Inspection Reports for
Penn Yan Manor Nursing Home Inc
655 N Liberty Street, Penn Yan, NY, 14527
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
No detailed data available for this inspection in the provided content.
Findings
No detailed data available for this inspection in the provided content.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
The inspection was conducted as part of the Recertification Survey to assess compliance with discharge planning and communication requirements.
Findings
The facility failed to ensure completion of a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan for one resident discharged during the survey period.
Deficiencies (1)
F 0661: The facility did not complete a discharge summary including a recapitulation of the resident's stay, a final status summary, and a post-discharge plan for Resident #40 at discharge.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Apr 25, 2024
Visit Reason
Inspection identified 2 health deficiencies including discharge summary and infection control, and 4 life safety deficiencies including aisle width and electrical systems; all corrected by June 21, 2024.
Findings
Inspection identified 2 health deficiencies including discharge summary and infection control, and 4 life safety deficiencies including aisle width and electrical systems; all corrected by June 21, 2024.
Deficiencies (6)
Discharge summary — quality of care
Infection control — quality of care
Aisle, corridor, or ramp width — life safety
Electrical systems - essential electric system — life safety
Elevators — life safety
Emergency lighting — life safety
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
The inspection was conducted as part of the Recertification Survey to assess compliance with discharge planning and communication requirements.
Findings
The facility failed to ensure completion of a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan for one resident discharged during the survey period.
Deficiencies (1)
F 0661: The facility did not complete a discharge summary including a recapitulation of the resident's stay, final status, and post-discharge plan for Resident #40 at discharge.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Registered Nurse Manager | Named in relation to discharge summary and medication list provision |
| Social Worker #1 | Social Worker | Named in relation to discharge summary and voluntary discharge form |
| Physician #1 | Physician | Documented resident stable for discharge |
| Occupational Therapist #1 | Occupational Therapist | Interviewed about discharge instructions |
| Physical Therapist #1 | Physical Therapist | Interviewed about discharge instructions |
| Registered Dietician #1 | Registered Dietician | Interviewed about discharge instructions |
| Director of Nursing | Director of Nursing | Interviewed about discharge summary requirements |
| Administrator | Administrator | Interviewed about discharge instructions |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
One health deficiency related to reporting to the national health safety network; no life safety deficiencies noted.
Findings
One health deficiency related to reporting to the national health safety network; no life safety deficiencies noted.
Deficiencies (1)
Reporting - national health safety network — quality of care
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 8, 2023
Visit Reason
One health deficiency related to reporting to the national health safety network; no life safety deficiencies noted.
Findings
One health deficiency related to reporting to the national health safety network; no life safety deficiencies noted.
Deficiencies (1)
Reporting - national health safety network — quality of care
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 2, 2023
Visit Reason
One health deficiency related to reporting to the national health safety network; no life safety deficiencies noted.
Findings
One health deficiency related to reporting to the national health safety network; no life safety deficiencies noted.
Deficiencies (1)
Reporting - national health safety network — quality of care
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Aug 5, 2022
Visit Reason
Multiple health and life safety deficiencies identified including abuse/neglect policies, refuse disposal, PASARR screening, resident rights, construction standards, electrical systems, fire extinguishers, and vertical openings; all corrected by October 4, 2022.
Findings
Multiple health and life safety deficiencies identified including abuse/neglect policies, refuse disposal, PASARR screening, resident rights, construction standards, electrical systems, fire extinguishers, and vertical openings; all corrected by October 4, 2022.
Deficiencies (11)
Develop/implement abuse/neglect policies — quality of care
Dispose garbage and refuse properly — quality of care
Pasarr screening for md & id — quality of care
Request/refuse/dscntnue trmnt;formlte adv dir — quality of care
Respect, dignity/right to have prsnl property — quality of care
Standards of construction for new existing nh — quality of care
Electrical systems - essential electric system — life safety
Fundamentals - building system categories — life safety
Maintenance, inspection & testing - doors — life safety
Portable fire extinguishers — life safety
Vertical openings - enclosure — life safety
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 5, 2022
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for Penn Yan Manor Nursing Home Inc.
Findings
The survey identified multiple deficiencies including failure to provide timely assistance with eating for a resident, incorrect display of residents' code status on room name plates, lack of proper abuse screening for newly hired employees, failure to complete PASARR screening for a resident with mental disorders, and improper disposal of garbage due to an uncovered dumpster.
Deficiencies (5)
F 0557: Resident #13 did not receive timely assistance with eating during meals, despite being totally dependent on staff and having specific dietary and feeding requirements.
F 0578: For Residents #29, #17, and #19, the color-coded name plates on room doors did not match the residents' documented Medical Orders for Life Sustaining Treatment (MOLST) wishes.
F 0607: The facility failed to implement policies to prevent abuse, neglect, and exploitation by not completing Nurse Aide Registry abuse screenings prior to hire for four of five employees reviewed.
F 0645: Resident #27 was admitted without evidence of a completed Pre-admission Screening and Resident Review (PASARR) for mental disorder or intellectual disability as required.
F 0814: The facility failed to properly dispose of garbage as the outside dumpster lacked a tight-fitting lid or cover, creating potential pest harborage.
Report Facts
Residents reviewed: 13
Employees reviewed: 5
Employees without prior NAR abuse screening: 4
Residents affected: 1
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding color-coded name plates and feeding assistance |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding checking residents' MOLST forms |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding identification of residents needing feeding assistance and code status |
| Charge RN | Registered Nurse / Charge Nurse | Interviewed regarding feeding assistance expectations and code status verification |
| Human Resources Director | Human Resources Director | Interviewed regarding Nurse Aide Registry abuse screening procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding PASARR screening and abuse screening procedures |
| Kitchen Supervisor | Kitchen Supervisor | Interviewed regarding garbage dumpster conditions |
| Director of Nutritional Services | Director of Nutritional Services | Interviewed regarding garbage dumpster conditions |
| Nurse Practitioner | Nurse Practitioner | Interviewed jointly with Charge RN regarding code status verification |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Nov 12, 2019
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home care.
Complaint Details
The complaint investigation (#NY00244354) was incorporated into the Recertification Survey and identified inadequate supervision leading to resident elopement and fall.
Findings
The facility was found deficient in multiple areas including failure to provide timely written transfer/discharge notices, lack of written bedhold policy notification, incomplete baseline care plans, inadequate person-centered care plans for activities, insufficient supervision to prevent resident elopement, improper catheter care, inadequate behavioral health services, and a medication error rate exceeding 5 percent.
Deficiencies (8)
F 0623: The facility did not provide a written Transfer or Discharge Notice to the resident or representative when the resident was transferred to the hospital.
F 0625: The facility failed to provide written notification of the bedhold policy duration to the resident or representative at the time of hospital transfer.
F 0655: The facility did not consistently develop and implement Baseline Care Plans within 48 hours of admission that included necessary healthcare information or provide written summaries to residents or representatives.
F 0656: The facility did not develop a person-centered care plan with measurable goals and interventions for resident activities, specifically lacking an activities care plan for Resident #13.
F 0689: The facility failed to provide adequate supervision to prevent accidents, as Resident #2 eloped undetected and fell outside the building, and the care plan was not revised to include the elopement.
F 0690: The facility did not ensure appropriate assessment for removal of an indwelling urinary catheter for Resident #44, despite frequent urinary tract infections and lack of documented removal plan.
F 0740: The facility did not provide necessary behavioral health care and services to Resident #36, lacking specific interventions in the care plan and psychotherapy services.
F 0759: The facility had a medication error rate of 6 percent, including administration of eye drops in both eyes instead of one and giving medication before meals contrary to orders.
Report Facts
Residents reviewed for Baseline Care Plans: 8
Residents reviewed for activities care plan: 1
Residents reviewed for accidents: 2
Residents reviewed for urinary catheter care: 1
Residents reviewed for behavioral health care: 1
Residents observed for medication administration: 11
Medication error rate: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding transfer notification, bedhold policy, supervision, catheter care, and behavioral health services. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Administered eye drops incorrectly and reported medication error. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Administered Vitamin C medication early. |
| Registered Nurse | Registered Nurse | Provided statements about medication administration and behavioral health care. |
| Social Worker | Social Worker | Discussed behavioral health services and care plan reviews. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about resident activities and behavioral observations. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about resident behaviors and supervision. |
| Nurse Practitioner | Nurse Practitioner | Provided information on catheter care and behavioral health treatment. |
| Interim Recreation Director | Interim Recreation Director | Interviewed about resident activity preferences and care planning. |
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