Inspection Reports for
Sodus Rehabilitation & Nursing Center
6884 Maple Ave, Sodus, NY, 14551
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Inspection Report — Oct 11, 2024
Annual Inspection CMS
Date: Oct 11, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 10/07/2024 to 10/11/2024 to assess compliance with regulatory standards for nursing home operations.
Findings
The facility was found deficient in maintaining resident privacy, monitoring nutritional status, medication administration timeliness and accuracy, and food service safety standards. Several residents experienced privacy breaches, significant unmonitored weight loss, medication errors, and food safety violations.
Citations (4)
F 0550: The facility failed to protect residents' privacy by posting advanced directives with residents' full names in a public library and displaying resident photos and names in the lobby accessible to the public.
F 0692: Resident #35 was not consistently monitored for significant weight loss, and the facility lacked documented evidence of meal monitoring or interventions despite a 14.8% weight loss in one month and 16.8% over three months.
F 0760: Residents #43 and #66 experienced significant medication errors including late administration of Parkinson's and seizure medications and missed or late insulin doses, risking therapeutic failure and adverse effects.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, including keeping perishable foods beyond policy limits, dirty food contact surfaces, and inadequate sanitizer practices.
Report Facts
Residents with privacy breach: 54
Residents on CPR list posted publicly: 44
Residents with photos and names displayed publicly: 17
Weight loss percentage: 14.8
Weight loss percentage: 16.8
Meals documented: 21
Medication late administration occurrences: 26
Insulin missed doses: 4
Insulin late doses: 8
Perishable food items kept beyond 3 days: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Manager #1 | Licensed Practical Nurse Manager | Interviewed regarding resident privacy and medication administration issues |
| Licensed Practical Nurse Manager #2 | Licensed Practical Nurse Manager | Interviewed regarding Resident #35 meal intake and weight loss |
| Administrator | Administrator | Interviewed regarding privacy breaches and facility policies |
| Dietary Technician | Dietary Technician | Interviewed regarding weight tracking and nutritional monitoring |
| Registered Dietitian | Registered Dietitian | Consultant interviewed regarding Resident #35 nutritional interventions |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding medication errors and weight loss follow-up |
| Director of Nursing | Director of Nursing | Interviewed regarding weight loss monitoring and medication administration |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication administration policy and errors |
| Food Service Director | Food Service Director | Interviewed regarding food storage and sanitation practices |
| Food Service Worker #1 | Food Service Worker | Interviewed regarding sanitizer bucket use and cleaning practices |
Inspection Report — Oct 11, 2024
Certification/complaint State
Date: Oct 11, 2024
Visit Reason
State-compiled facility profile showing 10 inspections from 2022 to 2024 with deficiency and enforcement history.
Complaint Details
Facility received 172 complaints with 24 on-site inspections; 7 citations resulted from those complaints.
Findings
Across 10 inspections, 7 resulted in citations totaling 30 deficiencies primarily related to standard health and Life Safety Code issues. The facility had 172 complaints with 24 on-site inspections and 3 enforcement actions totaling $20,000 in fines.
Citations (29)
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary found unsanitary conditions in multiple inspections.
Standard Health Citation — quality of care: Nutrition/hydration status maintenance was deficient in isolated instances.
Standard Health Citation — quality of care: Resident rights/exercise of rights violations noted in isolated cases.
Standard Health Citation — quality of care: Residents are free of significant medication errors was deficient in isolated cases.
Life Safety Code Citation — NFPA requirements: Egress doors failed to meet code in isolated instances.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance was deficient in a pattern of violations.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure was deficient in a pattern of violations.
Life Safety Code Citation — NFPA requirements: Vertical openings enclosure was deficient in isolated instances.
Standard Health Citation — quality of care: Investigate/prevent/correct alleged violation was deficient in isolated cases.
Standard Health Citation — quality of care: Accuracy of assessments was deficient in isolated cases.
Standard Health Citation — quality of care: Activities meet interest/needs of each resident was deficient in isolated cases.
Standard Health Citation — quality of care: Care plan timing and revision was deficient in isolated cases.
Standard Health Citation — quality of care: Colostomy, urostomy, or ileostomy care was deficient in isolated cases.
Standard Health Citation — quality of care: Drug regimen review, report irregularities, and act on findings was deficient in a pattern of violations.
Standard Health Citation — quality of care: Free from unnecessary psychotropic medications/prn use was deficient in isolated cases.
Standard Health Citation — quality of care: Free of accident hazards/supervision/devices was deficient in a pattern of violations.
Standard Health Citation — quality of care: Physical environment was deficient with potential for minimal harm in a pattern of violations.
Standard Health Citation — quality of care: Safe, clean, comfortable, homelike environment was deficient in isolated cases.
Standard Health Citation — quality of care: Treatment/services to prevent or heal pressure ulcers was deficient in isolated cases.
Standard Health Citation — quality of care: Tube feeding management and restoration of eating skills was deficient in a pattern of violations.
Life Safety Code Citation — NFPA requirements: Doors with self-closing devices were deficient in a pattern of violations.
Life Safety Code Citation — NFPA requirements: Electrical equipment testing and maintenance was deficient in a pattern of violations.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system was deficient in widespread violations.
Life Safety Code Citation — NFPA requirements: Emergency lighting was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Fire drills were deficient in a pattern of violations.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing was deficient in isolated instances.
Standard Health Citation — quality of care: Free from abuse and neglect was deficient in a pattern of violations posing immediate jeopardy.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary was deficient in a pattern of violations.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient in widespread violations and not yet corrected.
Report Facts
Inspections on page: 10
Total violations/deficiencies cited: 30
Inspections with violations: 7
Inspections without violations: 3
Total complaints: 172
On-site complaint inspections: 24
Total enforcement actions: 3
Total fines: 20000
Citations from complaints: 7
Inspection Report — Apr 10, 2024
Abbreviated Survey CMS
Date: Apr 10, 2024
Visit Reason
The visit was conducted as an abbreviated survey to investigate an allegation of abuse involving Resident #1 and a staff member reported on 3/25/24.
Complaint Details
The complaint involved an alleged abuse incident reported on 3/25/24 concerning an event on 3/20/24. The investigation was incomplete and the incident was not reported to the Department of Health within five days as required.
Findings
The facility did not ensure a thorough investigation of the alleged abuse incident on 3/20/24, failing to interview all staff witnesses and delaying reporting the incident by 13 days. The investigation concluded no abuse occurred, but later staff interviews indicated Resident #1 was hit with food thrown back by a nurse.
Citations (1)
F 0610: The facility failed to thoroughly investigate an alleged abuse incident involving Resident #1 by not interviewing all staff witnesses and delayed reporting the incident by 13 days.
Report Facts
Residents reviewed: 3
Days delayed in reporting: 13
Date of alleged incident: Mar 20, 2024
Date of report: Mar 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Manager #1 | Licensed Practical Nurse Manager | Named in investigation and interviews regarding the abuse incident |
| Director of Nursing | Director of Nursing | Completed the facility's Investigation Summary and conducted interviews |
| Administrator | Administrator | Interviewed regarding incident reporting and investigation |
Inspection Report — Oct 12, 2023
Abbreviated Survey CMS
Date: Oct 12, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with food service safety standards following reports of a wastewater backup and flooding in the kitchen area.
Findings
The facility did not store, prepare, distribute, and serve food in accordance with professional standards due to food service operations being conducted in an area affected by an active wastewater backup. The incident was not reported to the New York State Department of Health.
Citations (1)
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards due to food service operations conducted in an area of active wastewater backup. The incident was not reported to the New York State Department of Health.
Report Facts
Vendor invoice line plug length: 45
Vendor invoice snaked pipe length: 130
Vendor invoice snaked pipe length: 30
Date of flood event: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Provided statements about kitchen flooding and food service operations during the flood | |
| Director of Operations | Provided statements about grease trap backup and kitchen flooding | |
| Certified Nursing Assistant #1 | Reported knowledge of septic backup in kitchen | |
| Certified Nursing Assistant #2 | Reported inability to use sinks on units due to kitchen flooding | |
| Administrator | Briefed Food Service Director and made decisions about continuing meal service during flooding | |
| Director of Maintenance | Arrived early to remove standing water from kitchen | |
| Regional Registered Nurse | Certified in infection prevention and provided expert opinion on sewage water and food service safety |
Inspection Report — Nov 2, 2022
Annual Inspection CMS
Date: Nov 2, 2022
Visit Reason
The visit was a Recertification Survey conducted 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 non-functioning exhaust ventilation and hot water temperatures exceeding safe limits, inaccurate resident assessments and care plans, inadequate pressure ulcer care, failure to provide appropriate activities, improper medication management including lack of monitoring of psychotropic medication use and gradual dose reductions, and insufficient colostomy and feeding tube care.
Citations (10)
F 0584: The facility failed to maintain a safe, clean, and homelike environment due to non-working exhaust ventilation, leaking water softener tank and circulating pump, and presence of soiled towels on windowsills.
F 0641: The facility did not accurately code Minimum Data Set (MDS) assessments for two residents regarding restraint use, medication use, and discharge disposition.
F 0657: The facility failed to revise a resident's comprehensive care plan to reflect discontinued use of antipsychotic medications.
F 0679: The facility did not provide an ongoing program of activities based on resident preferences and needs for one resident.
F 0686: The facility failed to provide appropriate pressure ulcer care, including incomplete treatment administration and documentation.
F 0689: The facility allowed hot water temperatures exceeding 120°F accessible to residents and failed to supervise medications left unattended at a resident's bedside.
F 0691: The facility did not provide appropriate colostomy care consistent with professional standards and failed to include colostomy care in the resident's care plan.
F 0693: The facility failed to track and monitor daily total intakes of feeding tubes for two residents to ensure nutritional needs were met.
F 0756: The facility did not ensure that the attending physician documented review and action on pharmacist medication regimen review recommendations for one resident.
F 0758: The facility failed to implement gradual dose reductions or document clinical contraindications for psychotropic medications for one resident, and did not provide resident-specific non-pharmacological interventions.
Report Facts
Residents on Empire Unit: 39
Weight loss: 4.4
Hot water temperature: 130
Medication cups: 15
Tube feeding volume: 1560
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager #1 | Nurse Manager | Provided information on Resident #54's behaviors and care plan. |
| Assistant Director of Maintenance | Assistant Director of Maintenance | Interviewed regarding facility maintenance issues including ventilation and hot water system. |
| Director of Nursing | Director of Nursing | Provided information on medication regimen review process and care plan responsibilities. |
| Licensed Practical Nurse / Nurse Manager | Licensed Practical Nurse / Nurse Manager | Discussed colostomy care and feeding tube monitoring. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Provided observations on resident behaviors and wandering. |
| Pharmacist | Consulting Pharmacist | Discussed medication regimen review and recommendations for psychotropic medications. |
| Social Worker #1 | Social Worker | Provided information on Resident #54's behavioral status and care plan involvement. |
| Medical Director | Physician / Medical Director | Discussed medication orders, documentation, and gradual dose reductions. |
Inspection Report — Sep 24, 2020
Annual Inspection CMS
Date: Sep 24, 2020
Visit Reason
The Recertification Survey was conducted to evaluate the facility's compliance with regulatory requirements and assess the quality of care provided to residents.
Findings
The survey identified multiple deficiencies including failure to investigate bruises of unknown origin, incomplete care plans for pressure ulcers and infections, lack of assistive devices for vision, inadequate pressure ulcer care, insufficient range of motion interventions, inconsistent dialysis care, missing dental services for lost dentures, absence of onsite registered dietician services, and an incomplete infection control program.
Citations (9)
F 0610: The facility did not thoroughly investigate bruises of unknown origin for Resident #92, failing to rule out abuse, neglect, or mistreatment.
F 0656: The facility did not develop a comprehensive care plan with measurable goals and timeframes for Resident #49's pressure ulcer and bone infection.
F 0685: The facility failed to provide proper treatment and assistive devices to maintain vision for Resident #11, who lost their glasses and was not assisted in replacing them.
F 0686: The facility did not provide appropriate pressure ulcer care for Resident #6, who was not wearing heel booties consistently and was not repositioned every two hours.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident #84, resulting in increased pain and skin integrity decline.
F 0698: The facility did not ensure safe and appropriate dialysis care for Resident #57, including inconsistent monitoring of fluid restriction and lack of communication with dialysis center.
F 0791: The facility did not promptly refer Resident #57 for dental services after dentures were lost and did not address dental needs in the care plan.
F 0801: The facility did not employ a qualified dietician onsite since March 2020, resulting in lack of physical nutritional assessments and participation in care planning.
F 0880: The facility failed to establish and maintain a complete infection prevention and control program, lacking consistent tracking, analysis, and trending of infection data.
Report Facts
Vital signs not documented: 11
Fluid intake days: 4
Fluid intake days: 2
Fluid intake days: 2
Fluid intake days: 2
Turning and positioning not signed off: 31
Bilateral booties not signed off: 10
Missing documentation for treatments: 4
Missing documentation for treatments: 6
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