4 Reports
Inspection Report — May 16, 2025
State
Date: May 16, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2025 with deficiency and complaint history.
Complaint Details
The state logged 30 complaints about this facility; 3 led to on-site inspections. No citations resulted from those complaints during the reporting period.
Findings
Across 4 inspections in the reporting period, 24 citations were issued including 8 standard health and 16 Life Safety Code citations. The facility had 30 complaints with 3 on-site inspections and no formal enforcement actions.
Citations (24)
Standard Health Citation — quality of care: Label/store Drugs And Biologicals citation noted.
Life Safety Code Citation — NFPA requirements: Egress Doors did not meet requirements.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenance deficiencies found.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System issues noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Other deficiencies identified.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Receptacles noncompliant.
Life Safety Code Citation — NFPA requirements: Exit Signage did not comply with standards.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance issues found.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficiencies noted.
Life Safety Code Citation — NFPA requirements: HVAC system issues identified.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors noncompliant.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General deficiencies found.
Life Safety Code Citation — NFPA requirements: Physical Environment issues noted.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation deficiencies identified.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing issues found.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure noncompliant.
Standard Health Citation — quality of care: Physician Visits - Review Care/notes/order deficiencies.
Standard Health Citation — quality of care: Reasonable Accommodations Needs/preferences not met.
Standard Health Citation — quality of care: Reporting Of Alleged Violations issues noted.
Standard Health Citation — quality of care: Requirements Before Submitting A Request For not fully met.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficiencies found.
Standard Health Citation — quality of care: Services Provided Meet Professional Standards issues.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation noncompliance noted.
Standard Health Citation — quality of care: Reporting - National Health Safety Network deficiencies not corrected.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 24
Inspections with violations: 3
Inspections without violations: 1
Total complaints: 30
On-site complaint inspections: 3
Number of enforcement actions: 0
Total citations: 24
Inspection Report — May 16, 2025
Renewal CMS
Date: May 16, 2025
Visit Reason
The inspection was conducted as a Recertification Survey from 05/12/2025 to 05/16/2025 to assess compliance with medication storage and labeling regulations.
Findings
The facility failed to ensure that all drugs and biologicals were stored according to accepted professional principles, specifically noting expired medications stored in the Unit C medication cabinet.
Citations (1)
Expired medications were stored in Unit C medication cabinet, including Zinc Sulfate, Iron tablets, and Vitamin C with expiration dates past the current date.
Report Facts
Number of bottles of Zinc Sulfate: 2
Number of tablets in Iron bottle: 200
Volume of Vitamin C bottle: 473
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Interviewed and stated it is the nurse's responsibility to check expiration dates but did not check on the day of observation | |
| Assistant Director of Nursing | Interviewed and stated responsibility of night shift Licensed Practical Nurse and Central Supply Room person to check and replace expired medications |
Inspection Report — Jan 23, 2024
Annual Inspection CMS
Date: Jan 23, 2024
Visit Reason
The inspection was conducted as a recertification survey from 01/16/2024 to 01/23/2024 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in several areas including failure to accommodate a resident's right to use their bathroom due to a locked door and non-functional toilet, failure to maintain a safe and clean environment with dirty equipment and stained furnishings, failure to timely report a resident's fall resulting in spinal fracture to the state, failure to meet professional standards in managing a diabetic resident's high blood sugar readings, and failure of the physician to adequately review and address the resident's care related to diabetes management.
Citations (5)
Resident #15 was prevented from using their room's bathroom due to the door being locked and the toilet being clogged and non-functional.
Resident rooms and common areas had loose wires, dusty and dirty equipment, stained wheelchairs, and dirty window shades.
Resident #30's fall resulting in spinal fracture was not reported to the New York State Department of Health within the required timeframe.
Nurse did not inform Physician #1 of Resident #16's high fingerstick blood sugar readings as ordered.
Physician #1 did not address Resident #16's consistently high blood glucose levels during care reviews.
Report Facts
Residents sampled: 21
Units observed: 3
Residents sampled: 18
Fingerstick blood sugar readings above 350: 5
Hemoglobin A1c: 12.8
Hemoglobin A1c: 12.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Interviewed regarding Resident #15's bathroom use and maintenance reporting | |
| Licensed Practical Nurse #1 | Interviewed regarding awareness of Resident #15's bathroom access and toilet functionality | |
| Director of Environmental Services | Interviewed regarding maintenance and cleaning responsibilities and awareness of toilet clogging behavior | |
| Director of Social Services | Interviewed regarding awareness of Resident #15's bathroom access | |
| Director of Nursing | Interviewed regarding staff rounds and bathroom access for Resident #15 | |
| Licensed Practical Nurse #2 | Interviewed regarding management of Resident #16's high blood sugar readings | |
| Physician #1 | Interviewed regarding management of Resident #16's diabetes and blood glucose levels | |
| Acting Director of Nursing | Interviewed regarding failure to report Resident #30's fall and fracture |
Inspection Report — Feb 16, 2022
Recertification/complaint Investigation CMS
Date: Feb 16, 2022
Visit Reason
The survey was conducted as a Recertification and Complaint Survey to assess compliance with regulatory requirements, including review of Minimum Data Set (MDS) assessments, medication management, and resident care.
Complaint Details
The survey included complaint investigation elements related to failure to complete timely Significant Change MDS assessments and medication management issues. The complaint was substantiated with findings of deficiencies.
Findings
The facility failed to complete a Significant Change MDS assessment within 14 days for a resident with decline in multiple ADLs, delayed submission of a resident's Discharge MDS assessment beyond the required timeframe, administered unnecessary drugs without appropriate response to elevated drug levels, and improperly stored refrigerated medications.
Citations (4)
Failure to complete a Significant Change MDS assessment within 14 days after a resident's decline in more than two ADLs.
Delayed submission and transmission of a resident's Discharge MDS assessment beyond 14 calendar days after completion.
Failure to ensure resident's drug regimen was free from unnecessary drugs despite elevated Dilantin blood levels and lack of timely physician response.
Failure to store refrigerated medications properly; unopened eye drop requiring refrigeration was found unrefrigerated in medication cart drawer.
Report Facts
Residents reviewed for ADL decline: 23
Residents reviewed for Resident Assessment: 23
Residents reviewed for medication regimen: 16
Dilantin blood level: 37.8
Dilantin blood level: 40
Medication dispensing date: Jan 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor | LPN Supervisor | Interviewed regarding resident feeding and transfer status changes |
| Rehab Director | Rehab Director | Interviewed regarding resident assessments and MDS Coordinator responsibilities |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment completion and submission delays |
| Director of Nursing | Director of Nursing | Interviewed regarding requirements for Significant Change MDS assessments |
| Administrator | Administrator | Interviewed regarding MDS Coordinator responsibilities and awareness of deficiencies |
| Primary Medical Doctor | Primary Medical Doctor | Interviewed regarding elevated Dilantin blood levels and treatment plan |
| Registered Nursing Supervisor | Registered Nursing Supervisor | Interviewed regarding lab result handling and communication with physician |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding communication of lab results to physician |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage and nurse responsibilities |
| Licensed Practical Nurse | LPN | Interviewed regarding medication distribution and storage |
| Registered Nurse | RN | Interviewed regarding medication receipt and storage practices |
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