Inspection Reports for
Palatine Nursing Home

154 Lafayette Street, Palatine Bridge, NY, 13428

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Deficiencies (last 7 years)

Deficiencies (over 7 years) 5.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

4% worse than New York average
New York average: 5.1 deficiencies/year

Deficiencies per year

16 12 8 4 0
2019
2021
2022
2023
2024
2025
2026

Inspection Report

Abbreviated Survey
Deficiencies: 1 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.

Deficiencies (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
NameTitleContext
Administrator #1 Administrator Interviewed regarding responsibility for submitting abuse reports and lack of awareness of reporting timelines.

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 4 Date: Jun 11, 2025

Visit Reason
Inspection identified 4 Life Safety Code deficiencies related to electrical systems, training, organization, and hazard risk assessment, all without actual harm but with potential for minor discomfort.

Findings
Inspection identified 4 Life Safety Code deficiencies related to electrical systems, training, organization, and hazard risk assessment, all without actual harm but with potential for minor discomfort.

Deficiencies (4)
Electrical systems - essential electric syste
Ep training program
Organization and administration
Plan based on all hazards risk assessment

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Apr 8, 2024

Visit Reason
Covid-19 Survey found 1 standard health citation for reporting to the national health safety network with no actual harm but potential for minor discomfort.

Findings
Covid-19 Survey found 1 standard health citation for reporting to the national health safety network with no actual harm but potential for minor discomfort.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Annual Inspection
Deficiencies: 3 Date: Jun 6, 2023

Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory standards in areas 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 response and documentation of therapy referrals for residents requiring specialized rehabilitative services.

Deficiencies (3)
F 0583: The facility did not ensure residents' personal and medical records were kept private and confidential, 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 sanitizer concentrations exceeding 400 ppm as required by manufacturer specifications.
F 0825: The facility failed to provide timely specialized rehabilitative services for Resident #44, as a therapy referral made on 05/24/2023 was not addressed or documented within the required 72 hours.
Report Facts
Food temperature thermometer calibration deviation: 5 Sanitizer concentration range: 400 Therapy referral response time: 72 Therapy referral date: May 24, 2023 Therapy evaluation date: May 31, 2023

Employees mentioned
NameTitleContext
Licensed Practical Nurse #1 LPN Stated staff should lock computer screens before leaving medication carts
Director of Nursing DON Stated computer screens should be locked to protect resident privacy and addressed repeated privacy breaches
Registered Nurse #1 RN Confirmed staff responsibility to sign out or lock screens to protect resident information
Physical Therapist #1 PT Acknowledged delay in evaluating Resident #44 and lack of documentation
Dietary Manager Dietary Manager Committed to purchasing correct sanitizer test strips and retraining staff on thermometer calibration
Administrator Administrator Confirmed plans to purchase correct test strips for sanitizer concentration

Inspection Report

Annual Inspection
Deficiencies: 3 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.

Deficiencies (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
NameTitleContext
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

Complaint Investigation
Capacity: 60 Deficiencies: 5 Date: Jun 6, 2023

Visit Reason
Complaint Survey identified 3 standard health citations related to food sanitation, privacy, and rehab services, and 2 life safety code citations related to doors and electrical systems. Several deficiencies were corrected.

Findings
Complaint Survey identified 3 standard health citations related to food sanitation, privacy, and rehab services, and 2 life safety code citations related to doors and electrical systems. Several deficiencies were corrected.

Deficiencies (5)
Food procurement,store/prepare/serve-sanitary
Personal privacy/confidentiality of records
Provide/obtain specialized rehab services
Doors with self-closing devices
Electrical systems - essential electric syste

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Jan 10, 2022

Visit Reason
Covid-19 Survey found 1 standard health citation for reporting to the national health safety network with no actual harm but potential for minor discomfort.

Findings
Covid-19 Survey found 1 standard health citation for reporting to the national health safety network with no actual harm but potential for minor discomfort.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Dec 13, 2021

Visit Reason
Covid-19 Survey found 1 standard health citation for reporting to the national health safety network with no actual harm but potential for minor discomfort.

Findings
Covid-19 Survey found 1 standard health citation for reporting to the national health safety network with no actual harm but potential for minor discomfort.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Annual Inspection
Deficiencies: 4 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.

Deficiencies (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
NameTitleContext
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

Annual Inspection
Deficiencies: 14 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.

Deficiencies (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
NameTitleContext
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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