Inspection Reports for
Lockport Rehab & Health Care Center
909 Lincoln Ave, Lockport, NY, 14094
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Jun 4, 2024
Visit Reason
Complaint Survey with 3 standard health citations and 7 life safety code citations, all Level 2 severity, corrected by August 2, 2024.
Findings
Complaint Survey with 3 standard health citations and 7 life safety code citations, all Level 2 severity, corrected by August 2, 2024.
Deficiencies (10)
ADL care provided for dependent residents
Self-determination
Tube feeding mgmt/restore eating skills
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Exit signage
Fire alarm system - testing and maintenance
Smoke detection
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NY00323467) regarding the facility's failure to provide appropriate care and feeding tube formula as per hospital discharge instructions for a resident fed by enteral means.
Complaint Details
Complaint #NY00323467 was substantiated. The investigation found that the facility did not provide the ordered tube feeding formula to Resident #127, who was admitted with a feeding tube and multiple diagnoses. Staff failed to obtain or administer the feed and did not notify the responsible medical personnel in a timely manner.
Findings
The facility did not ensure that Resident #127 received the prescribed enteral feeding formula after admission, resulting in a failure to provide adequate hydration and nutrition. Staff failed to obtain or administer the ordered feed promptly and did not notify appropriate personnel in a timely manner.
Deficiencies (1)
F 0693: The facility failed to provide the prescribed enteral feeding formula to Resident #127 as ordered in the hospital discharge summary, resulting in inadequate nutrition and hydration. Staff did not promptly notify the Nurse Practitioner or Director of Nursing about the missing feed supply.
Report Facts
Feeding rate: 70
Water flush volume: 150
Medication administration record period: 30
Date of inspection: Jun 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor #1 | Licensed Practical Nurse Supervisor | Named in medication error finding and failure to notify appropriate personnel |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Noted missing feed and contacted Nurse Practitioner |
| Nurse Practitioner #1 | Nurse Practitioner | Provided sliding scale insulin order and expected staff to follow feed orders |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to obtain feed and staff communication |
| Registered Dietitian | Registered Dietitian | Provided expert opinion on feeding and substitute feed options |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 4, 2024
Visit Reason
The visit was conducted as a complaint investigation regarding concerns about resident care, including resident rights to self-determination, personal hygiene, and feeding tube management.
Complaint Details
Complaint investigation (Complaint #NY00323467) focused on feeding tube care for Resident #127 and other resident care issues. The complaint was substantiated with findings of inadequate feeding tube management and other care deficiencies.
Findings
The facility failed to ensure that Resident #9 received showers according to their care plan and preferences, resulting in a violation of resident rights. Resident #29 did not receive adequate nail care, with long, jagged nails observed despite care plans. Resident #127 did not receive prescribed enteral feeding formula as per hospital discharge orders, risking inadequate nutrition and hydration.
Deficiencies (3)
F 0561: The facility did not ensure Resident #9 received showers twice a week during the day as care planned and preferred, instead providing one shower weekly in the evening.
F 0677: The facility did not ensure Resident #29 received necessary nail care; nails were long, jagged, and dirty despite care plans and staff awareness.
F 0693: The facility failed to provide Resident #127 with the prescribed enteral feeding formula per hospital discharge summary, resulting in missed nutrition and hydration for over 15 hours.
Report Facts
Deficiencies cited: 3
Feeding rate: 70
Water flush volume: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Supervisor #1 | Licensed Practical Nurse Supervisor | Named in feeding tube formula omission and communication failure. |
| Certified Nursing Aide #1 | Certified Nursing Aide | Interviewed regarding shower scheduling and care for Resident #9. |
| Certified Nursing Aide #2 | Certified Nursing Aide | Interviewed regarding shower scheduling and nail care. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding nail care responsibilities for Resident #29. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding nail care for Resident #29. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Interviewed regarding shower scheduling and care plan updates for Resident #9. |
| Director of Nursing | Director of Nursing | Interviewed regarding shower scheduling, nail care expectations, and feeding tube formula issues. |
| Administrator | Administrator | Interviewed regarding expectations for honoring Resident #9's preferences. |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding feeding tube orders and expectations for nursing staff. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding feeding tube formula supply and recommendations. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Jun 28, 2022
Visit Reason
Complaint Survey with 4 standard health citations and 4 life safety code citations, all Level 2 severity, corrected by August 26, 2022.
Findings
Complaint Survey with 4 standard health citations and 4 life safety code citations, all Level 2 severity, corrected by August 26, 2022.
Deficiencies (8)
Bowel/bladder incontinence, catheter, uti
Free from abuse and neglect
Notify of changes (injury/decline/room, etc. )
Reporting of alleged violations
Cooking facilities
Corridors - construction of walls
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Inspection Report
Routine
Deficiencies: 4
Date: Jun 28, 2022
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident care, abuse prevention, and catheter care at Lockport Rehab & Health Care Center.
Findings
The facility failed to notify a resident's responsible party prior to initiating psychotropic medication, did not prevent resident-to-resident abuse resulting in a skin tear, failed to timely report the abuse incident to the state, and did not ensure proper anchoring of an indwelling urinary catheter for one resident.
Deficiencies (4)
F 0580: The facility did not inform Resident #55's responsible party prior to starting antipsychotic medication (Zyprexa) for dementia-related aggression.
F 0600: Resident #55 was bitten by Resident #75, causing a skin tear, and the facility failed to ensure resident rights to be free from abuse and to prevent further incidents.
F 0609: The facility did not report the resident-to-resident abuse incident involving Residents #55 and #75 to the New York State Department of Health within the required 2-hour timeframe.
F 0690: Resident #44's indwelling urinary catheter was not anchored to prevent tension, and the facility policy did not address catheter anchoring.
Report Facts
Skin tear size: 3
Medication dosage: 2.5
Antibiotic dosage: 500
Incident notification time: 2
Catheter flush volume: 50
Catheter size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Unit Manager | Did not notify family when Resident #55 was started on Zyprexa. |
| RN #1 | Unit Manager | Completed incident report and investigation of resident-to-resident abuse involving Residents #55 and #75. |
| Director of Nursing | Director of Nursing | Stated expectation to notify family of medication changes and reported on abuse incident handling and reporting. |
| LPN #2 | Licensed Practical Nurse | Observed Resident #44's catheter was not anchored and acknowledged responsibility for catheter care. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Witnessed resident-to-resident biting incident. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Provided catheter care to Resident #44 and noted catheter was not anchored. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 29, 2021
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to national health safety network, Level 2 severity, not corrected as of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to national health safety network, Level 2 severity, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Routine
Deficiencies: 5
Date: Aug 30, 2019
Visit Reason
The facility underwent a standard routine survey inspection to assess compliance with regulatory requirements including employee screening, resident assessments, medication management, and food service quality.
Findings
The inspection identified deficiencies in employee pre-hire screening procedures, inaccurate resident assessments related to psychotropic medication dose reductions, failure to implement gradual dose reductions (GDR) for antipsychotic medications, and issues with food service including improper food temperatures and poor food quality.
Deficiencies (5)
F 0607: The facility failed to implement written policies and procedures for screening employees to prevent abuse, neglect, and exploitation, with four of fifteen employee files lacking timely Nurse Aide Registry verification prior to employment.
F 0641: The facility did not ensure accurate resident assessments reflecting recent gradual dose reductions (GDR) of psychotropic medications for two residents, resulting in inaccurate Minimum Data Set (MDS) entries.
F 0756: The pharmacist failed to report irregularities in medication regimens for two residents, specifically not identifying or reporting antipsychotic medications prescribed without attempts at gradual dose reduction (GDR).
F 0758: The facility did not ensure residents using antipsychotic drugs received gradual dose reductions or behavioral interventions unless contraindicated, with two residents maintained on antipsychotics without documented GDR or behavioral justification.
F 0804: The facility failed to provide food and drink that was palatable, attractive, and served at safe and appetizing temperatures, with observations of lukewarm or cold food and resident complaints about food quality.
Report Facts
Employee files lacking timely Nurse Aide Registry verification: 4
Resident count reviewed for MDS accuracy: 23
Residents reviewed for Drug Regimen Reviews: 5
Residents reviewed for antipsychotic medication use: 2
Medication refusal instances: 49
Food temperature measurements: 118
Food temperature measurements: 104
Food temperature measurements: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources and Payroll Coordinator | Interviewed regarding employee screening and Nurse Aide Registry verification errors. | |
| Director of Nursing | Interviewed about resident assessments and medication management. | |
| Pharmacist Consultant #1 | Pharmacist Consultant | Interviewed regarding medication regimen reviews and GDR implementation. |
| Licensed Practical Nurse Unit Manager #1 | LPN Unit Manager | Interviewed about MDS completion and resident behaviors. |
| Medical Director | Medical Director | Interviewed about pharmacy reviews and medication management. |
| Food Service Director | Food Service Director | Interviewed about food service quality and temperature monitoring. |
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