Inspection Reports for
Essex Center for Rehabilitation and Healthcare
81 Park Street, Elizabethtown, NY, 12932
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 13, 2024
Visit Reason
The inspection was a recertification survey and abbreviated survey to assess compliance with regulatory requirements for Essex Center for Rehabilitation and Healthcare.
Findings
The facility was found deficient in maintaining a clean and homelike environment, protecting residents from abuse and neglect, and ensuring comprehensive care plans were reviewed and updated. Specific issues included soiled floors and walls in multiple areas, a resident being placed in a locked utility room by a terminated employee, and failure to hold an interdisciplinary care plan meeting for a resident.
Deficiencies (3)
F 0584: The facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment on resident units and common areas. Floors and windows were not clean, and walls were not in good repair.
F 0600: The facility did not protect a resident from abuse and neglect when the resident was placed in a locked utility room by a terminated employee. The investigation found no injuries but could not determine how the resident accessed the locked area without alarms sounding.
F 0657: The facility did not ensure comprehensive care plans were reviewed and revised after each assessment for a resident. An interdisciplinary care plan meeting was not held as required.
Report Facts
Residents reviewed: 20
Residents reviewed: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator #1 | Assistant Administrator | Assisted with investigation and follow-up of resident abuse incident |
| Director of Housekeeping #1 | Director of Housekeeping | Interviewed regarding housekeeping deficiencies |
| Social Worker #1 | Social Worker | Interviewed regarding care plan meeting scheduling |
| Administrator #1 | Administrator | Interviewed regarding resident abuse incident and investigation |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 13, 2024
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Essex Center for Rehabilitation and Healthcare.
Findings
The facility was found deficient in several areas including failure to provide proper Medicare Part A non-coverage notices, inadequate housekeeping and maintenance leading to unclean and damaged resident areas, unsafe storage of maintenance tools, and multiple food service safety violations. Additionally, garbage dumpsters were not properly covered.
Deficiencies (5)
F 0582: The facility failed to provide residents with the required Advance Beneficiary Notice of Noncoverage form for Medicare Part A and timely Notice of Medicare Non-Coverage, resulting in residents not being informed of potential financial liability for non-covered rehabilitative services.
F 0584: The facility did not maintain a clean, sanitary, and homelike environment; floors and windows were soiled and walls were scraped in multiple resident rooms and common areas.
F 0689: Dangerous tools were left unattended in resident areas on Unit 3, including a maintenance tool cart with an exposed six-inch fixed blade knife, posing accident hazards.
F 0812: Food service areas including the main kitchen and nourishment kitchenettes were not maintained according to professional standards; issues included uncalibrated thermometers, expired sanitizer test papers, leaking dishwashing machine, unlabeled bulk food containers, and soiled surfaces and equipment.
F 0814: The facility failed to properly dispose of garbage and refuse; three of four dumpsters were not closed and contained exposed garbage.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 15
Dumpster count: 4
Dumpsters not closed: 3
Dishwashing machine rinse pressure: 9
Thermometers tested: 3
Expired sanitizer test papers date: Nov 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Date Set Coordinator #1 | Interviewed regarding incorrect use of Medicare Part B notice instead of Part A | |
| Director of Housekeeping #1 | Interviewed about cleaning responsibilities and maintenance reporting | |
| Director of Maintenance #1 | Interviewed about unattended tool cart and tool storage procedures | |
| Administrator #1 | Interviewed about expectations for maintenance staff and dumpster closure | |
| Food Service Director #1 | Interviewed about food service deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Nov 13, 2024
Visit Reason
Inspection revealed multiple Level 2 deficiencies in standard health and life safety code citations, all corrected within a month or two.
Findings
Inspection revealed multiple Level 2 deficiencies in standard health and life safety code citations, all corrected within a month or two.
Deficiencies (11)
Care plan timing and revision
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Free from abuse and neglect
Free of accident hazards/supervision/devices
Medicaid/medicare coverage/liability notice
Safe/clean/comfortable/homelike environment
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Subdivision of building spaces - smoke barrie
Utilities - gas and electric
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Jun 18, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with residents' rights, privacy, abuse reporting, and activities of daily living care at Essex Center for Rehabilitation and Healthcare.
Findings
The facility failed to ensure residents' rights to dignified existence and privacy, timely abuse reporting, and adequate assistance with activities of daily living including grooming and hygiene. Multiple residents were observed with unkempt appearance, and staff used a non-HIPAA compliant texting application to share protected health information.
Deficiencies (4)
F 0550: The facility did not ensure Resident #1's right to a dignified existence as they were observed with exposed colostomy bag, uncovered upper body, and inappropriate clothing.
F 0583: The facility did not maintain confidentiality of Residents #1 and #2's personal and medical records by staff texting HIPAA-protected information using a non-sanctioned personal cell phone application.
F 0609: The facility failed to timely report an alleged sexual abuse incident involving Residents #1 and #2 to the State Survey Agency within 2 hours as required by law.
F 0677: The facility did not ensure residents #1, 3, and 7 received necessary assistance with activities of daily living, resulting in unkempt appearance, greasy hair, and soiled clothing.
Report Facts
Residents reviewed for dignified existence: 7
Residents affected by dignity deficiency: 1
Residents reviewed for privacy and confidentiality: 2
Residents affected by privacy deficiency: 2
Residents reviewed for activities of daily living: 7
Residents affected by ADL deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Named in relation to redirection of Resident #1's disrobing behavior | |
| Director of Nursing #1 | Director of Nursing | Named in relation to Resident #1's disrobing behavior and care refusals |
| Licensed Practical Nurse #1 | Named in relation to reporting and observations of alleged abuse incident | |
| Registered Nurse #2 | Named in relation to texting about Residents #1 and #2 and alleged abuse | |
| Administrator #1 | Administrator | Named in relation to investigation and reporting of alleged abuse incident |
| Certified Nurse Aide #3 | Named in relation to providing nail care and showering residents | |
| Licensed Practical Nurse Manager #4 | Licensed Practical Nurse Manager | Named in relation to observations about residents' grooming and refusals of care |
| Registered Nurse Unit Manager #3 | Registered Nurse Unit Manager | Named in relation to nail care and showering procedures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Jun 18, 2024
Visit Reason
Inspection identified several Level 2 deficiencies related to ADL care, privacy, reporting violations, and resident rights, all corrected by late July 2024.
Findings
Inspection identified several Level 2 deficiencies related to ADL care, privacy, reporting violations, and resident rights, all corrected by late July 2024.
Deficiencies (4)
ADL care provided for dependent residents
Personal privacy/confidentiality of records
Reporting of alleged violations
Resident rights/exercise of rights
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 19, 2022
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights regarding advance directives, inadequate environmental cleanliness and odor control, failure to timely report a fire incident to the state health department, incomplete and unimplemented comprehensive care plans for several residents, failure to provide necessary assistance with activities of daily living, and food service safety violations related to cleaning and equipment maintenance.
Deficiencies (6)
F 0551: The facility did not ensure Resident #75's representative was court appointed under State law to act on the resident's behalf regarding advance directives.
F 0584: The facility did not maintain a clean, comfortable, and homelike environment on Units 1 and 2, with strong urine odors and dirty floors observed repeatedly.
F 0609: The facility failed to notify the New York State Department of Health within 5 days of a fire incident in the basement involving a smoldering trash can.
F 0656: The facility did not develop and implement comprehensive care plans with measurable goals and interventions for Residents #11, #22, and #48 to address urinary incontinence, cellulitis, and fall prevention respectively.
F 0677: The facility did not ensure Resident #47 received showers and hair washing as scheduled, and documentation was falsified indicating care was provided when it was not.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; dishwashing machine was not operating properly, and kitchen equipment and floors were soiled with food particles and black buildup.
Report Facts
Residents reviewed for advance directives: 2
Residents reviewed for environment: 3
Residents reviewed for Comprehensive Care Plans: 22
Residents reviewed for ADLs: 5
Dishwashing machine final rinse temperature: 190
Dishwashing machine water pressure: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPNUM #3 | Licensed Practical Nurse Unit Manager | Named in deficiencies related to advance directives, environment odor control, and care plan implementation. |
| Administrator | Named in deficiencies related to advance directives and failure to notify NYSDOH of fire incident. | |
| Director of Nursing (DON) | Director of Nursing | Named in deficiencies related to environment odor control and care plan implementation. |
| CNA #3 | Certified Nursing Assistant | Named in deficiency related to failure to provide scheduled shower and falsified documentation. |
| ADON/Nurse Educator | Assistant Director of Nursing / Nurse Educator | Named in deficiency related to ADL care and documentation. |
| Director of Maintenance (DM) | Director of Maintenance | Named in deficiency related to fire incident and investigation. |
| RN #1 | Registered Nurse | Named in deficiency related to environment odor control and ADL care. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Dec 19, 2022
Visit Reason
Inspection found multiple Level 2 deficiencies in ADL care, care planning, food sanitation, reporting violations, resident rights, and life safety code issues, all corrected by early 2023.
Findings
Inspection found multiple Level 2 deficiencies in ADL care, care planning, food sanitation, reporting violations, resident rights, and life safety code issues, all corrected by early 2023.
Deficiencies (11)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Reporting of alleged violations
Rights exercised by representative
Safe/clean/comfortable/homelike environment
Cooking facilities
Electrical systems - essential electric syste
Fire alarm system - installation
Maintenance, inspection & testing - doors
Sprinkler system - maintenance and testing
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 8, 2021
Visit Reason
Covid-19 Survey identified a Level 2 deficiency in infection prevention and control, corrected by December 2021.
Findings
Covid-19 Survey identified a Level 2 deficiency in infection prevention and control, corrected by December 2021.
Deficiencies (1)
Infection prevention & control
Inspection Report
Renewal
Deficiencies: 2
Date: Mar 6, 2020
Visit Reason
The inspection was a recertification survey to evaluate compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to ineffective housekeeping and maintenance services. Additionally, the facility failed to ensure food and drink were palatable, attractive, and served at safe temperatures across three units.
Deficiencies (2)
F 0584: The facility did not provide effective housekeeping and maintenance services. Floors were soiled and bathroom floor tiles were cracked in multiple resident rooms. Walls were scratched and missing paint, and wardrobe doors were cracked.
F 0804: The facility did not ensure food and drink were palatable, attractive, and served at safe temperatures. Cold foods were served above 41°F and warm foods below 135°F. Food was often dry, bland, and cold as reported by residents and confirmed by test tray temperatures.
Report Facts
Food temperature: 113
Food temperature: 124.8
Food temperature: 112
Food temperature: 44.6
Food temperature: 126
Food temperature: 45
Food temperature: 48
Food temperature: 132.2
Food temperature: 123.4
Food temperature: 123
Food temperature: 128.6
Inspection date: Mar 5, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Stated plans to clean floors, replace broken tiles, and repair walls and wardrobes | |
| Certified Nursing Assistant (CNA) #1 | Reported food reheating practices and resident complaints about cold food | |
| Dietician #1 | Described food preparation and serving process including food temperature monitoring |
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