Inspection Reports for
Iroquois Nursing Home Inc
4600 Southwood Heights Drive, Jamesville, NY, 13078
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% 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: 1
Date: Jan 30, 2026
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations regarding the use of psychotropic medications and ensure residents' drug regimens were free from unnecessary drugs.
Findings
The facility failed to ensure that one resident's (Resident #2) drug regimen was free from unnecessary drugs. The resident was administered an as needed antipsychotic medication without documented medical rationale, non-pharmacological interventions were not attempted prior to administration, and no care plan addressed the resident's behaviors or personalized interventions.
Deficiencies (1)
F 0757: The facility did not ensure Resident #2's drug regimen was free from unnecessary drugs. The resident received as needed antipsychotic medication without documented medical necessity or prior non-pharmacological interventions, and lacked a care plan for behaviors or personalized interventions.
Report Facts
Residents affected: 3
Medication doses administered: 4
Medication dosage: 12.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #19 | Nurse Practitioner | Completed history and physical, reviewed medication indications, and provided clinical input on medication use. |
| Registered Nurse Unit Manager #15 | Registered Nurse Unit Manager | Responsible for care plans and behavior documentation; provided interview about medication administration and care planning. |
| Licensed Practical Nurse #25 | Licensed Practical Nurse | Administered as needed antipsychotic medication and described documentation practices. |
| Licensed Practical Nurse #24 | Licensed Practical Nurse | Provided information on medication administration and documentation. |
| Social Worker #17 | Social Worker | Responsible for baseline care plans and care plan meetings; provided interview about resident behaviors. |
| Medical Director #20 | Medical Director | Provided interview regarding medication reconciliation and clinical rationale for medication use. |
| Director of Nursing | Director of Nursing | Provided interview about care plans, staff training, and expectations for documentation of behaviors and medication use. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Aug 20, 2024
Visit Reason
Inspection identified 6 health and 3 life safety deficiencies mostly Level 2 severity, all corrected by early October 2024.
Findings
Inspection identified 6 health and 3 life safety deficiencies mostly Level 2 severity, all corrected by early October 2024.
Deficiencies (9)
ADL care provided for dependent residents
Dialysis
Increase/prevent decrease in rom/mobility
Posted nurse staffing information
Right to be free from physical restraints
Safe/clean/comfortable/homelike environment
Aisle, corridor, or ramp width
Electrical systems - essential electric syste
Exit signage
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 20, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with care standards and regulatory requirements at the nursing home.
Findings
The facility failed to ensure timely toileting assistance for a resident dependent on care, and did not post daily nurse staffing information as required on multiple days during the survey period.
Deficiencies (2)
F 0677: The facility did not ensure residents unable to perform activities of daily living received necessary grooming and hygiene services. Resident #36 was not assisted with timely toileting as required by their care plan.
F 0732: The facility did not post daily nurse staffing information at the beginning of each shift as required on 4 of 5 survey days, failing to include total number and hours worked by nursing staff.
Report Facts
Days nurse staffing not posted as required: 4
Residents reviewed for toileting: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #22 | Documented resident care and admitted not toileting Resident #36 as required on 8/16/2024. | |
| Licensed Practical Nurse Manager #3 | Oversaw unit staff and confirmed expectations for toileting and documentation. | |
| Director of Nursing | Provided information on Resident #36's toileting needs and risks of not following care plan. | |
| Administrative Assistant/Day Staffing Coordinator #15 | Provided information about nurse staffing schedule posting issues. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 20, 2024
Visit Reason
The survey was a recertification and abbreviated annual inspection conducted from 8/14/2024 to 8/20/2024 to assess compliance with regulatory requirements for Iroquois Nursing Home Inc.
Findings
The facility was found deficient in multiple areas including maintaining a safe and homelike environment with damaged and unclean resident chairs, improper use and documentation of physical restraints, failure to assist residents with activities of daily living such as timely toileting, inadequate therapy evaluation and care planning for mobility devices, lack of dialysis care planning for a resident receiving hemodialysis, and failure to post daily nurse staffing information as required.
Deficiencies (6)
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment on Unit 1 due to multiple unclean and damaged wheelchairs and positioning devices.
F 0604: The facility did not ensure indicated restraints were used for the least amount of time and lacked documentation of parameters for use and ongoing re-evaluation for Resident #7 using a Merry Walker restraint.
F 0677: The facility did not ensure residents unable to perform activities of daily living received necessary services to maintain grooming and hygiene, specifically Resident #36 was not assisted with timely toileting.
F 0688: The facility did not ensure Resident #22 with limited mobility received appropriate therapy evaluation or care planning for the use of a scoot chair, which was used without proper assessment or documentation.
F 0698: The facility did not ensure Resident #301 receiving hemodialysis had a comprehensive care plan addressing dialysis care and related interventions.
F 0732: The facility did not post daily nurse staffing information at the beginning of each shift for 4 of 5 days surveyed as required by regulation.
Report Facts
Days nurse staffing not posted: 4
Dates of survey: Survey conducted from 2024-08-14 to 2024-08-20.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Interviewed regarding cleaning responsibilities and restraint use for Resident #7. | |
| Licensed Practical Nurse Unit Manager #3 | Interviewed regarding cleaning, restraint use, and toileting care. | |
| Director of Nursing | Interviewed regarding work order process, restraint policies, toileting care, therapy referrals, and care plan responsibilities. | |
| Director of Maintenance | Interviewed regarding maintenance work orders for chair repairs. | |
| Nurse Practitioner #7 | Interviewed regarding restraint use and release requirements. | |
| Certified Nurse Aide #22 | Interviewed regarding toileting care for Resident #36. | |
| Occupational Therapist #19 | Interviewed regarding therapy evaluation and care planning for Resident #22. | |
| Registered Nurse #13 | Interviewed regarding admission assessment and dialysis care planning for Resident #301. | |
| Assistant Director of Nursing | Interviewed regarding dialysis care planning and policy compliance. | |
| Registered Nurse Unit Manager #12 | Interviewed regarding dialysis care planning for Resident #301. | |
| Administrative Assistant/Day Staffing Coordinator #15 | Interviewed regarding posting of daily nurse staffing schedules. | |
| Registered Nurse Manager #18 | Interviewed regarding therapy referrals and care plan updates for Resident #22. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
One Level 2 health deficiency related to respiratory/tracheostomy care, corrected by January 2024.
Findings
One Level 2 health deficiency related to respiratory/tracheostomy care, corrected by January 2024.
Deficiencies (1)
Respiratory/tracheostomy care and suctioning
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with respiratory care standards for residents requiring continuous positive airway pressure therapy.
Findings
The facility failed to ensure that a resident requiring continuous positive airway pressure therapy received appropriate care consistent with professional standards. Documentation was lacking regarding refusals of therapy or missing machine parts, and the medical provider was not notified as required.
Deficiencies (1)
F 0695: The facility did not provide safe and appropriate respiratory care for Resident #2. The continuous positive airway pressure machine was not applied on multiple dates due to refusals or missing parts, and there was no documentation that the issues were addressed or that the medical provider was notified.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Interviewed regarding documentation and care of Resident #2's CPAP therapy | |
| Assistant Director of Nursing #3 | Assistant Director of Nursing | Interviewed about expectations for notification of missing CPAP parts or refusals |
| Registered Nurse Supervisor #5 | Registered Nurse Supervisor | Interviewed about notification procedures for refusals or missing CPAP parts |
| Director of Nursing #4 | Director of Nursing | Interviewed about orders and documentation requirements for CPAP therapy |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 15, 2023
Visit Reason
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 8, 2023
Visit Reason
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 2, 2023
Visit Reason
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 13, 2022
Visit Reason
One Level 3 health deficiency for free from abuse and neglect, corrected by November 2022.
Findings
One Level 3 health deficiency for free from abuse and neglect, corrected by November 2022.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jul 15, 2022
Visit Reason
Multiple Level 2 health deficiencies related to food procurement, accident hazards, nutritive value, and multiple Level 2 life safety deficiencies, all corrected by September 2022.
Findings
Multiple Level 2 health deficiencies related to food procurement, accident hazards, nutritive value, and multiple Level 2 life safety deficiencies, all corrected by September 2022.
Deficiencies (7)
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Nutritive value/appear, palatable/prefer temp
Aisle, corridor, or ramp width
Electrical equipment - testing and maintenanc
Elevators
Sprinkler system - maintenance and testing
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jul 15, 2022
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards, including resident safety during fire drills and food service quality.
Findings
The facility failed to ensure adequate supervision to prevent accidents during a fire drill, resulting in a resident wandering off a secured unit unnoticed. Additionally, the facility failed to provide food at safe and palatable temperatures and maintain kitchen cleanliness according to professional standards.
Deficiencies (3)
F 0689: The facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 6 residents during a fire drill, allowing a resident to leave a secured unit undetected and be found in a hazardous non-resident area.
F 0804: The facility failed to provide food and drinks at safe and palatable temperatures for 2 test trays, with hot foods served lukewarm and cold foods served too warm, not meeting required temperature standards.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards due to unclean kitchen equipment, frozen and melted water on the walk-in cooler floor, leaking handwash sink, and unclean walls and frying pans.
Report Facts
Residents affected: 1
Residents affected: 2
Food temperatures recorded: 129
Food temperatures recorded: 126
Food temperatures recorded: 122
Food temperatures recorded: 61
Food temperatures recorded: 57
Food temperatures recorded: 114
Food temperatures recorded: 60
Food temperatures recorded: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Completed elopement risk assessment and notified of missing resident incident |
| RN #2 | Clinical Supervisor | Documented missing resident and fire drill procedures |
| CNA #5 | Certified Nurse Aide | Provided information about secured unit and fire drill door monitoring |
| LPN #11 | Unit Manager | Described fire safety training and fire drill procedures |
| Food Service Director | Food Service Director | Provided information on food temperature audits and kitchen cleanliness |
| Director of Maintenance | Director of Maintenance | Reported on maintenance work orders and walk-in cooler conditions |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 5, 2022
Visit Reason
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 survey with one Level 2 health deficiency related to reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 24, 2022
Visit Reason
One Level 2 health deficiency for investigate/prevent/correct alleged violation, corrected by July 2022.
Findings
One Level 2 health deficiency for investigate/prevent/correct alleged violation, corrected by July 2022.
Deficiencies (1)
Investigate/prevent/correct alleged violation
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to provide food and drink at safe and appetizing temperatures for some meals and did not maintain an effective infection prevention and control program, specifically regarding hand hygiene during wound care.
Deficiencies (2)
F 0804: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Food items such as pork dijonnaise and scrambled eggs were served below safe temperature standards.
F 0880: Provide and implement an infection prevention and control program. A nurse failed to perform hand hygiene between glove changes during wound care, risking infection spread.
Report Facts
Food temperature: 118
Food temperature: 97
Food temperature: 57
Food temperature: 139
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Failed to perform hand hygiene between glove changes during wound care |
| RN Unit Manager #2 | RN Unit Manager | Stated RN #1 should have performed hand hygiene and required re-education |
| Infection Control RN/Staff Educator | Infection Control RN/Staff Educator | Confirmed RN #1 had received education but needed re-education on hand hygiene |
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