Inspection Reports for Premier Genesee Center for Nursing & Rehabilitation
NY
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Relicensure
Capacity: 60
Deficiencies: 13
Date: Jun 6, 2025
Visit Reason
Relicensure and complaint survey with 13 violations; plan/notice of correction under review.
Findings
Relicensure and complaint survey with 13 violations; plan/notice of correction under review.
Deficiencies (13)
487.3 (g) (1-2) — General provisions
487.4 (a) — Admission standards
487.7 (f) (8) — Resident services
487.8 (e) (1) — Food service
487.11 (b) (1-2) — Environmental standards
487.11 (f) (8) — Environmental standards
487.11 (h) (5) — Environmental standards
487.11 (k) (1-3) — Environmental standards
487.12 (a-b) — Disaster and emergency planning
1001.7 (g)(1-3) — Admission and retention standards
1001.7 (h) (1) — Admission and retention standards
1001.11 (c) (2) (i-iv) — Personnel
1001.13 (b)(1)(i-iii)(2)(3)(4)(iv-vi) — Structural and environmental standards
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation (#NY00355148) to assess the facility's compliance with appropriate care and management of residents with indwelling (foley) catheters.
Complaint Details
The complaint investigation (#NY00355148) found substantiated issues related to catheter care and infection control for residents with indwelling catheters.
Findings
The facility failed to ensure appropriate catheter care for three of four residents reviewed, including failure to change a resident's foley catheter monthly as ordered and inadequate infection control practices such as catheter tubing and drainage bags lying on the floor, increasing risk of urinary tract infections.
Deficiencies (2)
Resident #355's foley catheter was not changed monthly as per physician order; an incorrect catheter size was used without an order.
Residents #38 and #121 had catheter tubing and drainage bags lying directly on the floor, violating infection control protocols.
Report Facts
Residents reviewed with catheter care issues: 3
Residents reviewed: 4
Foley catheter size: 22
Balloon size: 30
Foley catheter size used without order: 20
Balloon size used without order: 5
Catheter tubing length on floor: 18
Catheter tubing length on floor: 12
Catheter tubing length on floor: 10
Drainage bag on floor percentage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Replaced Resident #355's foley catheter with incorrect size without order |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Documented foley catheter not administered due to unavailability of correct size |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Unaware of unavailability of correct catheter size and expected to ensure supply |
| Nurse Practitioner #1 | Nurse Practitioner | Expected proper catheter changes and notification if catheter size unavailable |
| Certified Nurse Aide #4 | Certified Nurse Aide | Observed and corrected catheter tubing placement for Resident #38 |
| Certified Nurse Aide #5 | Certified Nurse Aide | Noted catheter drainage bag not attached correctly for Resident #121 |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Noted hematuria and improper catheter bag placement for Resident #38 |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Stated catheter drainage bag and tubing should not be on floor for contamination reasons |
| Certified Nurse Aide #3 | Certified Nurse Aide | Observed catheter bag touching floor and stated it should be kept off floor |
| Director of Nursing | Director of Nursing | Acknowledged catheter care deficiencies and supply issues |
| Infection Preventionist | Infection Preventionist | Stated catheter tubing and bag should never lay on floor due to infection risk |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 3
Date: Apr 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation (#NY00355148) regarding the facility's failure to ensure appropriate care and services for residents with indwelling catheters and other regulatory compliance issues.
Complaint Details
Complaint investigation (#NY00355148) focused on catheter care and infection control practices for residents with indwelling catheters.
Findings
The facility failed to ensure residents' advanced directives were properly identified and honored, with incorrect code status identifiers for residents #105 and #139. Additionally, catheter care was inadequate for residents #38, #121, and #355, including failure to change catheters as ordered and poor infection control practices. The facility also lacked 8 consecutive hours of Registered Nurse coverage on multiple dates as required.
Deficiencies (3)
Failure to ensure advanced directives were implemented consistent with residents' wishes, including incorrect code status identifiers and inaccessible MOLST binder.
Failure to provide appropriate care for residents with indwelling catheters, including failure to change catheter as ordered and poor infection control practices.
Failure to have a Registered Nurse on duty for at least 8 consecutive hours, 7 days a week as required.
Report Facts
Dates without 8 consecutive hours of RN coverage: 16
Facility bed capacity: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Stated resident code status identification methods and location of MOLST forms. | |
| Licensed Practical Nurse Unit Manager #2 | Acknowledged incorrect bracelet on Resident #105 and responsibility for error with Resident #139. | |
| Social Worker #1 | Interviewed regarding familiarity with advance directives and code status identifiers. | |
| Registered Nurse #1 | Observed incorrect code status identifiers and discussed potential for CPR against wishes. | |
| Certified Nurse Aide #3 | Described access to resident care plans and MOLST forms on 5th floor. | |
| Assistant Director of Nursing | Discussed procedures for checking MOLST forms and concerns about accessibility. | |
| Nurse Practitioner #1 | Provided clinical expectations regarding catheter care and advance directive identification. | |
| Registered Nurse Unit Manager #1 | Discussed lack of awareness of catheter supply issues and failure to ensure proper catheter changes. | |
| Licensed Practical Nurse #6 | Replaced catheter with incorrect size without notifying provider. | |
| Licensed Practical Nurse #7 | Documented catheter not changed due to unavailable size. | |
| Certified Nurse Aide #4 | Observed tubing on floor and took corrective action. | |
| Certified Nurse Aide #5 | Noted catheter drainage bag not attached properly and tubing on floor. | |
| Licensed Practical Nurse #5 | Discussed infection control concerns with catheter tubing on floor. | |
| Licensed Practical Nurse #8 | Stated catheter drainage bag and tubing should not be on floor due to contamination risk. | |
| Director of Nursing | Acknowledged lack of RN coverage and concerns about catheter care and advance directive identifiers. | |
| Administrator | Acknowledged lack of RN coverage and issues with advance directive identifiers. | |
| Scheduling Coordinator | Unaware of RN coverage regulation until shortly before survey. | |
| Infection Preventionist | Stated catheter tubing and bag should never touch floor to prevent infection. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation (#NY00369028) regarding concerns that the facility did not ensure residents received treatment and care according to professional standards, the person-centered care plan, and residents' choice, specifically related to Resident #1 leaving the facility without proper authorization and use of an electronic monitoring device without adequate indications.
Complaint Details
Complaint investigation #NY00369028 substantiated that the facility did not ensure appropriate care and treatment for Resident #1, including unauthorized leave and improper use of monitoring device.
Findings
The facility allowed Resident #1, who lacked medical decision-making capacity, to leave the facility independently without an approved leave of absence order and without proper supervision or emergency transport. The resident was later placed on an electronic monitoring device without adequate indication. Interviews with staff and review of policies revealed failures in following proper procedures and safeguards, including lack of signed release forms and inappropriate use of the wander guard device. The device was later removed when it was determined the resident was not at risk for wandering.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including permitting Resident #1 to leave the facility without an approved leave of absence and initiating electronic monitoring without adequate indications.
Report Facts
Date of complaint investigation completion: Feb 3, 2025
Date of physician order for wander guard: Jan 14, 2025
Date of resident assessment: Jan 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Assistant Director of Nursing | Authored progress note documenting resident's request to leave and signing out | |
| Licensed Practical Nurse #2 | Nursing supervisor who allowed resident to leave and obtained release form | |
| Licensed Practical Nurse #3 | Administered medications and unaware resident left unit | |
| Director of Nursing | Stated proper procedures were not followed and removed wander guard | |
| Director of Social Work | Stated it was unsafe for resident to leave and resident lacked decision-making capacity | |
| Nurse Practitioner | Stated resident had cognitive impairments and supervisor acted improperly | |
| Licensed Practical Nurse #4 | Placed wander guard on resident's left lower extremity | |
| Licensed Practical Nurse #1 | Documented placement of wander guard and resident education |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Oct 1, 2024
Visit Reason
Complaint survey with 3 violations; plan/notice of correction approved.
Findings
Complaint survey with 3 violations; plan/notice of correction approved.
Deficiencies (3)
487.4 (b) (5) — Admission standards
1001.10 (i) (5-8) — Resident services
1001.10 (l)(1) — Medication management
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
Complaint survey with 1 violation; plan/notice of correction approved.
Findings
Complaint survey with 1 violation; plan/notice of correction approved.
Deficiencies (1)
487.4 (c) (5) — Admission standards
Inspection Report
Relicensure
Capacity: 60
Deficiencies: 11
Date: Jun 7, 2023
Visit Reason
Relicensure and complaint survey with 12 violations; plan/notice of correction under review.
Findings
Relicensure and complaint survey with 12 violations; plan/notice of correction under review.
Deficiencies (11)
402.7(d)(2) — Department criminal history review
487.5 (a) (3) (xi) — Resident protections
487.7 (d) (8) — Resident services
487.11 (h) (5) — Environmental standards
487.11 (i) ((4) (i),( — Environmental standards
1001.6 (e) (1) (i-iii) — General provisions
1001.10 (j) (1) — Resident services
1001.10 (l) (2) — Medication management
1001.10 (n) (7) (i) (a-c) — Case management in special needs assisted liv
1001.11 (c) (2) (i-iv) — Personnel
1001.11 (l) (4) — Personnel
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NY00308552) to determine whether the facility thoroughly investigated allegations of abuse, neglect, exploitation, or mistreatment for three residents (Resident #93, #109, and #212).
Complaint Details
The complaint investigation revealed that the facility did not thoroughly investigate allegations of abuse and injuries of unknown origin for Residents #93, #109, and #212. The investigation lacked staff statements, root cause analysis, and proper reporting to the Director of Nursing. The facility's Nursing Supervisors failed to initiate investigations or follow up appropriately.
Findings
The facility failed to ensure thorough investigations of alleged abuse and injuries of unknown origin for the three residents. Specifically, there was a lack of investigation into verbal abuse allegations against CNA #7 for Resident #93, incomplete investigation of bruises of unknown origin for Residents #109 and #212, and insufficient staff statements and root cause analysis.
Deficiencies (3)
Failure to investigate Resident #93's allegation of verbal abuse by CNA #7 reported to LPN #9 Nursing Supervisor.
Lack of staff statements, root cause, and analysis for Resident #109's bruise of unknown origin.
Lack of staff statements and description for Resident #212's bilateral chest bruising of unknown origin.
Report Facts
Complaint number: Complaint #NY00308552
Residents reviewed for abuse: 4
Residents affected: 3
Date of survey completed: 05/24/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Nursing Supervisor | Named in failure to investigate verbal abuse allegation for Resident #93 |
| CNA #7 | Certified Nurse Aide | Named in verbal abuse allegation for Resident #93 |
| LPN #8 | Licensed Practical Nurse | Reported verbal abuse incident and communicated with Nursing Supervisor |
| LPN #11 | Unit Nurse Manager | Notified Director of Nursing about verbal abuse and involved in reporting |
| DON | Director of Nursing | Expected investigations and verified communication failures |
| Administrator | Expected Nursing Supervisors to investigate incidents and initiate investigations | |
| RN Supervisor #1 | Registered Nurse Supervisor | Interviewed regarding bruising incident for Resident #212 |
| LPN #3 | MDS Assistant and former Unit Manager | Described investigation procedures for bruising incidents |
| LPN #4 | Licensed Practical Nurse | Reported bruise on Resident #109 and communicated with Nursing Supervisor |
| LPN #5 | Nursing Supervisor | Involved in bruise investigation for Resident #109 |
| CNA #3 | Certified Nurse Aide | Documented no witness to fall for Resident #109 bruise incident |
| Assistant Administrator | Provided statements about bruise investigations and expectations |
Inspection Report
Routine
Deficiencies: 8
Date: May 24, 2023
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident dignity, abuse prevention, care, activities, medication management, infection control, and other aspects of facility operation.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to timely report and investigate abuse allegations, incomplete investigations of abuse and injuries of unknown origin, failure to submit MDS assessments timely, inadequate assistance with activities of daily living, failure to provide adequate activities, failure to monitor medication parameters, and lapses in infection control practices.
Deficiencies (8)
Failure to ensure resident dignity by not toileting a resident who was continent of bowel and instructing them to use their brief instead.
Failure to timely report alleged abuse and injuries of unknown origin to the Administrator and State Survey Agency within required timeframes.
Failure to thoroughly investigate allegations of abuse, neglect, and injuries of unknown origin for multiple residents.
Failure to submit Minimum Data Set (MDS) assessments electronically to CMS within 14 days of completion for multiple residents.
Failure to provide necessary assistance with activities of daily living including incontinence care and grooming for residents.
Failure to provide an ongoing program of activities to meet residents' interests and needs, including lack of one-on-one visits and encouragement to participate.
Failure to ensure medication regimen was free from unnecessary drugs by not monitoring heart rate as ordered for a resident on metoprolol.
Failure to maintain infection prevention and control practices including inadequate hand hygiene during incontinent care and improper disposal of contaminated washbasin water.
Report Facts
Residents with late MDS assessments: 8
Pulse monitoring occasions: 20
Bruise size: 15.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Certified Nurse Aide | Named in dignity violation for telling resident to use brief instead of commode. |
| LPN #6 | Licensed Practical Nurse | Stated expectation that CNAs put residents on commode when requested. |
| Director of Nursing | Director of Nursing | Stated expectation for CNAs to answer call lights and take care of residents' needs. |
| CNA #7 | Certified Nurse Aide | Involved in verbal abuse allegation against Resident #93. |
| LPN #8 | Licensed Practical Nurse | Documented and reported verbal abuse incident involving CNA #7 and Resident #93. |
| LPN #9 | Nursing Supervisor | Failed to initiate investigation or report verbal abuse incident timely. |
| Administrator | Administrator | Stated expectation for timely reporting and investigation of abuse allegations. |
| RN Supervisor #1 | Registered Nurse Supervisor | Commented on investigation procedures for bruising and abuse. |
| LPN #3 | MDS Assistant / Former Unit Manager | Discussed MDS submission and investigation responsibilities. |
| RN #3 | Registered Nurse / MDS Coordinator | Admitted failure to submit MDS assessments timely due to computer issues. |
| CNA #1 | Certified Nurse Aide | Involved in incontinent care observation and acknowledged care plan requirements. |
| CNA #6 | Certified Nurse Aide | Observed failing to change gloves and improper infection control during incontinent care. |
| LPN #7 | Licensed Practical Nurse | Stated expectations for glove use and infection control. |
| RNUM #2 | Registered Nurse Unit Manager | Stated expectations for activities and infection control practices. |
| PA #1 | Physician Assistant | Stated expectation for pulse monitoring with metoprolol. |
| Pharmacy Consultant | Consultant Pharmacist | Discussed metoprolol use and monitoring. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 5, 2023
Visit Reason
Complaint survey with 1 violation; plan/notice of correction under review.
Findings
Complaint survey with 1 violation; plan/notice of correction under review.
Deficiencies (1)
1001.10 (n) (5) (i-iii) — Supervision in special needs assisted living
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Nov 3, 2021
Visit Reason
The inspection was conducted as a complaint investigation regarding multiple issues including resident rights, abuse prevention, timely reporting of abuse, care for activities of daily living, accident hazards, nutritional status, and staffing adequacy.
Complaint Details
Complaint investigations included issues related to resident rights and transportation (Complaint #NY00280885), abuse prevention and reporting (Complaint #NY00281939), and staffing adequacy (Complaint #NY00284800).
Findings
The facility was found deficient in multiple areas including failure to ensure resident choice and transportation to appointments, inadequate screening of employees, delayed reporting of alleged abuse, insufficient care for activities of daily living, unsafe hot water temperatures, lack of supervision in smoking areas, failure to address significant weight loss, and inadequate nursing staff to meet resident needs.
Deficiencies (8)
Failure to ensure resident's right to choose health care and providers, including arranging transportation to outside medical appointments, resulting in missed neurological appointments.
Failure to implement written policies and procedures for screening employees through the New York State Nurse Aide Registry prior to employment for four of nine employees reviewed.
Failure to timely report alleged abuse incidents to appropriate officials within two hours as required.
Failure to provide necessary assistance for activities of daily living including timely toileting and proper hand hygiene and glove changes during incontinence care for residents.
Failure to maintain water temperatures within safe limits, with multiple resident rooms and care areas having water temperatures exceeding 120°F.
Failure to ensure residents smoking outside designated areas are supervised and to complete timely smoking assessments.
Failure to maintain acceptable nutritional status for a resident with significant weight loss without identification or intervention by the Registered Dietician.
Failure to provide sufficient nursing staff to meet the needs of residents, with multiple shifts and units below the facility's minimum staffing requirements.
Report Facts
Weight loss: 20.8
Hot water temperature: 130.6
Hot water temperature: 145
Staffing minimum: 4
Staffing minimum: 8
Staffing minimum: 4
Residents requiring total assistance with meals: 14
Residents requiring 2 staff to assist with transferring: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Temporary Nurse Aide | Hired 10/5/21; lacked timely Nurse Aide Registry screening. |
| Employee B | Activities Aide | Hired 10/5/21; lacked timely Nurse Aide Registry screening. |
| Employee C | Social Work Assistant | Hired 10/12/21; lacked timely Nurse Aide Registry screening. |
| Employee D | Country Store Attendant | Hired 10/12/21; lacked timely Nurse Aide Registry screening. |
| Licensed Practical Nurse Unit Manager #1 | LPN Unit Manager | Interviewed regarding missed transportation and appointment scheduling. |
| Licensed Practical Nurse Unit Manager #2 | LPN Unit Manager | Interviewed regarding care planning and expectations for toileting and glove use. |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including transportation, abuse reporting, infection control, smoking supervision, nutritional follow-up, and staffing. |
| Registered Dietician | RD | Interviewed regarding nutritional assessment and follow-up on weight loss. |
| Maintenance Director | Maintenance Director | Interviewed regarding hot water temperature issues and mixing valve adjustments. |
| Scheduling Coordinator | Scheduling Coordinator | Interviewed regarding staffing plans and minimum staffing deficiencies. |
| Administrator | Administrator | Interviewed regarding staffing, transportation, and smoking policies. |
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