Inspection Reports for
Charles T Sitrin Health Care Center Inc
2050 Tilden Avenue, New Hartford, NY, 13413
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
20
15
10
5
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: May 28, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with care standards following concerns about resident treatment and accident prevention.
Findings
The facility failed to ensure appropriate treatment and care for Resident #1 who was reported choking on liquids without proper assessment or diet modification. Additionally, the facility did not provide adequate supervision and training to prevent accidents, resulting in Resident #2 sustaining a fracture due to family transferring without proper education.
Deficiencies (2)
F 0684: The facility did not ensure residents received treatment and care according to professional standards and resident preferences. Resident #1 was reported choking on liquids with no documented assessment or diet modification by a qualified professional.
F 0689: The facility failed to ensure adequate supervision and assistance devices to prevent accidents. Resident #2 sustained a fracture of unknown origin after family members transferred the resident without documented training on safe transfer techniques.
Report Facts
Residents reviewed: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Mentioned in relation to Resident #1 choking incident and reporting | |
| Registered Nurse #10 | Assistant Director of Nursing | Mentioned as Resident #1's Unit Manager and involved in assessment expectations |
| Speech Therapist #19 | Provided expectations for assessment and therapy referral for Resident #1 | |
| Licensed Practical Nurse #12 | Documented Resident #2's complaints and transfer issues | |
| Registered Nurse #20 | Documented Resident #1's death | |
| Certified Nurse Aide #11 | Reported family transferring Resident #2 and noted bruising | |
| Director of Therapy Services | Discussed therapy discharge and family transfer education for Resident #2 | |
| Physical Therapist #14 | Discussed Resident #2's functional status and transfer safety | |
| Director of Nursing | Investigated Resident #2's fracture and family transfer issues |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: May 28, 2025
Visit Reason
Three standard health deficiencies were cited including accident hazards, quality of care, and medication errors; two were corrected by July 27, 2025.
Findings
Three standard health deficiencies were cited including accident hazards, quality of care, and medication errors; two were corrected by July 27, 2025.
Deficiencies (3)
Free of accident hazards/supervision/devices
Quality of care
Residents are free of significant med errors
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 12, 2025
Visit Reason
The abbreviated survey was conducted due to concerns about resident abuse and failure to report abuse at Charles T Sitrin Health Care Center Inc.
Findings
The facility failed to protect residents from abuse when Licensed Practical Nurse #4 physically removed Resident #1 from the dining room against their will, causing the resident to fall multiple times. The facility also failed to timely report the abuse incident to administration, law enforcement, and the State Agency. Immediate Jeopardy was identified and later removed after corrective actions including staff education and assessments.
Deficiencies (2)
F 0600: The facility failed to protect Resident #1 from physical abuse by Licensed Practical Nurse #4, who forcibly removed the resident from the dining room causing multiple falls and injuries. The resident was at immediate jeopardy due to this abuse.
F 0609: The facility failed to timely report the abuse incident involving Resident #1 to the State Agency, law enforcement, and administration, delaying appropriate investigation and response.
Report Facts
Residents affected: 1
Residents in facility: 173
Falls: 3
Staff education completion: 100
Staff education completion: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Named as the staff member who physically abused Resident #1 and failed to report the incident properly. | |
| Certified Nurse Aide #5 | Reported the abuse incident to the Program Director of the Neurocare Unit. | |
| Program Director of the Neurocare Unit | Reviewed video footage and reported findings of abuse to facility leadership. | |
| Registered Nurse Supervisor #7 | Was informed of the incident by Licensed Practical Nurse #4 and involved in follow-up. | |
| Director of Nursing | Provided statements regarding staff training and abuse reporting policies. | |
| Licensed Practical Nurse #11 | Witnessed part of the incident and attempted to intervene. | |
| Dietary Aide #17 | Witnessed Licensed Practical Nurse #4 pulling Resident #1 by their chair and pushing them out of the dining room. | |
| [NAME] President of Long-term Care | Notified of Immediate Jeopardy and involved in corrective actions. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Feb 12, 2025
Visit Reason
Two immediate jeopardy level 4 deficiencies related to abuse and reporting of alleged violations; both corrected by March 18, 2025.
Findings
Two immediate jeopardy level 4 deficiencies related to abuse and reporting of alleged violations; both corrected by March 18, 2025.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 19, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in protecting residents' rights related to mail delivery on weekends, resolving grievances promptly for a resident missing a hearing aid, and ensuring adequate nutritional assessment following significant weight loss for a resident.
Deficiencies (3)
10NYCRR 415.3(d)(2)(i) The facility did not deliver mail to residents on Saturdays, denying residents the same rights as other citizens.
10NYCRR 415.13(c)(I)(ii) The facility failed to promptly resolve a grievance for Resident #126 whose right hearing aid was missing and was not replaced or reimbursed.
10NYCRR415.12(i)(1) The facility did not ensure clinical nutrition staff assessed Resident #73 following a significant 6% weight loss within one month.
Report Facts
Residents affected: 182
Residents affected: 1
Residents affected: 1
Weight loss percentage: 6
Hearing aid value: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #25 | Certified Nurse Aide | Documented missing right hearing aid during PM care for Resident #126 |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Documented missing right hearing aid and placed left hearing aid in medication cart |
| Social Worker #27 | Social Worker | Spoke with family representative about missing hearing aid and reimbursement |
| Administrator | Administrator | Provided statements regarding mail delivery and hearing aid investigation |
| Dietetic Technician #21 | Dietetic Technician | Responsible for nutrition assessments and care plans; stated Resident #73 was not assessed after weight loss |
| Physician #22 | Physician | Provided medical orders and statements regarding Resident #73's condition and hearing aids |
Inspection Report
Annual Inspection
Census: 182
Deficiencies: 12
Date: Nov 19, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 11/12/2024 to 11/19/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident rights, grievance resolution, care planning, medication management, food safety and temperature control, infection control, pest control, and environmental cleanliness. Specific issues included failure to deliver mail on Saturdays, missing resident hearing aid without replacement, incomplete care plans for anticoagulant use, inadequate nutritional assessments after weight loss, failure to follow dementia care plans, inappropriate psychotropic medication use, unsecured medications, unsafe food temperatures, unclean kitchen areas, and lapses in infection prevention practices.
Deficiencies (12)
F 0550: The facility did not deliver mail to residents on Saturdays, denying residents their right to receive mail equally.
F 0585: Resident #126's missing right hearing aid was not recovered or replaced, and the facility did not resolve the grievance promptly.
F 0645: Resident #104 was admitted without a required Preadmission Screening and Resident Review Level I to assess mental disorders or intellectual disabilities.
F 0656: Resident #2 receiving anticoagulant therapy did not have an individualized care plan addressing this medication.
F 0692: Resident #73 experienced significant weight loss without timely clinical nutrition assessment or intervention.
F 0744: Resident #40 with dementia did not receive care consistent with their individualized behavior care plan, including provision of fidget items and respecting sleep preferences.
F 0758: Residents #17 and #62 received psychotropic medications without appropriate indications, care plans, or timely review of as needed orders limited to 14 days.
F 0761: Resident #2 had medications left unsecured on their tray table during breakfast, posing a safety risk.
F 0804: Food and beverages served to residents were not maintained at safe and palatable temperatures, including cold milk, juices, and underheated hot foods.
F 0812: The main kitchen and multiple house kitchenettes had unclean surfaces, undated and improperly stored food items, and equipment with grease and debris buildup.
F 0880: Resident #475 was cared for without appropriate enhanced barrier precautions despite an active order; Resident #17 was not on contact precautions as ordered and lacked posted signage and PPE availability.
F 0925: The facility lacked an effective pest control program, with observations of fruit flies, drain flies, unidentified insects, and resident family reports of mice in the facility.
Report Facts
Residents affected: 182
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Pest control service dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #25 | Documented missing hearing aid and involved in investigation. | |
| Registered Nurse #17 | Reviewed missing property form for hearing aid. | |
| Social Worker #27 | Involved in missing hearing aid investigation and family communication. | |
| Administrator | Provided statements regarding mail delivery and hearing aid incident. | |
| Registered Nurse Unit Manager #9 | Responsible for care plan updates and medication security. | |
| Dietetic Technician #21 | Responsible for nutrition assessments and care plans. | |
| Certified Nurse Aide #31 | Observed not wearing gown during enhanced barrier precautions care. | |
| Licensed Practical Nurse #37 | Provided statements on transmission based precautions. | |
| Assistant Director of Nursing | Infection Preventionist, provided statements on infection control practices. | |
| Pharmacy Consultant #42 | Provided information on psychotropic medication reviews. | |
| Food Service Director #14 | Provided statements on food safety and kitchen cleanliness. | |
| Operations Manager #15 | Provided statements on pest control and kitchen sanitation. | |
| Licensed Practical Nurse #10 | Left medications unsecured at resident bedside. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate the facility's pest control program and ensure the facility was free of pests, specifically mice, across multiple nursing units.
Findings
The facility did not maintain an effective pest control program, with evidence of mouse droppings and infestation observed in 4 of 10 nursing units (Sequoia, Sycamore, Chestnut, and Aspen). Multiple sightings and mouse-related issues were documented over several months despite ongoing pest control efforts.
Deficiencies (1)
F 0925: The facility failed to maintain an effective pest control program to prevent and deal with mice, insects, or other pests. Evidence of mouse infestation and droppings was observed in multiple nursing units including Sequoia, Sycamore, Chestnut, and Aspen.
Report Facts
Mouse droppings count: 4
Mouse droppings count: 2
Mouse traps count: 3
Mouse droppings trail length: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Facilities | Interviewed about pest control program and ongoing mouse issues | |
| Housekeeping Supervisor | Interviewed about pest control sightings and work order system | |
| Licensed Practical Nurse #4 | Reported ongoing mouse sightings and use of work order system | |
| Certified Nurse Aide #6 | Interviewed about awareness of mouse droppings and infestation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
One level 2 deficiency for maintaining an effective pest control program; corrected by August 2, 2024.
Findings
One level 2 deficiency for maintaining an effective pest control program; corrected by August 2, 2024.
Deficiencies (1)
Maintains effective pest control program
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
The visit was an abbreviated survey to assess compliance with pressure ulcer care and treatment protocols for residents, specifically reviewing care provided to Resident #5 with pressure ulcers.
Findings
The facility failed to ensure timely assessment and appropriate treatment of a resident's pressure ulcer. Licensed practical nurse applied ointment and dressing without a qualified professional's assessment or medical provider's order, and notification protocols were not properly followed.
Deficiencies (1)
F 0686: The facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards to promote healing and prevent new ulcers. Licensed practical nurse applied ointment and dressing without assessment or order from a qualified professional.
Report Facts
Residents reviewed: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #13 | Applied ointment and dressing without assessment or order; documented notifying supervisor | |
| Registered Nurse Manager #4 | Observed wound treatment and dressing change; completed treatment as ordered | |
| Registered Nurse Supervisor #10 | Supervisor on duty who did not receive notification of skin impairment | |
| Registered Nurse #14 | Entered skin/wound progress note documenting pressure ulcer | |
| Director of Nursing | Interviewed regarding notification and treatment protocols |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
One level 2 deficiency for treatment/services to prevent or heal pressure ulcers; corrected by March 29, 2024.
Findings
One level 2 deficiency for treatment/services to prevent or heal pressure ulcers; corrected by March 29, 2024.
Deficiencies (1)
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 31, 2023
Visit Reason
The survey was a recertification and abbreviated survey conducted from 1/23/23 to 1/31/23 to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment; providing appropriate treatment and care according to professional standards; ensuring adequate supervision to prevent accidents including elopement risks; serving food at palatable and safe temperatures; and storing and preparing food in accordance with professional standards.
Deficiencies (5)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with issues such as unclean and peeling carpeted walls, damaged walls, broken toilet lids, and leaking ceilings in multiple resident houses and the community center.
F 0684: The facility failed to provide appropriate treatment and care for Resident #26 who was not assessed timely for decreased food and fluid intake and change in condition, resulting in hospitalization for sepsis secondary to UTI.
F 0689: The facility failed to ensure adequate supervision and accident hazard prevention, resulting in Immediate Jeopardy when Resident #103 eloped and was found outside unattended, with inadequate investigation and delayed reporting to the state.
F 0804: The facility failed to ensure food was served at palatable and safe temperatures, with multiple meals served at temperatures below acceptable standards.
F 0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, with issues including dented cans, unclean kitchen areas, expired bread, damaged countertops, and unclean shelves in multiple kitchens and kitchenettes.
Report Facts
Staff educated on elopement: 321
Agency/per diem staff: 35
Food temperature measurements: 131
Food temperature measurements: 125
Food temperature measurements: 119
Food temperature measurements: 145
Food temperature measurements: 124
Food temperature measurements: 93
Food temperature measurements: 91
Food temperature measurements: 51
Food temperature measurements: 52
Food temperature measurements: 134
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jan 31, 2023
Visit Reason
Multiple level 2 and level 4 deficiencies including food sanitation, accident hazards, nutritive value, quality of care, environment, and life safety code issues; all corrected by March 31, 2023.
Findings
Multiple level 2 and level 4 deficiencies including food sanitation, accident hazards, nutritive value, quality of care, environment, and life safety code issues; all corrected by March 31, 2023.
Deficiencies (13)
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Nutritive value/appear, palatable/prefer temp
Quality of care
Safe/clean/comfortable/homelike environment
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Elevators
Emergency lighting
Hazardous areas - enclosure
Multiple occupancies - construction type
Sprinkler system - installation
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 29, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including ensuring a safe and comfortable environment, providing meaningful activities, proper treatment for constipation, accident hazard prevention, and medication storage and labeling.
Deficiencies (5)
F 0584: The facility did not ensure a safe, clean, and comfortable environment for 1 of 5 residents due to a loud unit door alarm outside Resident #88's room causing disturbance.
F 0679: The facility did not provide meaningful activities as care planned for 1 of 3 residents (Resident #145), who was not approached or included in scheduled activities.
F 0684: Resident #77 was not provided medications as ordered to relieve constipation, with no documentation of administration or refusal of bowel protocol medications.
F 0689: Resident #18 had a 1-liter bottle of alcohol on their dresser visible and accessible to other residents, posing a safety risk with no facility policy on alcohol storage.
F 0761: Medication room and cupboards were found unlocked with multiple resident medications accessible, including an opened undated vial of lidocaine, violating medication storage and labeling standards.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication storage rooms reviewed: 1
Oxycodone doses: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #12 | Licensed Practical Nurse | Documented bowel protocol refusal for Resident #77 |
| LPN #13 | Licensed Practical Nurse | Interviewed regarding bowel protocol procedures |
| LPN #14 | Licensed Practical Nurse | Interviewed regarding bowel protocol procedures |
| RN #15 | Registered Nurse | Interviewed regarding bowel protocol and documentation |
| LPN #6 | Licensed Practical Nurse | Reported alcohol bottle safety risk in Resident #18's room |
| RNS #17 | Registered Nurse Supervisor | Observed unlocked medication room and cupboards |
| LPN #18 | Licensed Practical Nurse | Left medication room door and cupboards unlocked after fall incident |
| RN Unit Manager #19 | Registered Nurse Unit Manager | Confirmed medication room and cupboard should be locked and noted undated lidocaine vial |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Interviewed about alcohol policy and monitoring for Resident #18 |
| CNA #7 | Certified Nurse Aide | Reported alcohol occasionally left out in Resident #18's room |
| LPN #8 | Licensed Practical Nurse | Interviewed about alcohol storage and Resident #18's behavior |
| Recreation Therapy Leader #21 | Recreation Therapy Leader | Observed not engaging Resident #145 in activities as planned |
| RN Unit Manager #20 | Registered Nurse Unit Manager | Interviewed about activities program and Resident #145 |
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