Inspection Reports for
Central Park Rehabilitation and Nursing Center
116 Martin Luther King E, Syracuse, NY 13205, USA, NY, 13205
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
224% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 5, 2025
Visit Reason
The inspection was a recertification survey conducted from 4/28/2025 to 5/5/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in ensuring residents' dignity related to timely laundry return and appropriate dining utensils, maintaining a safe and clean environment including unclean floors and kitchen areas, timely reporting of an injury of unknown origin, and providing adequate assistance with activities of daily living including showering and incontinence care.
Deficiencies (4)
F 0550: The facility failed to ensure residents' right to a dignified existence by providing unplanned plastic silverware and cups during meals and delayed return of personal laundry causing a resident to wear soiled clothing.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment with unclean surfaces, sticky floors, food debris in resident dining areas, and unclean shelving and walls in the main kitchen.
F 0609: The facility failed to timely report an injury of unknown origin (human bite mark) sustained by a resident to the New York State Department of Health within 24 hours as required.
F 0677: The facility did not provide necessary assistance with activities of daily living; one resident did not receive showers as planned and another resident did not receive incontinence care as scheduled.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #50 | Notified Director of Nursing about resident bite mark injury and involved in injury investigation | |
| Director of Nursing | Responsible for injury assessment and reporting decisions | |
| Registered Nurse Unit Manager #31 | Provided information on incontinence care deficiency for Resident #158 | |
| Certified Nurse Aide #32 | Reported laundry delays and toileting assistance issues | |
| Laundry Personnel #46 | Responsible for returning laundry, reported backlog | |
| Director of Housekeeping | Oversaw laundry and housekeeping processes, acknowledged issues | |
| Licensed Practical Nurse #16 | Reported resident complaints about laundry and toileting care | |
| Registered Nurse Unit Manager #22 | Discussed shower scheduling and documentation discrepancies | |
| Social Worker #30 | Received resident complaints about shower frequency |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: May 5, 2025
Visit Reason
Recertification survey conducted from 4/28/2025 to 5/5/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including residents' dignity and timely laundry return, ineffective resident council grievance follow-up, unclean resident units and kitchen, failure to timely report suspected abuse, inadequate assistance with activities of daily living, insufficient resident activities, nutritional deficiencies including significant weight loss and improper meal assistance, food served at unsafe temperatures, failure to provide food accommodating resident preferences, and improper food storage leading to immediate jeopardy.
Deficiencies (11)
F 0550: The facility failed to ensure residents' dignity by providing unplanned plastic silverware and cups to residents without care plans and delayed returning personal laundry, causing residents to wear soiled clothing.
F 0565: The facility did not ensure resident council grievances were addressed or responded to with rationales, despite repeated resident concerns over housekeeping, laundry, call bell wait times, and staff phone usage.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment due to unclean floors, walls, and shelving in resident units and the main kitchen.
F 0585: The facility did not ensure residents had access to grievance forms or knowledge of grievance procedures, including anonymous filing, resulting in many residents unaware of their rights and how to file grievances.
F 0609: The facility failed to timely report an injury of unknown origin (human bite mark) to the New York State Department of Health within 24 hours and did not thoroughly investigate or implement a plan to prevent further potential abuse.
F 0677: The facility failed to provide necessary assistance with activities of daily living, including showers and incontinence care, resulting in residents not receiving showers as planned and being frequently incontinent without timely care.
F 0679: The facility did not provide meaningful activities tailored to resident preferences and failed to offer ongoing programs to support residents' interests, particularly on the second floor.
F 0692: The facility failed to maintain acceptable nutritional status for a resident with significant weight loss by not completing weekly weights as ordered, not reassessing nutritional needs, and not providing meal assistance as planned.
F 0804: The facility failed to serve food and drink at palatable, flavorful, and safe temperatures during lunch meals on 4/30/2025 and 5/2/2025, including serving meatloaf and stroganoff below required temperatures.
F 0806: The facility did not ensure residents received food accommodating allergies, intolerances, and preferences, including failure to provide double portions as requested by a resident and voiced as a concern by 20 residents at a Food Committee meeting.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, resulting in the main kitchen walk-in cooler operating at 50 degrees Fahrenheit and potentially hazardous foods stored improperly on resident units, placing all residents at immediate jeopardy of foodborne illness.
Report Facts
Residents affected: 4
Residents affected: 14
Residents affected: 153
Residents affected: 2
Residents affected: 153
Weight loss percentage: 11.56
Weight loss percentage: 16.99
Weight loss percentage: 17.82
Weight loss percentage: 15.2
Weight loss percentage: 6
Temperature: 118
Temperature: 117
Temperature: 88
Temperature: 120
Temperature: 50
Temperature: 54
Temperature: 47.8
Temperature: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 50 | Licensed Practical Nurse | Notified of bite mark injury on Resident #121 |
| Director of Nursing | Director of Nursing | Responsible for injury assessment and reporting Resident #121 bite mark |
| Certified Nurse Aide 26 | Certified Nurse Aide | Discovered bite mark on Resident #121 |
| Registered Nurse Unit Manager 22 | Registered Nurse Unit Manager | Responsible for weight monitoring and shower schedule for Resident #56 and #60 |
| Certified Nurse Aide 29 | Certified Nurse Aide | Provided shower and meal assistance to residents including Resident #95 |
| Food Service Director | Food Service Director | Responsible for food safety and temperature monitoring |
| Registered Dietitian 21 | Registered Dietitian | Responsible for nutritional assessments and care planning for Resident #56 and #95 |
| Activities Leader 18 | Activities Leader | Responsible for activities on fourth floor and 1:1 visits |
| Director of Activities | Director of Activities | Responsible for overall activities program |
Inspection Report
Certification/complaint Survey
Capacity: 60
Deficiencies: 1
Date: May 2, 2025
Visit Reason
Multiple health citations including minor potential harm and one immediate jeopardy related to food sanitation. All deficiencies were corrected by June 17, 2025.
Findings
Multiple health citations including minor potential harm and one immediate jeopardy related to food sanitation. All deficiencies were corrected by June 17, 2025.
Deficiencies (1)
Standard Health Citation — deficiencies in resident activities, ADL care, food sanitation, grievances, nutrition, abuse reporting, resident rights, and environment. Immediate jeopardy found in food sanitation.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations regarding residents' rights to a safe, clean, comfortable, and homelike environment.
Findings
The facility failed to ensure Resident #2's room was clean and properly maintained, with food debris on the floor, no linens on the bed, a mattress with large tears, and a stained privacy curtain. Housekeeping and nursing staff interviews revealed delays and communication issues in cleaning and linen supply.
Deficiencies (1)
F 0584: The facility did not ensure Resident #2's bedroom was clean and homelike, with food debris on the floor, no bed linens, a mattress with large tears, and a stained privacy curtain.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding housekeeping and mattress issues |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding room cleaning and linen availability |
| Housekeeper #1 | Housekeeper | Interviewed about cleaning schedules and responsibilities |
| Housekeeping Supervisor #4 | Housekeeping Supervisor | Interviewed about housekeeping expectations and linen supply |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
One minor potential harm citation for safe, clean, and comfortable environment. Corrected by August 31, 2024.
Findings
One minor potential harm citation for safe, clean, and comfortable environment. Corrected by August 31, 2024.
Deficiencies (1)
Standard Health Citation — safe, clean, and comfortable environment with minor potential harm.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Findings
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Deficiencies (1)
Standard Health Citation — reporting to National Health Safety Network with minor potential harm.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Findings
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Deficiencies (1)
Standard Health Citation — reporting to National Health Safety Network with minor potential harm.
Inspection Report
Abbreviated Survey
Deficiencies: 8
Date: Sep 12, 2023
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' dignity and respect, access to medical records, safe and clean environment, abuse prevention, assistance with activities of daily living, accident hazard prevention, feeding tube care, and respiratory care. Several residents were not provided care consistent with their plans, and staff failed to follow policies and procedures.
Deficiencies (8)
F 0550: The facility failed to ensure residents were treated with dignity and respect; Resident #133 was dressed in other residents' clothing and Resident #70's urinary catheter bag was uncovered and visible.
F 0573: The facility did not provide Resident #360's legal representative access to medical records within 24 hours of request as required.
F 0584: The facility did not ensure a safe, clean, comfortable environment; floors, walls, equipment were unclean or damaged, linen supplies were insufficient, and maintenance issues were unaddressed.
F 0600: CNA #60 verbally abused Resident #422 and was not immediately removed; the supervising LPN #59 failed to intervene.
F 0677: The facility failed to provide necessary assistance with activities of daily living for 7 residents, including grooming, showering, turning, positioning, and use of palm guards.
F 0689: The facility did not ensure a resident environment free of accident hazards; Resident #65 had medications on the floor and Resident #95's fall prevention interventions were not updated or implemented.
F 0693: Resident #17's tube feeding care was deficient; formula was not infused as ordered, medication administration and tube flushes were improperly performed, and PPE was not used during care.
F 0695: Resident #28's portable oxygen tank was empty and not replaced; Resident #28 and #33's care plans did not include oxygen use details, risking inadequate respiratory care.
Report Facts
Medication cups on floor: 2
Medication pills on floor: 3
Fall assessment score: 11
Fall assessment score: 15
Tube feeding rate: 70
Tube feeding volume: 1540
Oxygen flow rate: 2
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #60 | Certified Nurse Aide | Named in verbal abuse incident involving Resident #422. |
| LPN #59 | Licensed Practical Nurse | Supervising nurse who failed to intervene in abuse incident with Resident #422. |
| SW #6 | Social Worker | Witnessed verbal abuse by CNA #60 and intervened. |
| RN Unit Manager #3 | Registered Nurse Unit Manager | Responsible for care plan oversight and tube feeding management. |
| DON | Director of Nursing | Provided statements on facility policies and oversight responsibilities. |
| LPN #23 | Licensed Practical Nurse | Involved in tube feeding care and medication administration for Resident #17. |
| RN #15 | Registered Nurse | Infection control nurse involved in Resident #17 care. |
| LPN #25 | Licensed Practical Nurse | Involved in tube feeding care and medication administration for Resident #17. |
| RN #19 | Registered Nurse | Provided statements on oxygen care and care plan responsibilities. |
| LPN #18 | Licensed Practical Nurse | Provided statements on oxygen care and care plan responsibilities. |
| CNA #41 | Certified Nurse Aide | Provided statements on oxygen care for Resident #28 and #33. |
Inspection Report
Certification/complaint Survey
Capacity: 60
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
Multiple minor potential harm citations for quality of care and life safety code issues. All corrected by late October 2023.
Findings
Multiple minor potential harm citations for quality of care and life safety code issues. All corrected by late October 2023.
Deficiencies (1)
Standard Health Citation — multiple quality of care deficiencies including ADL care, care planning, abuse prevention, accident hazards, pest control, staffing info, resident rights, respiratory care, and feeding management. Life Safety Code citations for electrical systems and vertical openings enclosure.
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Sep 12, 2023
Visit Reason
The inspection 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 resident dignity and respect, access to medical records, safe and clean environment, abuse prevention, care planning, activities of daily living assistance, fall prevention, feeding tube care, respiratory care, staffing information posting, and pest control.
Deficiencies (13)
F 0550: The facility failed to ensure residents were treated with dignity and respect; Resident #133 was dressed in another resident's clothing and Resident #70's urinary catheter bag was left uncovered and visible.
F 0573: The facility did not provide requested medical records to Resident #360's legal representative within 24 hours as required.
F 0577: The facility did not post the most recent survey results and plan of correction in a place readily accessible to residents, family members, and legal representatives.
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment; floors, walls, and equipment were unclean or damaged, linen supplies were insufficient, and residents' rooms and common areas had maintenance issues.
F 0600: The facility failed to protect residents from abuse; CNA #60 verbally abused Resident #422 and was not immediately removed from the unit, and the investigation was incomplete.
F 0640: The facility did not transmit Minimum Data Set (MDS) assessments for Residents #24, 30, 81, and 100 within 14 days of completion as required.
F 0656: The facility did not implement person-centered care plans; Resident #119 was not provided a communication board, Resident #143 was addressed by a name not in their care plan, and Resident #506 wore broken glasses.
F 0677: The facility did not ensure residents received necessary assistance with activities of daily living; Residents #3, 27, 76, 95, 110, 133, and 417 were not properly assisted with grooming, range of motion, toileting, turning, positioning, or showering as planned.
F 0689: The facility did not maintain a safe environment free from accident hazards; Resident #65 had unidentified medications on the floor, and Resident #95's care plan was not updated or implemented with fall prevention interventions such as fall mats.
F 0693: The facility failed to provide appropriate care for Resident #17 with a feeding tube; the ordered amount of feeding formula was not infused, medications were crushed and administered improperly, tube flushes and placement checks were not performed as ordered, and staff did not wear required PPE.
F 0695: The facility did not provide safe and appropriate respiratory care; Resident #28's portable oxygen tank was empty and not replaced timely, care plans for oxygen use were incomplete or missing for Residents #28 and #33.
F 0732: The facility did not post daily nurse staffing information including resident census and actual hours worked by licensed and unlicensed nursing staff; the last posted report was dated 9/9/2023.
F 0925: The facility did not maintain an effective pest control program; live fruit fly infestations were observed on all nursing units and the main kitchen.
Report Facts
Medication cups and pills on floor: 2
Fruit flies observed: 20
Fruit flies observed: 20
MDS assessments late: 4
Tube feeding formula container volume: 300
Tube feeding formula container volume: 450
Tube feeding formula container volume: 300
Tube feeding formula infusion rate: 70
Oxygen flow rate: 2
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #60 | Certified Nurse Aide | Verbally abused Resident #422 and was not immediately removed from the unit. |
| RN/Unit Manager #3 | Registered Nurse/Unit Manager | Responsible for care plan oversight and assisted with tube feeding occlusion. |
| Director of Nursing | Director of Nursing | Provided statements on dignity, care plans, and incident investigations. |
| LPN #23 | Licensed Practical Nurse | Administered tube feeding and medications improperly and did not wear PPE. |
| RN #15 | Registered Nurse | Provided wound care and corrected tube feeding occlusion. |
| CNA #8 | Certified Nurse Aide | Provided personal care to Resident #95 and stated resident was not shaved or nails clipped. |
| LPN #11 | Licensed Practical Nurse | Responsible for tube feeding formula and tubing change at 7:00 AM. |
| RN #19 | Registered Nurse | Responsible for care plan updates and oxygen care oversight. |
| Physical Therapist #32 | Physical Therapist | Provided palm guards for Resident #27. |
| Social Worker #6 | Social Worker | Observed abuse incident and interviewed residents. |
| Certified Nurse Aide #40 | Certified Nurse Aide | Checked oxygen care card and monitored oxygen tanks. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 23, 2023
Visit Reason
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Findings
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Deficiencies (1)
Standard Health Citation — reporting to National Health Safety Network with minor potential harm.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Findings
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Deficiencies (1)
Standard Health Citation — reporting to National Health Safety Network with minor potential harm.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 13, 2023
Visit Reason
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Findings
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Deficiencies (1)
Standard Health Citation — reporting to National Health Safety Network with minor potential harm.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with infection control practices, specifically regarding transmission-based precautions for residents with multidrug-resistant organisms (MDROs).
Findings
The facility failed to ensure appropriate transmission-based precautions signage and personal protective equipment (PPE) were available for Resident #3, who had a history of MDRO infections. Staff and administration were unaware of the resident's MDRO status, and the care plan did not include necessary precautions.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences by not implementing transmission-based precautions for Resident #3 with a history of MDRO infection. Staff lacked PPE and signage outside the resident's room, and the care plan did not address MDRO precautions.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Unit Manager #1 | Documented resident's septic shock and care notes | |
| Physician #21 | Completed History and Physical documenting resident hospitalization and treatment | |
| Certified Nurse Aide (CNA) #6 | Reported on residents with COVID-19 and infection precautions | |
| Licensed Practical Nurse (LPN) #4 | Stated no residents assigned had infection precautions | |
| RN Unit Managers #1 and #2 | Unaware of any residents with MDRO infection | |
| Director of Nursing (DON)/Infection Preventionist (IP) | Unaware of Resident #3's MDRO status and responsible for infection prevention | |
| Administrator | Unaware of MDRO presence until recently and described admission procedures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
One minor potential harm citation for quality of care. Corrected by March 30, 2023.
Findings
One minor potential harm citation for quality of care. Corrected by March 30, 2023.
Deficiencies (1)
Standard Health Citation — quality of care with minor potential harm.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 30, 2023
Visit Reason
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Findings
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Deficiencies (1)
Standard Health Citation — reporting to National Health Safety Network with minor potential harm.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 6, 2023
Visit Reason
Two minor potential harm citations for pharmacy services and safe, clean environment. Corrected by February 22, 2023.
Findings
Two minor potential harm citations for pharmacy services and safe, clean environment. Corrected by February 22, 2023.
Deficiencies (1)
Standard Health Citation — pharmacy services and safe, clean environment with minor potential harm.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 19, 2022
Visit Reason
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Findings
One minor potential harm citation for reporting to National Health Safety Network. Not yet corrected.
Deficiencies (1)
Standard Health Citation — reporting to National Health Safety Network with minor potential harm.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 13, 2022
Visit Reason
Multiple citations including minor potential harm for abuse training, accident hazards, investigation, licensing, and treatment of pressure ulcers. One immediate jeopardy for accident hazards. All corrected by May 24, 2022.
Findings
Multiple citations including minor potential harm for abuse training, accident hazards, investigation, licensing, and treatment of pressure ulcers. One immediate jeopardy for accident hazards. All corrected by May 24, 2022.
Deficiencies (1)
Standard Health Citation — abuse training, accident hazards, investigation, licensing compliance, and pressure ulcer treatment. Immediate jeopardy found in accident hazards.
Inspection Report
Routine
Deficiencies: 14
Date: Feb 17, 2022
Visit Reason
Recertification and abbreviated surveys conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident care and safety, infection control, nutrition, medication administration, environmental safety, and staff vaccination compliance. Specific issues included improper mealtime positioning, unclean environment, resident abuse incidents, incomplete care plan participation, inadequate assistance with activities of daily living, failure to provide meaningful activities, improper medication and treatment administration, failure to maintain food temperatures, infection control lapses, and equipment maintenance deficiencies.
Deficiencies (14)
F 0558: The facility failed to reasonably accommodate resident needs and preferences for proper mealtime positioning, resulting in difficulty accessing food for 2 residents.
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment with unclean floors, surfaces, privacy curtains, wheelchairs, linens, and excessive noise during meal service.
F 0600: The facility failed to protect residents from abuse, neglect, and mistreatment, including incidents of sexually inappropriate behavior and inadequate supervision.
F 0657: The facility failed to ensure resident and representative participation in comprehensive care plan meetings for 3 residents.
F 0677: The facility failed to provide necessary assistance with activities of daily living including toileting, bathing, and timely care for multiple residents.
F 0684: The facility failed to provide treatment and care according to orders, including failure to apply thrombo-embolic deterrent stockings as ordered for a resident.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers by not ensuring an air mattress was in place as ordered for a resident at risk.
F 0689: The facility failed to ensure adequate supervision and accident prevention for residents at risk of wandering, elopement, and injury, including failure to investigate injuries and prevent recurrence.
F 0692: The facility failed to provide adequate nutrition and maintain residents' nutritional status, including failure to provide all ordered food items and failure to obtain weekly weights as ordered.
F 0679: The facility failed to provide meaningful activities based on resident preferences and needs, resulting in lack of appropriate stimulation and engagement for a resident.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to maintain hot food temperatures above 135°F in a steam table.
F 0880: The facility failed to provide and implement an infection prevention and control program to prevent transmission of COVID-19, including failure to isolate COVID-19 positive residents properly and failure to offer COVID-19 vaccinations to residents.
F 0888: The facility failed to ensure staff were vaccinated for COVID-19 or implement additional precautions for unvaccinated staff, including housekeepers and certified nurse aides.
F 0908: The facility failed to keep all essential equipment working safely, including a steam table with a faulty electrical outlet and plug that caused intermittent power loss.
Report Facts
Residents reviewed: 10
Residents reviewed: 6
Residents reviewed: 4
Weight loss: 14.8
Weight loss percentage: 7.9
Weight loss percentage: 10.94
Temperature: 120
Temperature: 121
Temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #19 | Licensed Practical Nurse | Documented application of TEDS stockings but admitted not applying them |
| RN Unit Manager #4 | Registered Nurse Unit Manager | Interviewed regarding multiple care and supervision issues |
| CNA #15 | Resident Assistant | Observed failing to redirect COVID-19 positive resident and prevent exposure |
| Housekeeper #16 | Housekeeper | Not fully vaccinated for COVID-19 and worked on resident units |
| Housekeeper #38 | Housekeeper | Not fully vaccinated for COVID-19 |
| CNA #39 | Certified Nurse Aide | Not fully vaccinated for COVID-19 and tested positive for COVID-19 |
| Food Service Director | Interviewed regarding steam table temperature and equipment issues | |
| Director of Nursing | Interviewed regarding infection control, staff vaccination, and care issues | |
| Infection Control Nurse | Interviewed regarding infection control program and staff vaccination |
Inspection Report
Certification/complaint Survey
Capacity: 60
Deficiencies: 1
Date: Feb 17, 2022
Visit Reason
Multiple minor potential harm citations for activities, ADL care, care planning, vaccination, equipment, food sanitation, abuse prevention, accident hazards, infection control, nutrition, quality of care, accommodations, and environment. All corrected by April 12, 2022.
Findings
Multiple minor potential harm citations for activities, ADL care, care planning, vaccination, equipment, food sanitation, abuse prevention, accident hazards, infection control, nutrition, quality of care, accommodations, and environment. All corrected by April 12, 2022.
Deficiencies (1)
Standard Health Citation — multiple quality of care issues including activities, ADL care, care planning, vaccination, equipment safety, food sanitation, abuse prevention, accident hazards, infection control, nutrition, quality of care, accommodations, and environment.
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