Inspection Reports for
Masonic Care Community of New York
2150 Bleecker Street, Utica, NY, 13501
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 1
Date: Nov 12, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety and supervision requirements, specifically focusing on elopement risks and accident prevention for residents.
Findings
The facility failed to provide adequate supervision to prevent elopements for two residents, resulting in Immediate Jeopardy and Substandard Quality of Care. Resident #1 eloped twice undetected from the facility, and Resident #3 left the facility grounds on a motorized scooter without staff knowledge. The facility's policies and staff responses to door alarms and wander detection devices were inadequate.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent accidents and elopements, resulting in Immediate Jeopardy to resident health or safety. Resident #1 eloped twice undetected, and Resident #3 left the facility grounds on a motorized scooter without staff awareness.
Report Facts
Residents affected: 59
Elopement incidents: 3
Staff education completion: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Assessed Resident #1 after elopement incidents and documented care |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Witnessed Resident #1 elopement and involved in search and care |
| Certified Nurse Aide #5 | Certified Nurse Aide | Witnessed alarm sounding and stairwell door open during Resident #1 elopement |
| Certified Nurse Aide #6 | Certified Nurse Aide | Witnessed alarm and stairwell door open, took accountability of unit residents |
| Certified Nurse Aide #19 | Certified Nurse Aide | Involved in search for Resident #1 and turning off alarm |
| Registered Nurse Manager #16 | Registered Nurse Manager | Provided information on elopement risk screens and scooter use policies |
| Certified Nurse Aide #27 | Certified Nurse Aide | Witnessed Resident #3 leaving facility grounds on motorized scooter |
| Medical Director | Medical Director | Provided clinical assessment and commentary on incidents |
| Administrator | Administrator | Provided statements on staff expectations and facility policies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: May 17, 2024
Visit Reason
Complaint Survey with 7 Standard Health and 6 Life Safety Code citations, all Level 2 severity, corrected by July 15, 2024.
Findings
Complaint Survey with 7 Standard Health and 6 Life Safety Code citations, all Level 2 severity, corrected by July 15, 2024.
Deficiencies (13)
Bedrails
Develop/implement comprehensive care plan
Grievances
Infection prevention & control
Resident self-admin meds-clinically approp
Residents are free of significant med errors
Treatment/svcs to prevent/heal pressure ulcer
Hazardous areas - enclosure
Illumination of means of egress
Means of egress - general
Multiple occupancies - construction type
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 17, 2024
Visit Reason
The survey was a recertification annual inspection conducted from 5/13/2024 to 5/17/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including medication self-administration, grievance process, comprehensive care planning, pressure ulcer care, bed rail safety, medication administration errors, and infection prevention and control.
Deficiencies (7)
F 0554: The facility failed to ensure residents #96 and #155 had physician orders and assessments for safe self-administration of medications, including eye drops and nasal sprays.
F 0585: The facility did not have an effective grievance process for residents, with 6 anonymous residents unaware of how to file grievances and no process for anonymous grievances.
F 0656: Resident #170's care plan lacked a comprehensive, person-centered plan addressing anticoagulant therapy despite documented use of apixaban.
F 0686: Resident #106 did not receive the ordered left heel float boot for pressure ulcer prevention until two weeks after the order, risking skin breakdown.
F 0700: Resident #40 was provided bed rails without documented assessment, informed consent, or physician orders, risking entrapment and injury.
F 0760: Resident #28 missed four consecutive doses of carbidopa-levodopa for Parkinson's Disease due to medication unavailability and lack of medical notification.
F 0880: Resident #15's urinary catheter drainage bag was observed resting on the bare floor without a protective barrier, increasing infection risk.
Report Facts
Residents affected: 2
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Missed medication doses: 4
Date survey completed: May 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #16 | Nurse Practitioner | Named in medication self-administration assessment and interview |
| Registered Nurse Manager #15 | Nurse Manager | Named in multiple interviews regarding care plans, medication administration, and wound care |
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Named in interviews regarding care plans and bed rail policies |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Named in interviews regarding medication self-administration and wound care |
| Registered Nurse Supervisor #11 | Registered Nurse Supervisor | Named in medication administration and missed medication interviews |
| Certified Nurse Aide #12 | Certified Nurse Aide | Named in interview regarding care plan knowledge |
| Registered Nurse Unit Manager #3 | Registered Nurse Unit Manager | Named in interviews regarding bed rail use and medication administration |
| Physician #17 | Physician | Named in interview regarding missed medication notification |
| Director of Physical Therapy #4 | Director of Physical Therapy | Named in interview regarding bed rail assessments |
| Registered Nurse Infection Preventionist | Infection Preventionist | Named in interview regarding catheter care and infection control |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 14, 2022
Visit Reason
Complaint Survey with 1 Standard Health citation for reporting of alleged violations, Level 2 severity, corrected by November 21, 2022.
Findings
Complaint Survey with 1 Standard Health citation for reporting of alleged violations, Level 2 severity, corrected by November 21, 2022.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 18, 2022
Visit Reason
Covid-19 Survey with 1 Standard Health citation for reporting to national health safety network, Level 2 severity, not corrected as of report.
Findings
Covid-19 Survey with 1 Standard Health citation for reporting to national health safety network, Level 2 severity, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 27, 2022
Visit Reason
Complaint Survey with 1 Standard Health citation for free of accident hazards/supervision/devices, Level 2 severity, corrected by March 11, 2022.
Findings
Complaint Survey with 1 Standard Health citation for free of accident hazards/supervision/devices, Level 2 severity, corrected by March 11, 2022.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Dec 7, 2021
Visit Reason
Complaint Survey with 9 Standard Health and 8 Life Safety Code citations, mostly Level 2 severity, corrected by February 4, 2022.
Findings
Complaint Survey with 9 Standard Health and 8 Life Safety Code citations, mostly Level 2 severity, corrected by February 4, 2022.
Deficiencies (17)
Develop/implement comprehensive care plan
Drinks avail to meet needs/prefs/hydration
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection control
Label/store drugs and biologicals
Posted nurse staffing information
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Elevators
Emergency lighting
Fire alarm system - testing and maintenance
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 7, 2021
Visit Reason
The survey was a recertification and abbreviated survey conducted from 12/1/21 to 12/7/21 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including environmental safety hazards such as damaged flooring and unlabeled or expired medications, failure to follow care plans for mechanical lift sling sizes, inadequate investigation of a fall incident, failure to post daily resident census and staffing information timely, medication administration errors related to blood pressure monitoring, failure to provide residents with hot beverages as per meal tickets, and improper food storage with undated and unlabeled food items in refrigerators.
Deficiencies (9)
F 0584: The facility failed to provide a safe environment with damaged flooring posing tripping hazards on Buffalo and Amherst units and failed to maintain cleanliness of resident equipment, evidenced by a soiled Broda chair for Resident #88.
F 0656: The facility failed to develop and implement a comprehensive care plan with measurable objectives for Resident #187, who was transferred using a mechanical lift with an incorrect sling size.
F 0689: The facility failed to ensure accident hazards were minimized and adequate supervision provided, as Resident #164 fell from a mechanical lift and the investigation was incomplete regarding sling size and condition.
F 0732: The facility failed to post the most current daily resident census and nurse staffing information timely and consistently for 5 of 5 days reviewed.
F 0760: The facility failed to ensure Resident #240's blood pressure was obtained prior to administration of midodrine per physician ordered parameters.
F 0761: The facility failed to ensure all drugs and biologicals were labeled with appropriate accessory and cautionary instructions and expiration dates, including unlabeled insulin pens and expired medications on medication carts.
F 0761 (continued): The facility failed to ensure consistent weekly and quarterly checks for expired medications and proper labeling of opened insulin vials.
F 0807: The facility failed to ensure residents on the Saranac Unit received hot beverages or equivalent substitutions as documented on their meal tickets for 7 of 16 residents reviewed.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, evidenced by dented cans in the main kitchen and undated/unlabeled food items in unit refrigerators.
Report Facts
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dented cans: 2
Medication administration dates missing: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #12 | Certified Nurse Aide | Named in finding regarding failure to clean soiled Broda chair |
| LPN #10 | Licensed Practical Nurse | Named in finding regarding failure to clean soiled Broda chair |
| RN Unit Manager #15 | Registered Nurse Unit Manager | Named in finding regarding responsibility for cleaning resident chairs |
| Director of Plant Operations | Interviewed regarding damaged flooring and tripping hazards | |
| CNAs #34 and #35 | Certified Nurse Aides | Named in finding regarding use of incorrect sling size for Resident #187 |
| LPN #38 | Licensed Practical Nurse | Interviewed regarding sling size responsibility |
| RN Unit Manager #9 | Registered Nurse Unit Manager | Interviewed regarding sling size responsibility |
| Assistant Director of Nursing (ADON) | Interviewed regarding sling size responsibility | |
| Director of Physical Therapy | Interviewed regarding sling size responsibility | |
| RN Supervisor #3 | Registered Nurse Supervisor | Named in investigation of Resident #164 fall from mechanical lift |
| CNA #33 | Certified Nurse Aide | Named in investigation of Resident #164 fall from mechanical lift |
| CNA #34 | Certified Nurse Aide | Named in investigation of Resident #164 fall from mechanical lift |
| LPN #31 | Licensed Practical Nurse | Named in incident report for Resident #164 fall |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding medication administration and blood pressure monitoring |
| RN Unit Manager #3 | Registered Nurse Unit Manager | Interviewed regarding medication administration and blood pressure monitoring |
| Medical Director | Interviewed regarding medication administration and blood pressure monitoring | |
| Director of Nursing (DON) | Interviewed regarding multiple findings including medication administration and expired medications | |
| LPN #14 | Licensed Practical Nurse | Interviewed regarding expired medications and labeling |
| RN Unit Manager #13 | Registered Nurse Unit Manager | Interviewed regarding expired medications and labeling |
| Food Service Director | Interviewed regarding food storage and meal service | |
| RA #16 | Residence Aide | Interviewed regarding failure to provide hot beverages |
| RA #17 | Residence Aide | Interviewed regarding failure to provide hot beverages |
| Diet Technician #18 | Interviewed regarding meal service and hydration | |
| Registered Dietitian (RD) #20 | Interviewed regarding meal service and hydration | |
| Clinical Nutrition Manager RD #1 | Interviewed regarding meal service and hydration | |
| RA #23 | Residence Aide | Interviewed regarding checking for undated/outdated food in refrigerators |
| RA #24 | Residence Aide | Interviewed regarding checking for undated/outdated food in refrigerators |
| RN #7 | Registered Nurse | Interviewed regarding undated food in unit refrigerator |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 31, 2019
Visit Reason
The visit was a recertification and abbreviated survey to evaluate compliance with professional standards of practice, specifically reviewing treatment and care for Resident #406 with a change in condition related to diabetes management.
Findings
The facility failed to provide appropriate treatment and care for Resident #406 by not timely addressing his diabetic status upon admission. The resident's glucose levels were not monitored as ordered, and insulin orders were delayed or omitted.
Deficiencies (1)
F 0684: The facility did not ensure treatment and care was provided according to professional standards for Resident #406 with insulin-dependent diabetes. Glucose levels were inadequately monitored and insulin orders were delayed or missing after admission.
Report Facts
Glucose level: 211
Date of hospital discharge medication reconciliation: Jan 10, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Completed nursing progress note on 1/13/2019 documenting new glucose and insulin orders |
| RN #2 | Unit Manager | Interviewed regarding admission orders and medication input process |
Viewing
Loading inspection reports...
