Inspection Reports for
Palatine Nursing Home
154 Lafayette Street, Palatine Bridge, NY, 13428
Back to Facility Profile5 Reports
Inspection Report — Jan 22, 2026
Abbreviated Survey CMS
Date: Jan 22, 2026
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to evaluate compliance with regulations related to timely reporting of suspected abuse, neglect, or theft and the submission of investigation results to proper authorities.
Findings
The facility failed to ensure that alleged abuse violations were reported immediately, within two hours of the allegation, and that investigation reports were submitted within five working days, as required by state law. Four of five residents reviewed for abuse had incidents that were either reported late or not reported to the New York State Department of Health.
Citations (1)
F 0609: The facility did not timely report suspected abuse incidents within two hours as required and failed to submit investigation reports within five working days for four residents. Specifically, resident-to-resident abuse incidents and allegations involving staff were not reported or reported late to the State Agency.
Report Facts
Residents reviewed for abuse: 5
Residents with abuse reporting deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #1 | Administrator | Interviewed regarding responsibility for submitting abuse reports and lack of awareness of reporting timelines. |
Inspection Report — Jan 22, 2026
Complaint Investigation State
Date: Jan 22, 2026
Visit Reason
State-compiled facility profile showing 5 inspections from 2023 to 2026 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 41 complaints about this facility; 3 led to on-site inspections.
Findings
Across 5 inspections, 42 citations were issued including 20 standard health and 22 Life Safety Code citations. Two enforcement actions with fines totaling $22,000 were recorded, and multiple deficiencies were corrected while some remain uncorrected.
Citations (24)
Standard Health Citation — quality of care: Essential Equipment not maintained in safe operating condition.
Standard Health Citation — quality of care: Medication error rates exceeded 5 percent.
Standard Health Citation — quality of care: Quality of care deficiencies noted.
Standard Health Citation — quality of care: Failure in reporting alleged violations.
Standard Health Citation — quality of care: Resident records contained identifiable information breaches.
Standard Health Citation — quality of care: Resident self-administered medications not clinically appropriate.
Standard Health Citation — quality of care: Residents not free of significant medication errors.
Standard Health Citation — quality of care: Environment not safe, functional, sanitary, or comfortable.
Life Safety Code Citation — NFPA requirements: Cooking facilities deficiencies.
Life Safety Code Citation — NFPA requirements: Exits discharge issues.
Life Safety Code Citation — NFPA requirements: Electrical equipment testing and maintenance deficiencies.
Life Safety Code Citation — NFPA requirements: Essential electrical systems deficiencies not yet corrected.
Life Safety Code Citation — NFPA requirements: Illumination of means of egress deficiencies.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing deficiencies.
Life Safety Code Citation — NFPA requirements: Essential electrical systems widespread deficiencies.
Life Safety Code Citation — NFPA requirements: Emergency preparedness training program deficiencies widespread.
Life Safety Code Citation — NFPA requirements: Organization and administration deficiencies.
Life Safety Code Citation — NFPA requirements: Plan based on all hazards risk assessment deficiencies widespread.
Standard Health Citation — quality of care: Reporting to National Health Safety Network not compliant, not yet corrected.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving not sanitary.
Standard Health Citation — quality of care: Personal privacy and confidentiality of records violated.
Standard Health Citation — quality of care: Failure to provide or obtain specialized rehab services.
Life Safety Code Citation — NFPA requirements: Doors with self-closing devices deficiencies.
Life Safety Code Citation — NFPA requirements: Essential electrical systems with potential for minimal harm.
Report Facts
Inspections on page: 5
Total violations/deficiencies cited: 42
Inspections with violations: 4
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 22000
Number of enforcement actions: 2
Inspection Report — Jun 6, 2023
Annual Inspection CMS
Date: Jun 6, 2023
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory standards for nursing home operations, including resident privacy, food safety, and rehabilitative services.
Findings
The facility was found deficient in maintaining resident privacy by leaving computer screens unattended with visible personal information, ensuring proper calibration and use of food temperature thermometers and sanitizer test kits in the kitchen, and timely provision and documentation of specialized rehabilitative services for a resident.
Citations (3)
F 0583: The facility did not ensure resident privacy and confidentiality of personal and medical records as computer screens displaying resident information were left unattended on multiple occasions.
F 0812: One of two food temperature thermometers was not calibrated correctly and the sanitizer test kit could not measure required sanitizer concentrations, risking food safety.
F 0825: The facility failed to provide timely specialized rehabilitative services and did not document therapy evaluations for a resident as required by policy.
Report Facts
Food temperature thermometer calibration deviation: 5
Sanitizer concentration range: 200
Sanitizer concentration range: 400
Therapy referral response time: 72
Therapy referral date: May 24, 2023
Therapy evaluation date: May 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in interview regarding computer screen privacy violation |
| Director of Nursing | DON | Named in interviews regarding privacy violations and therapy referral oversight |
| Registered Nurse #1 | RN | Named in interviews regarding computer screen privacy and therapy referral process |
| Physical Therapist #1 | PT | Named in interview regarding therapy referral and evaluation documentation |
| Occupational Therapist #1 | OT | Named in interview regarding therapy evaluation documentation; noted as unavailable due to illness |
| Administrator | Named in interview regarding food safety deficiencies | |
| Dietary Manager | Named in interview regarding food safety deficiencies and staff training |
Inspection Report — May 10, 2021
Annual Inspection CMS
Date: May 10, 2021
Visit Reason
The inspection was a recertification survey and an abbreviated survey to assess compliance with regulatory requirements for Palatine Nursing Home.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans for residents, providing appropriate pressure ulcer care, ensuring adequate supervision to prevent accidents, and maintaining an effective infection prevention and control program. Specific issues included failure to implement care plans for swallowing, pressure ulcer prevention, oxygen administration, and resident mobility; inadequate supervision of a resident at risk for choking; and lapses in infection control practices including PPE use, hand hygiene, and disinfection of multi-resident use equipment.
Citations (4)
F 0656: The facility did not develop and implement comprehensive care plans with measurable actions for five residents, including care for swallowing, pressure ulcer risk, cast care, oxygen administration, and mobility assistance.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for a resident at risk, lacking interventions such as turning schedules and wound care referrals.
F 0689: The facility did not ensure adequate supervision to prevent accidents for a resident at high risk for choking by leaving the resident alone in a room with the door closed during meals.
F 0880: The facility failed to maintain an effective infection prevention and control program, including inconsistent use of gowns and gloves, inadequate hand hygiene, failure to disinfect multi-resident use glucometers, and lack of a surveillance system for infections.
Report Facts
Residents reviewed for care plans: 19
Residents with deficient care plans: 5
Residents reviewed for pressure sores: 2
Residents affected by pressure ulcer deficiency: 1
Residents reviewed for accident prevention: 4
Residents affected by accident prevention deficiency: 1
Units on contact and droplet precautions: 2
Staff COVID-19 positive date: Apr 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Registered Nurse Manager | Named in care planning deficiencies and interviews regarding care plan omissions and pressure ulcer care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding oxygen administration and resident refusal |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding cast care instructions |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding resident mobility assistance |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan expectations and infection control |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Observed and interviewed regarding infection control practices and glucometer disinfection |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Observed and interviewed regarding infection control practices |
| Infection Control Practitioner | Infection Control Practitioner | Interviewed regarding infection control expectations and surveillance deficiencies |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene and medication administration |
Inspection Report — Apr 18, 2019
Annual Inspection CMS
Date: Apr 18, 2019
Visit Reason
Recertification survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including timely notification of resident transfers to the Ombudsman, comprehensive and accurate resident assessments, care planning, provision of appropriate care and services, medication management, infection control, dietary services, and safety compliance.
Citations (14)
F 0623: Facility failed to provide timely written notification to the State Long-Term Care Ombudsman for resident transfers to hospital for 2 residents.
F 0636: Facility did not conduct comprehensive, accurate, and timely assessments for residents, resulting in inaccurate coding of dental status, range of motion, and weight loss for 3 residents.
F 0656: Facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for 6 residents, including nutritional and pain management needs.
F 0688: Facility did not provide appropriate care to maintain or improve range of motion for a resident with limited mobility, failing to apply prescribed positioning devices.
F 0689: Facility did not ensure adequate supervision and accident hazard prevention for a resident, failing to implement swallowing precautions and provide swallowing cue cards.
F 0692: Facility failed to provide therapeutic diets and nutritional interventions consistent with residents' needs, including failure to provide finger foods, adequate assistance at meals, and nutritional supplements.
F 0695: Facility did not provide safe and appropriate respiratory care, failing to ensure residents received physician-ordered oxygen flow rates on multiple occasions.
F 0757: Facility did not ensure residents' drug regimens were free from unnecessary drugs, including administration of acetaminophen without a physician order.
F 0758: Facility failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications, and did not document clinical indications or effects of medication changes for two residents.
F 0760: Facility did not ensure residents were free from significant medication errors, including lack of physician orders for sliding scale insulin and inconsistent medication administration.
F 0800: Facility did not ensure residents received diets meeting their nutritional and consistency needs, serving pureed foods with inappropriate texture and mechanical soft diets with inappropriate items.
F 0813: Facility lacked a policy regarding use and storage of foods brought to residents by family and visitors.
F 0836: Facility failed to provide carbon monoxide detection in areas with gas fuel fired equipment as required by fire code.
F 0880: Facility did not maintain an infection prevention and control program with annually reviewed policies and failed to maintain standard precautions during a wound dressing change.
Report Facts
Residents reviewed for dental, ROM, nutrition: 15
Residents reviewed for medication: 5
Residents reviewed for respiratory care: 2
Residents reviewed for infection control: 3
Residents reviewed for diet: 6
Residents affected by deficiencies: 2
Residents affected by care plan deficiencies: 6
Residents affected by medication errors: 1
Residents affected by psychotropic medication issues: 2
Residents affected by respiratory care deficiencies: 2
Residents affected by infection control deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in wound dressing change infection control deficiency |
| Director of Nursing | Interviewed regarding multiple deficiencies including medication errors and infection control | |
| Registered Nurse Manager | Interviewed regarding medication and wound care deficiencies | |
| Food Service Director #1 | Interviewed regarding dietary deficiencies and food brought in by visitors | |
| Registered Dietitian #2 | Interviewed regarding dietary and nutrition deficiencies | |
| Speech Language Pathologist #5 | Interviewed regarding diet consistency and swallowing precautions | |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration and PRN medication documentation |
| Registered Nurse #1 | Interviewed regarding psychotropic medication effects | |
| Director of Resident and Family Services | Interviewed regarding psychotropic medication monitoring | |
| Physical Therapist #9 | Interviewed regarding resident mobility and range of motion | |
| Physical Therapist #10 | Interviewed regarding resident positioning devices |
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