Inspection Reports for
Lockport Rehab & Health Care Center
909 Lincoln Ave, Lockport, NY, 14094
Back to Facility ProfileCitations (last 4 years)
Citations (over 4 years)
7 citations/year
Citations are regulatory findings recorded during state inspections.
37% worse than New York average
New York average: 5.1 citations/year
Citations per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 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.
Citations (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
Capacity: 60
Citations: 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.
Citations (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
Citations: 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.
Citations (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
Citations: 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.
Citations (1)
Reporting - national health safety network
Inspection Report
Routine
Citations: 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.
Citations (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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