Inspection Reports for
The Waters of Dunkirk Skilled Nursing Facility

The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified in emergency lighting documentation, sprinkler system maintenance, corridor door latching, electrical receptacle grounding, fire damper inspection, fire drill documentation, emergency generator testing, automatic transfer switch indicators, and patient care related electrical equipment maintenance.

The facility was cited for deficiencies including failure to post survey results at an accessible height, failure to notify resident representatives in writing of transfer/discharge appeal rights, failure to follow menus and resident preferences, poor palatability of meals, and inadequate sanitation and food storage practices in the kitchen.

The facility was found deficient in multiple areas including failure to post survey results accessibly, failure to notify residents and representatives of transfer/discharge appeal rights in writing, failure to follow menus and meet resident preferences, poor food quality and palatability, inadequate dishwasher sanitization, and improper food storage practices.

Complaint IN00448842 was substantiated with federal/state deficiencies cited at F689 related to the allegations of improper physical transfers causing injury.

The facility failed to identify the number of staff needed for physical transfers and to ensure transfers were provided consistently for a resident requiring extensive assistance, resulting in a fracture to the resident's right ankle. The investigation included review of clinical records, interviews, and observations confirming inconsistent transfer practices and lack of staff awareness.

This citation relates to complaint IN00448842. The complaint was substantiated as the facility failed to provide the required two-person transfer assistance to Resident B, leading to injury.

The facility failed to identify the appropriate number of staff needed for physical transfers and did not consistently provide the required assistance for a resident needing extensive help with mobility. This failure led to Resident B sustaining a right ankle fracture during transfer.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included issues with exit door locking, hazardous area enclosure, unsecured electrical panels, improper use of power strips, and lack of mechanical ventilation in the oxygen storage room.

This Federal tag relates to complaint IN00409625. The complaint involved unqualified personnel administering medications and providing care without proper authorization.

The facility failed to ensure that medications were administered by qualified nursing personnel, allowing an unlicensed nursing student to administer insulin and other medications to five residents. This deficient practice had the potential to affect all 41 residents in the facility.

Complaint IN00409625 was substantiated with federal and state deficiencies cited at F726 and F835 related to medication administration by unqualified personnel.

The facility failed to ensure residents received medications, including insulin injections, from qualified nursing personnel. An unlicensed nursing student administered medications to five residents during a job shadowing activity without proper authorization or facility policy, potentially affecting all 41 residents.

Complaint IN00406798 was substantiated with federal/state deficiencies cited at F684 related to quality of care and failure to properly assess and document bruising on Resident B.

The facility failed to assess and document bruising of unknown origin on a resident's hand (Resident B) during a respite stay. The bruising was noted but not properly documented or investigated, and the resident was discharged with a significant bruise and fracture. The facility implemented corrective actions including staff education and increased skin assessments.

This Federal tag relates to complaint IN00406798.

The facility failed to properly assess and document bruising on Resident B's hand. Interviews and record reviews revealed inconsistent documentation and uncertainty about the origin of the bruising, which was later found to be a fracture dislocation.

The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including exit door accessibility, fire alarm system maintenance, fuel-fired water heater inspections, ground fault circuit interrupter functionality, smoking policy enforcement, fire door inspections, kitchen serving door operation, and power strip usage.

The facility was found deficient for failing to develop and implement interventions to reduce the risk of falls for one resident, resulting in a fall with fracture requiring hospitalization. The facility requested a desk review due to the low scope and severity and only one deficiency cited.

The facility failed to develop and implement adequate interventions to reduce the risk of falls for one resident, resulting in a fall with a fracture requiring hospitalization. The resident had frequent falls and needed more assistance after returning from the hospital, but new interventions were not implemented following a fall.

Complaint IN00397976 was substantiated with federal/state deficiencies cited at F802, F803, and F812.

The facility failed to ensure dietary employees were competently trained in food storage, safe food temperatures, and completion of dietary duties; menus were not approved by a Registered Dietitian and lacked proper guidance for diet types; and food was not prepared, stored, and served under safe and sanitary conditions, potentially impacting all 40 residents.