Inspection Reports for
Cooperstown Center for Rehabilitation and Nursing
128 Phoenix Mills Cross Road, Cooperstown, NY, 13326
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
16.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
218% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: May 2, 2024
Visit Reason
Complaint survey with 6 health and 6 life safety code citations, including deficiencies in food sanitation, abuse reporting, medication labeling, emergency plan, and fire safety systems. All deficiencies corrected by mid-2024.
Findings
Complaint survey with 6 health and 6 life safety code citations, including deficiencies in food sanitation, abuse reporting, medication labeling, emergency plan, and fire safety systems. All deficiencies corrected by mid-2024.
Deficiencies (12)
Food procurement,store/prepare/serve-sanitary
Free from abuse and neglect
Label/store drugs and biologicals
Permitting residents to return to facility
Reporting of alleged violations
Sufficient nursing staff
Develop ep plan, review and update annually
Discharge from exits
Egress doors
Electrical equipment - testing and maintenanc
Fire alarm system - installation
Ltc and icf/iid sharing plan with patients
Inspection Report
Abbreviated Survey
Census: 168
Capacity: 174
Deficiencies: 4
Date: May 2, 2024
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements and investigate specific complaints and incidents.
Complaint Details
The survey included complaint investigations related to neglect and abuse involving Resident #45 and issues with resident return after hospitalization for Resident #165. The neglect complaint was substantiated with findings of staff not following care plans and failure to report incidents.
Findings
The facility was found deficient in ensuring resident safety and adherence to care plans, timely reporting of abuse and neglect, permitting resident return after hospitalization, and maintaining adequate nursing staff levels. Multiple incidents of neglect, failure to report, refusal to readmit a resident, and staffing shortages were documented.
Deficiencies (4)
F 0600: The facility failed to protect a resident from neglect when a Certified Nurse Aide did not use two staff for bed mobility as required, resulting in the resident falling out of bed.
F 0609: The facility failed to timely report suspected abuse and neglect to the proper authorities following a resident fall caused by staff not following the care plan.
F 0626: The facility did not permit a resident to return after hospitalization despite medical clearance, citing safety concerns and lack of supervision capability.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs, resulting in delayed call light responses and 34 documented falls in April 2024.
Report Facts
Falls documented: 34
Facility capacity: 174
Facility census: 168
Certified Nurse Aides required vs present: 20
Certified Nurse Aides present: 18
Medication Nurses required vs present: 10
Medication Nurses present: 6.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #4 | Certified Nurse Aide | Named in neglect finding for not using two staff for bed mobility leading to resident fall |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding neglect incident and staff adherence to care plans |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding reporting failures and staffing issues |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Interviewed regarding staffing shortages and working conditions |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Interviewed regarding staffing shortages and working conditions |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding staffing and medication cart assignments |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding staffing and workload |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 2, 2024
Visit Reason
The inspection was a recertification survey to assess compliance with regulations related to medication management and food service safety at the nursing home.
Findings
The facility failed to ensure proper labeling, storage, and security of medications, including expired and unattended medications. Additionally, food service safety deficiencies were found, including improper sanitizing solution concentration, uncalibrated thermometers, and unsanitary conditions in the kitchen and multiple kitchenettes.
Deficiencies (2)
F 0761: The facility did not ensure drugs and biologicals were labeled and stored according to professional standards. Opened medications lacked open or expiration dates, controlled substances were not double locked, expired medications were present, and medications were left unattended on medication carts.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. Sanitizing solution concentration was zero ppm, thermometers were uncalibrated, and multiple kitchen and kitchenette surfaces and equipment were soiled or broken.
Report Facts
Medication carts reviewed: 10
Medication storage rooms reviewed: 5
Expired Epinephrine pen expiration date: 202312
Oxycodone 10 mg tablets left in blister pack: 13
Sanitizing solution concentration: 0
Thermometers uncalibrated: 2
Kitchenettes with food safety issues: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Observed administering medication and discussed narcotic medication administration |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed leaving medication unattended and handling expired epinephrine pen |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Stated narcotic book was kept on medication cart and updated with each narcotic given |
| Director of Nursing #1 | Director of Nursing | Reported staff medication administration training and narcotic box replacement |
| Food Service Director #1 | Food Service Director | Reported on sanitizing solution dilution and staff education |
| Administrator #1 | Administrator | Reported on staff education and corrective actions for food service deficiencies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 27, 2023
Visit Reason
Complaint survey with 2 health citations related to nursing staff competency and qualifications, both corrected by early 2024.
Findings
Complaint survey with 2 health citations related to nursing staff competency and qualifications, both corrected by early 2024.
Deficiencies (2)
Competent nursing staff
Qualified persons
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 27, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with nursing care standards, specifically focusing on the provision of care by qualified persons and nursing competencies related to nephrostomy tube care for residents.
Findings
The facility failed to ensure that nephrostomy tube flushing was performed only by Registered Nurses as required by policy and medical orders. Licensed Practical Nurses flushed nephrostomy tubes despite not being qualified or authorized, and the facility lacked documented nursing competencies for Registered Nurses who performed this care.
Deficiencies (2)
F 0659: The facility did not ensure nephrostomy tubes were flushed only by Registered Nurses as required. Licensed Practical Nurses flushed Resident #1's nephrostomy tubes, which was outside their scope of practice.
F 0726: The facility failed to document nursing competencies for Registered Nurses who flushed nephrostomy tubes. Training and competency validations were incomplete or missing for staff performing this care.
Report Facts
Nephrostomy tube flushes by Licensed Practical Nurses: 15
Registered Nurse flushes: 6
Date of survey completion: Dec 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Interviewed regarding flushing nephrostomy tubes and training. | |
| Registered Nurse Staff Educator | Interviewed about nephrostomy tube flushing training and scope of practice. | |
| Director of Nursing | Interviewed about facility policy and nursing competencies related to nephrostomy tube care. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
Complaint survey with one health citation for immediate jeopardy due to accident hazards and supervision issues, corrected by May 2023.
Findings
Complaint survey with one health citation for immediate jeopardy due to accident hazards and supervision issues, corrected by May 2023.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with regulations related to resident supervision and accident prevention following an incident of resident elopement.
Findings
The facility failed to ensure adequate supervision to prevent elopement of Resident #1, who left the building without authorization and without a Leave of Absence pass. The facility did not activate the missing person alert (Code Gray) promptly, resulting in immediate jeopardy to resident health and safety.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent accidents, resulting in Resident #1 leaving the facility without authorization and without a Leave of Absence pass. The missing person alert was delayed by 18 hours, creating immediate jeopardy to resident health and safety.
Report Facts
Distance resident located from facility: 120
Staff reeducation percentage: 99
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Last staff to see Resident #1 before elopement. | |
| Certified Nurse Aide #1 | Identified Resident #1 missing at 3:00 PM on 5/22/2023. | |
| Registered Nurse #1 | Reported Resident #1 missing to Director of Nursing on 5/23/2023. | |
| Director of Nursing | Notified of Resident #1 missing on 5/23/2023 at 9:30 AM. | |
| Nursing Home Administrator | Provided information on corrective actions and staff reeducation. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Jun 23, 2023
Visit Reason
Complaint survey with 4 health citations including criminal history checks, care plan development, general requirements, and grievance handling, all corrected by August 2023.
Findings
Complaint survey with 4 health citations including criminal history checks, care plan development, general requirements, and grievance handling, all corrected by August 2023.
Deficiencies (4)
Criminal history record check process
Develop/implement comprehensive care plan
General requirements
Grievances
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 23, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate grievances and care plan compliance related to resident rights and care interventions.
Findings
The facility failed to promptly resolve a grievance regarding missing resident money and did not maintain proper grievance documentation. Additionally, the facility did not implement a resident's care plan intervention prohibiting male caregivers, resulting in a sexual encounter with a male staff member.
Deficiencies (2)
F 0585: The facility did not ensure prompt efforts were made to resolve a grievance for Resident #3 regarding missing money and failed to maintain evidence of grievance results for at least 3 years.
F 0656: The facility did not implement Resident #1's care plan intervention prohibiting male caregivers, resulting in a sexual encounter with a male Certified Nurse Aide.
Report Facts
Amount of missing money: 260
Reimbursement amount: 265
Dates of grievance follow-up: May 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADMIN #1 | Administrator | Signed grievance form and acknowledged failure to follow through with original grievance. |
| Director of Social Work | Grievance Officer | Responsible for facilitating grievance process; no documentation found for grievance follow-up. |
| CNA #1 | Certified Nurse Aide | Involved in sexual encounter with Resident #1 despite care plan intervention. |
| DON #1 | Director of Nursing | Acknowledged lack of knowledge about male caregiver assignment to Resident #1. |
| LPN #1 | Licensed Practical Nurse | Noted intervention for no male caregivers and attempted to manage assignments accordingly. |
| LPN Manager #2 | LPN Manager | Unaware of no male caregiver intervention and discussed staff assignment issues. |
| Regional Administrator #2 | Regional Administrator | Explained rationale for no male caregiver intervention to prevent accusations. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 17, 2023
Visit Reason
Complaint survey with one health citation for immediate jeopardy related to failure in reporting alleged violations, corrected by February 2023.
Findings
Complaint survey with one health citation for immediate jeopardy related to failure in reporting alleged violations, corrected by February 2023.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 17, 2023
Visit Reason
The visit was an abbreviated survey triggered by an allegation of sexual abuse involving a physician and a resident, focusing on the facility's failure to timely report the suspected abuse as required by state law.
Findings
The facility failed to report an alleged sexual abuse incident involving a physician and Resident #1 within the required 2-hour timeframe. Several staff members did not follow abuse reporting protocols, resulting in delayed notification to administration and the state health department. The facility removed the physician and educated staff on abuse protocols to correct the noncompliance.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse involving a sexual interaction between a physician and Resident #1. The incident was reported to administration and the state more than 12 hours after the allegation was made, violating state law and facility policy.
Report Facts
Staff education completion: 99
Date of alleged abuse incident: Feb 21, 2023
Date of survey completion: Mar 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to report the alleged abuse incident to administration after being informed by CNA #1 |
| CNA #1 | Certified Nursing Aide | Witnessed the alleged sexual abuse and reported it to LPN #1 |
| LPN #2 | Licensed Practical Nurse | Was informed about the bruise on Resident #1 and did not report the incident to administration |
| LPN #3 | Licensed Practical Nurse | Called law enforcement but did not report the incident to the facility |
| LPN Supervisor (LPN #6) | Licensed Practical Nurse Supervisor | Notified about the incident and stated staff failed to follow abuse reporting procedures |
| ADMIN #1 | Administrator | Received delayed report of the incident and called the physician to remove them from the facility |
| ADON #1 | Assistant Director of Nursing | Notified about the incident and reported it to the New York State Department of Health |
| DON #1 | Director of Nursing | Stated staff should have immediately reported the abuse allegation to administration |
| RN #4 | Corporate Educator Registered Nurse | Provided staff education on abuse and neglect reporting protocols |
| MD #2 | Medical Doctor | Stated the proper reporting procedure for abuse allegations |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 22
Date: Mar 8, 2022
Visit Reason
Complaint survey with 17 health and 5 life safety citations covering care plan development, dialysis, drug regimen review, food sanitation, nutrition, infection control, pest control, and multiple life safety code issues, all corrected by mid-2022.
Findings
Complaint survey with 17 health and 5 life safety citations covering care plan development, dialysis, drug regimen review, food sanitation, nutrition, infection control, pest control, and multiple life safety code issues, all corrected by mid-2022.
Deficiencies (22)
Develop/implement comprehensive care plan
Dialysis
Drug regimen review, report irregular, act on
Food procurement,store/prepare/serve-sanitary
Frequency of meals/snacks at bedtime
Infection prevention & control
Laboratory services
Maintains effective pest control program
Medicaid/medicare coverage/liability notice
Menus meet resident nds/prep in adv/followed
Nutrition/hydration status maintenance
Personal food policy
Quality of care
Resident records - identifiable information
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Cooking facilities
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Hazardous areas - enclosure
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Mar 8, 2022
Visit Reason
The survey was a recertification annual inspection conducted from 2/28/2022 through 3/8/2022 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicaid/Medicare notices, inadequate housekeeping and maintenance, incomplete comprehensive care plans, ineffective bowel management, significant weight loss without proper monitoring, insufficient dialysis care, staffing shortages, medication regimen review policy deficiencies, medication errors, delayed laboratory services, menu and meal service issues, improper handling of foods brought by visitors, incomplete and inaccurate medical record documentation, infection control lapses including COVID-19 precautions, improper handling of soiled linens, and pest control deficiencies.
Deficiencies (17)
F 0582: Facility failed to provide timely 2-day notice of Medicare service termination to residents receiving Medicare Part A services.
F 0584: Facility did not maintain a safe, clean, and homelike environment; floors and walls were soiled or in disrepair in multiple resident units.
F 0656: Facility failed to develop and implement comprehensive person-centered care plans for five residents addressing specific medical and psychosocial needs.
F 0684: Facility did not provide needed care for constipation resulting in a 12-day period without documented bowel movements for Resident #113.
F 0692: Facility failed to ensure Resident #113 was weighed and re-weighed according to professional standards and did not evaluate significant weight loss of 81.2 lbs. over 2 months.
F 0698: Facility did not ensure dialysis care plan included monitoring instructions and failed to monitor Resident #66 for complications related to missed dialysis treatments.
F 0725: Facility did not meet desired staffing levels for Licensed Practical Nurses and Certified Nursing Assistants for 9 of 9 days reviewed.
F 0756: Facility policy for monthly medication regimen review did not include time frames for completion of review steps.
F 0760: Resident #89 did not receive prescribed antiparkinsonian medication four times daily due to incomplete order entry; corrective actions were implemented.
F 0770: Facility did not ensure timely laboratory services; Resident #366's urine specimen was collected 7 days after physician order.
F 0803: Facility did not ensure resident menus were followed; alternate entrees were not consistently provided and meal tickets did not match food served.
F 0809: Facility did not provide nourishing bedtime snacks when there was more than 14 hours between evening meal and breakfast.
F 0812: Facility did not store, prepare, distribute, and serve food in accordance with professional standards; dishwashing machine and sanitizing chemical concentrations were inadequate; multiple kitchenettes required cleaning and repairs.
F 0813: Facility policy on foods brought by visitors lacked procedures to assist residents in accessing and consuming these foods; outdated food was not discarded.
F 0842: Facility did not ensure medical records were complete and accurate for six residents, including lack of documentation of resident condition after hospital return, inconsistent documentation of care, and incomplete respiratory monitoring.
F 0880: Facility failed to maintain infection prevention and control; Resident #55 with COVID-19 was not socially distanced from others and infection control practices were not maintained during soiled linen disposal.
F 0925: Facility did not maintain an effective pest control program; rodent droppings were found in multiple kitchenettes and pest control service was inadequate.
Report Facts
Residents reviewed: 33
Residents affected: 5
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staffing days below minimum: 9
Rodent activity last reported: 2021
Rodent droppings found: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in medication error report for incomplete medication order entry |
| ADON | Assistant Director of Nursing | Responsible for medication order review and error oversight |
| RN #1 | Registered Nurse | Provided documentation and interview regarding resident condition and documentation |
| LPNUM #2 | Licensed Practical Nurse Unit Manager | Interviewed regarding care plan responsibilities, documentation, and staffing |
| LPNUM #5 | Licensed Practical Nurse Unit Manager | Interviewed regarding dialysis care and staffing |
| CNA #2 | Certified Nursing Assistant | Observed and interviewed regarding improper soiled linen handling |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding meal service and resident preferences |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple care, staffing, and policy deficiencies |
| Director of Food Services | Director of Food Services | Interviewed regarding meal service and pest control |
| Administrator | Administrator | Interviewed regarding facility operations and corrective actions |
| Medical Doctor #1 | Physician | Interviewed regarding resident weight loss and clinical concerns |
| Licensed Practical Nurse Unit Manager (LPNUM) #5 | Licensed Practical Nurse Unit Manager | Interviewed regarding dialysis care and staffing |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 24, 2021
Visit Reason
Complaint survey with one health citation related to food meeting individual needs, corrected by February 2022.
Findings
Complaint survey with one health citation related to food meeting individual needs, corrected by February 2022.
Deficiencies (1)
Food in form to meet individual needs
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 20, 2019
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 accurate resident assessments, baseline and comprehensive care planning, activities of daily living assistance, medication self-administration, respiratory care, dialysis care, food safety, and infection prevention and control.
Deficiencies (9)
F0641: The facility failed to ensure accurate assessments for residents #22 and #29, with incorrect documentation of functional status in the Minimum Data Set (MDS).
F0655: The facility did not develop and implement baseline care plans including social services information for residents #73, #75, and #82.
F0656: The facility failed to develop and implement comprehensive care plans with measurable objectives for 6 residents, including contractures, respiratory issues, medication self-administration, and pressure ulcer care.
F0677: The facility did not ensure resident #82 received weekly showers as scheduled, compromising personal hygiene.
F0689: The facility did not ensure resident #152 was assessed for ability to self-administer medications, resulting in missed doses and lack of proper documentation.
F0695: The facility failed to provide safe and appropriate respiratory care for resident #152, including failure to prevent oxygen tank from running dry.
F0698: The facility did not ensure consistent communication and monitoring for resident #35 following dialysis treatments.
F0812: The facility did not maintain food service safety standards; satellite kitchenettes were unclean and in disrepair.
F0880: The facility failed to maintain infection prevention and control during dressing changes for residents #100 and #137, including improper glove use, hand hygiene, and handling of sterile supplies.
Report Facts
Residents reviewed for assessments: 32
Residents reviewed for baseline care plans: 13
Residents reviewed for comprehensive care plans: 32
Residents reviewed for Activities of Daily Living: 2
Residents reviewed for respiratory care: 2
Residents reviewed for dialysis care: 1
Missed doses of Dulera inhaler: 7
Scheduled dialysis treatments: 20
Post dialysis assessments documented: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in infection control deficiency during wound care for Resident #100 |
| LPN #2 | Licensed Practical Nurse | Named in infection control deficiency during wound care for Resident #137 |
| LPN #6 | Licensed Practical Nurse | Named in medication self-administration deficiency for Resident #152 |
| LPN #1 | Licensed Practical Nurse, Unit Nurse Manager | Named in dialysis care deficiency for Resident #35 |
| RNUM #2 | Registered Nurse Unit Manager | Named in infection control deficiency for Resident #137 |
| ADON/IPN #3 | Assistant Director of Nursing/Infection Prevention Nurse | Named in infection control deficiency for Residents #100 and #137 |
| Director of Nursing | Interviewed regarding multiple deficiencies including medication self-administration and respiratory care | |
| Director of Physical Therapy | Interviewed regarding assessment deficiencies for Resident #22 | |
| Director of Social Services | Interviewed regarding baseline care plan deficiencies |
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