperatures and food safety standards, failure to notify hospice of resident death, and failure to maintain proper infection prevention and control practices including mask use.
Citations (7)
F 0558: The facility did not ensure the call bell was within reach for Resident #72, limiting their ability to request assistance.
F 0584: Resident #62's room was stark and devoid of personal belongings, failing to provide a homelike environment.
F 0610: The facility failed to investigate and report alleged resident-to-resident sexual abuse involving Residents #50 and #65, and did not implement a plan to prevent further incidents.
F 0804: The facility did not ensure food was served at safe and palatable temperatures during two meals, with multiple food items outside acceptable temperature ranges.
F 0812: The facility failed to discard leftover food items (pork slices, crab salad, pureed peaches) that were stored beyond the three-day limit.
F 0849: The facility did not notify hospice of Resident #99's death as required by policy and regulation.
F 0880: LPN #1 was observed repeatedly wearing a surgical mask incorrectly, exposing nose and upper lip during resident care and in common areas, compromising infection control.
Report Facts
Deficiencies cited: 7
Food temperature measurements: 55
Food temperature measurements: 115
Food temperature measurements: 127
Food storage duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed repeatedly wearing surgical mask incorrectly during resident care and in common areas. |
| CNA #15 | Certified Nurse Aide | Provided witness statement regarding resident-to-resident sexual abuse incident. |
| LPN #14 | Licensed Practical Nurse | Charge nurse on evening of 5/2/21 who removed Resident #65 from Resident #50's room but failed to report incident properly. |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting and hospice notification policies. |
| Food Service Director | Food Service Director | Interviewed regarding food temperature and leftover food policies. |
| Infection Control RN #5 | Infection Control Registered Nurse | Interviewed regarding mask use policies and infection control training. |
| LPN Unit Manager #4 | Licensed Practical Nurse Unit Manager | Interviewed regarding mask use policies and staff education. |
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