Inspection Reports for Crown Park Rehabilitation and Nursing center
28 Kellogg Rd, Cortland, NY 13045, NY, 13045
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The visit was conducted as an abbreviated survey to evaluate compliance with care standards, specifically focusing on anticoagulant therapy monitoring for residents with mechanical heart valves and atrial fibrillation.
Findings
The facility failed to ensure appropriate monitoring and documentation of Prothrombin Time/International Normalized Ratio (INR) for one resident with a mechanical heart valve and atrial fibrillation, resulting in subtherapeutic INR levels and an acute stroke causing actual harm.
Deficiencies (1)
Failure to maintain and document appropriate Prothrombin Time/International Normalized Ratio monitoring and provider notification for a resident with a mechanical heart valve and atrial fibrillation.
Report Facts
Residents reviewed: 3
Resident affected: 1
INR level: 1.16
Recommended INR range: 2.5
Recommended INR range: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant #4 | Physician Assistant | Documented resident follow-ups and noted lack of notification for missed INR lab |
| Assistant Director of Nursing #3 | Assistant Director of Nursing | Interviewed regarding lab requisition process and notification expectations |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Documented awareness of missed INR lab and obtained new order |
| Medical Director | Medical Director | Interviewed about diagnosis documentation and INR monitoring standards |
| Nurse Practitioner #5 | Nurse Practitioner | Documented INR level and treatment plan |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
One isolated Level 3 quality of care deficiency with actual harm noted.
Findings
One isolated Level 3 quality of care deficiency with actual harm noted.
Deficiencies (1)
Quality of care — isolated Level 3 deficiency
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jan 17, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements, including grievance resolution and provision of care.
Findings
The facility failed to ensure prompt resolution of resident grievances related to long call bell wait times and did not provide oral care as planned for a resident requiring assistance, resulting in minimal harm or potential for harm.
Deficiencies (2)
Failure to ensure prompt efforts were made to resolve grievances related to long call bell wait times for 9 anonymous residents and 1 additional resident.
Failure to provide necessary oral care as planned for 1 resident requiring substantial/maximal assistance.
Report Facts
Residents affected: 9
Residents affected: 1
Residents affected: 1
Call bell wait times: 43
Call bell wait times: 28
Call bell wait times: 45
Dates of resident council meetings with call bell concerns: 5
Dates oral care was not documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Grievance Officer | Named as official grievance officer and involved in grievance investigations |
| Director of Activities | Attended resident council meetings and recorded concerns | |
| Director of Nursing | Interviewed regarding call bell wait times and staff in-services | |
| Certified Nurse Aide #8 | Certified Nurse Aide | Provided care to Resident #119 and missed oral care |
| Licensed Practical Nurse Unit Manager #5 | Licensed Practical Nurse Unit Manager | Interviewed about oral care expectations and resident condition |
| Registered Nurse Unit Manager #9 | Registered Nurse Unit Manager | Interviewed about oral care documentation expectations |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 17, 2025
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 1/13/2025 to 1/17/2025 to evaluate compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment; timely resolution of resident grievances; provision of oral care; medication labeling and storage; food palatability and temperature; food storage and kitchen sanitation; infection prevention and control; and maintenance of essential equipment such as walk-in coolers.
Deficiencies (8)
Facility did not ensure residents had a safe, clean, comfortable, and homelike environment with issues such as missing paint, unpainted patched holes, missing door thresholds causing tripping hazards, missing tiles, dirty linen on floors, and undecorated dining rooms.
Facility did not ensure prompt efforts were made to resolve grievances; residents were unaware of grievance officials and processes, and long call bell wait times were a recurrent complaint.
Resident #119 was not provided oral care as planned, resulting in dry mouth and visible oral hygiene neglect.
Drugs and biologicals were not labeled with opened or discard dates, expired medications were present, and medication carts were found unlocked and unattended.
Food served was not palatable, flavorful, or at safe and appetizing temperatures during lunch meals on 1/14/2025 and 1/15/2025; residents complained about cold and unappetizing food.
Food in the main kitchen was not stored, prepared, distributed, and served in accordance with professional standards; issues included uncovered food in the walk-in freezer, unprotected kitchen lighting, dirty and uncleanable surfaces, and broken floor tiles.
Facility did not establish and maintain an infection prevention and control program; Resident #17's urinary drainage bag was lying on the floor, and the 2 South B side medication room sink was non-functional.
Facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition; the left walk-in cooler was not maintaining proper temperature.
Report Facts
Dates of survey: 2025-01-13 to 2025-01-17
Food temperature: 121.1
Food temperature: 113.9
Food temperature: 52
Food temperature: 133
Food temperature: 110.8
Food temperature: 126.9
Food temperature: 128.5
Medication expiration: 30
Medication expiration: 28
Medication expiration: 40
Walk-in cooler temperature: 45
Walk-in cooler temperature: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #7 | Registered Nurse Unit Manager | Interviewed regarding work order system and call bell response |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding maintenance issues and tripping hazards |
| Housekeeper #2 | Housekeeper | Interviewed regarding cleaning responsibilities and work order system |
| License Practical Nurse Unit Manager #5 | Licensed Practical Nurse Unit Manager | Interviewed regarding environmental issues and oral care expectations |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed regarding maintenance issues and work order reporting |
| Director of Housekeeping and Laundry | Director of Housekeeping and Laundry | Interviewed regarding cleaning schedules and work order reporting |
| Director of Maintenance | Director of Maintenance | Interviewed regarding work order system and maintenance timelines |
| Certified Nurse Aide #8 | Certified Nurse Aide | Interviewed regarding missed oral care for Resident #119 |
| Licensed Practical Nurse Unit Manager #9 | Registered Nurse Unit Manager | Interviewed regarding oral care documentation and expectations |
| Licensed Practical Nurse #24 | Licensed Practical Nurse | Interviewed regarding medication labeling and expiration dates |
| Licensed Practical Nurse #25 | Licensed Practical Nurse | Interviewed regarding medication refrigerator contents and expiration dates |
| Licensed Practical Nurse #21 | Licensed Practical Nurse | Interviewed regarding medication labeling and sink issues |
| Licensed Practical Nurse Unit Manager #22 | Registered Nurse Unit Manager | Interviewed regarding medication labeling and catheter care |
| Director of Nursing | Director of Nursing | Interviewed regarding call bell issues and medication labeling |
| Director of Social Services | Director of Social Services | Interviewed regarding grievance process and call bell complaints |
| Director of Activities | Director of Activities | Interviewed regarding resident grievances and food complaints |
| Certified Nurse Aide #13 | Certified Nurse Aide | Interviewed regarding catheter care and food complaints |
| Certified Nurse Aide #14 | Certified Nurse Aide | Observed verifying food temperatures |
| Regional Food Service Director #18 | Regional Food Service Director | Interviewed regarding food storage, temperatures, and kitchen sanitation |
| Kitchen Supervisor #27 | Kitchen Supervisor | Interviewed regarding missing kitchen light covers |
| Maintenance Director #4 | Maintenance Director | Interviewed regarding sink maintenance and work orders |
| Infection Preventionist #23 | Infection Preventionist | Interviewed regarding infection control practices and catheter care |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Jan 17, 2025
Visit Reason
Multiple standard health and life safety code deficiencies mostly Level 2 severity, corrected by March 5, 2025.
Findings
Multiple standard health and life safety code deficiencies mostly Level 2 severity, corrected by March 5, 2025.
Deficiencies (16)
ADL care provided for dependent residents
Criminal history record check process
Essential equipment, safe operating condition
Food procurement, store/prepare/serve-sanitary
Grievances
Infection prevention & control
Label/store drugs and biologicals
Nutritive value/appear, palatable/prefer temp
Requirements before submitting a request for
Safe/clean/comfortable/homelike environment
Electrical equipment - testing and maintenanc
Hazardous areas - enclosure
Sprinkler system - maintenance and testing
Subsistence needs for staff and patients
Utilities - gas and electric
Vertical openings - enclosure
Inspection Report
Annual Inspection
Census: 145
Deficiencies: 6
Date: Jan 19, 2023
Visit Reason
The inspection was a recertification survey conducted from 1/11/23 to 1/19/23 to assess compliance with regulatory requirements for Crown Park Rehabilitation and Nursing Center.
Findings
The facility was found deficient in several areas including failure to deliver mail on Saturdays to residents, unsafe and unclean resident environment including damaged wheelchairs and walls, untimely reporting of an injury to the state, unsafe hot water temperatures at water dispensers, expired medications and biologicals, and ineffective pest control with presence of mice in resident rooms.
Deficiencies (6)
Failure to ensure residents received personal mail on Saturdays, denying residents their rights.
Failure to ensure residents had a safe, clean, comfortable, and homelike environment including damaged walls, stained ceiling tiles, and damaged wheelchairs.
Failure to timely report an injury (burn) to the New York State Department of Health within required timeframe.
Failure to ensure resident environment was free from accident hazards due to hot water dispensers dispensing water at unsafe temperatures (161-166°F).
Failure to ensure drugs and biologicals were labeled with expiration dates and stored properly; expired medications and biologicals found in medication carts and rooms.
Failure to maintain an effective pest control program; dead mice and mouse droppings found in multiple resident rooms.
Report Facts
Residents affected: 145
Temperature: 161
Temperature: 166
Burn size: 23
Burn size: 14
Medication expiration dates: 3
Medication expiration dates: 3
Number of water dispensers: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Unit Manager #11 | Registered Nurse Unit Manager | Commented on wheelchair condition and medication expiration checks. |
| LPN #19 | Licensed Practical Nurse | Observed expired medications and biologicals in Unit 2 South medication cart and room. |
| RN #21 | Registered Nurse | Observed expired biologicals and insulin pens without opened dates in Unit 3 medication cart. |
| Maintenance Director | Provided information on wheelchair maintenance, water dispensers, and pest control. | |
| Administrator | Provided information on mail delivery, incident reporting, and pest control. | |
| DON | Director of Nursing | Provided information on incident reporting and pest control. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Jan 19, 2023
Visit Reason
Several isolated Level 2 standard health deficiencies corrected by February 23, 2023.
Findings
Several isolated Level 2 standard health deficiencies corrected by February 23, 2023.
Deficiencies (6)
Free of accident hazards/supervision/devices
Label/store drugs and biologicals
Maintains effective pest control program
Reporting of alleged violations
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 16, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 2, 2022
Visit Reason
One isolated Level 2 deficiency related to accident hazards, corrected by July 5, 2022.
Findings
One isolated Level 2 deficiency related to accident hazards, corrected by July 5, 2022.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Apr 21, 2022
Visit Reason
Two isolated Level 2 deficiencies related to abuse prevention and compliance with laws, corrected by May 24, 2022.
Findings
Two isolated Level 2 deficiencies related to abuse prevention and compliance with laws, corrected by May 24, 2022.
Deficiencies (2)
Free from abuse and neglect
License/comply w/ fed/state/locl law/prof std
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 14, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 18, 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 resident dignity and self-determination, medication self-administration, maintenance of a clean and homelike environment, provision of activities of daily living care, food temperature and palatability, timely provision of rehabilitative services, infection prevention and control, and pest control.
Deficiencies (9)
Facility did not ensure residents' right to a dignified existence and care, including issues with poorly fitted clothing and lack of non-disposable dishware for fluids.
Facility did not determine clinical appropriateness for self-administration of medications for a resident and left medications without proper assessment.
Facility did not promote and facilitate resident self-determination through support of resident choice, including failure to assist a resident to eat meals in the dining area as preferred.
Facility did not maintain a clean and homelike environment, including stained ceiling tiles, damaged equipment, and unclean ice machines.
Facility did not provide necessary assistance for activities of daily living, including failure to provide nail care and showers as planned.
Facility did not provide food and drink at safe and appetizing temperatures; multiple meal trays tested were outside acceptable temperature ranges.
Facility did not ensure timely provision of specialized rehabilitative services; a resident did not receive a therapy evaluation and treatment in a timely manner after physician order.
Facility did not implement an infection prevention and control program adequately; staff failed to disinfect mechanical lift after use in a contact precaution room.
Facility did not maintain an effective pest control program; small flies were observed in the kitchen and on nursing units with no documented pest control response.
Report Facts
Temperature: 111.7
Temperature: 48.9
Temperature: 66
Temperature: 129
Temperature: 119
Temperature: 155
Temperature: 126
Temperature: 133
Temperature: 52
Temperature: 108
Temperature: 107
Temperature: 53
Temperature: 101
Temperature: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Unit Manager #11 | Registered Nurse Unit Manager | Commented on non-disposable cups shortage and care planning for Resident #100 |
| CNA #16 | Certified Nurse Aide | Reported on disposable cup use and feeding resistance of Resident #100 |
| RD #20 | Registered Dietitian and Food Service Director | Discussed non-disposable cup use and dignity issues related to Resident #100 |
| Food Service Worker #23 | Food Service Worker | Responsible for placing non-disposable cups on trays |
| CNA #15 | Certified Nurse Aide | Reported on Resident #95 clothing and staff assistance |
| LPN #12 | Licensed Practical Nurse | Commented on Resident #95 pants and clothing assistance |
| RN Unit Manager #7 | Registered Nurse Unit Manager | Discussed Resident #95 clothing and care plan notes |
| Director of Social Services #24 | Director of Social Services | Discussed clothing assistance and resident dignity for Resident #95 |
| Director of Housekeeping and Laundry #25 | Director of Housekeeping and Laundry | Described clothing donation and lost and found process |
| DON | Director of Nursing | Discussed clothing assistance expectations and resident rights |
| LPN #27 | Licensed Practical Nurse | Observed medication self-administration for Resident #66 |
| LPN #26 | Licensed Practical Nurse | Discussed medication self-administration assessment |
| RN Unit Manager #11 | Registered Nurse Unit Manager | Discussed medication self-administration assessment and orders |
| RN Educator #3 | Registered Nurse Educator | Discussed infection control education and mechanical lift cleaning |
| Infection Control RN #4 | Infection Control Registered Nurse | Discussed equipment disinfection for contact precautions |
| Director of Nursing | Director of Nursing | Discussed infection control and equipment disinfection expectations |
| CNA #28 | Certified Nurse Aide | Reported on pest control and small flies on Unit 3 South |
| CNA #22 | Certified Nurse Aide | Discussed shower schedule and resident refusal for Resident #164 |
| CNA #19 | Certified Nurse Aide | Provided shower schedule and discussed documentation issues for Resident #164 |
| LPN #21 | Licensed Practical Nurse | Discussed shower schedule and resident refusal documentation |
| RN Unit Manager #7 | Registered Nurse Unit Manager | Discussed shower schedule changes and resident preferences |
| CNA #29 | Certified Nurse Aide | Reported on nail care challenges for Resident #141 |
| CNA #16 | Certified Nurse Aide | Reported on nail care challenges for Resident #141 |
| RN Unit Manager #11 | Registered Nurse Unit Manager | Discussed hygiene care expectations |
| RN #6 | Registered Nurse | Discussed therapy referral process for Resident #70 |
| RN #7 | Registered Nurse | Discussed therapy referral process for Resident #70 |
| Physician Assistant #8 | Physician Assistant | Discussed expectations for therapy evaluation timing |
| PT #9 | Physical Therapist | Discussed therapy evaluation process and impact of delays |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Discussed therapy referral process and impact of delays |
| Director of Nursing | Director of Nursing | Discussed therapy referral process and impact of delays |
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