Inspection Reports for
Tupper Lake Center for Nursing and Rehabilitation
114 Wawbeek Ave, Tupper Lake, NY, 12986
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Inspection Report — Jan 30, 2024
Annual Inspection CMS
Date: Jan 30, 2024
Visit Reason
The inspection was a recertification survey conducted from 01/22/2024 to 01/30/2024 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare non-coverage notices, failure to notify the Ombudsman of resident transfers, lack of scheduled registered nurse coverage for one day, use of unnecessary medications without documented indications, and improper food storage and sanitation practices in the kitchen and kitchenettes.
Citations (5)
F 0582: The facility did not ensure residents or their representatives were fully informed of their right to expedited review of Medicare Part A service termination. Resident #111 did not receive timely 2-day notification of service termination.
F 0623: The facility failed to provide timely written notification to the Office of the State Long-Term Care Ombudsman of resident transfers to the hospital for Residents #17 and #57.
F 0727: The facility did not ensure a registered nurse was scheduled for at least 8 consecutive hours on 1/28/2024, resulting in no RN coverage that day.
F 0757: The facility did not ensure residents were free from unnecessary drugs. Residents #5, #16, and #42 had medications prescribed without documented indications or parameters for as-needed use.
F 0812: The facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards. Toxic vapor-emitting fly strips were used in food prep areas, cleaning equipment was improperly stored, and kitchen equipment and floors were soiled.
Report Facts
Residents reviewed for medication issues: 5
Residents with medication deficiencies: 3
Residents reviewed for transfer notification: 3
Residents with transfer notification deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Administrator #1 | Discussed failure to issue timely Medicare Non-Coverage notice. | |
| Social Worker #1 | Unaware of requirement to notify Ombudsman in writing of resident transfers. | |
| Administrator #1 | Acknowledged lack of RN coverage on 1/28/2024 and uncertainty about Ombudsman notification requirements. | |
| Scheduler #1 | Responsible for scheduling staff; missed scheduling RN on 1/28/2024. | |
| Director of Nursing #1 | Director of Nursing | Commented on RN scheduling and medication indication deficiencies. |
| Corporate Registered Nurse #1 | Explained medication order entry process and diagnosis documentation. | |
| Pharmacist #1 | Pharmacist | Described medication review process related to diagnosis lists. |
| Nutrition Manager #1 | Nutrition Manager | Addressed food safety deficiencies and cleaning responsibilities. |
Inspection Report — Jan 30, 2024
Certification State
Date: Jan 30, 2024
Visit Reason
State-compiled facility profile showing 7 inspections from June 2022 to January 2024 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 32 complaints about this facility; 3 led to on-site inspections.
Findings
Across 7 inspections, 46 citations were issued including 26 standard health and 20 life safety code citations. The facility had 32 complaints with 3 on-site inspections and 1 enforcement action involving fines.
Citations (33)
Definitions: Standard Health Citation — quality of care
Department Criminal History Review: Standard Health Citation — quality of care
Drug Regimen Is Free From Unnecessary Drugs: Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care
Medicaid/medicare Coverage/liability Notice: Standard Health Citation — quality of care
Notice Requirements Before Transfer/discharge: Standard Health Citation — quality of care
Requirements Before Submitting A Request For: Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif: Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif: Standard Health Citation — quality of care
Rn 8 Hrs/7 Days/wk, Full Time Don: Standard Health Citation — quality of care
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements
Elevators: Life Safety Code Citation — NFPA requirements
Maintenance, Inspection & Testing - Doors: Life Safety Code Citation — NFPA requirements
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care
Facility Assessment: Standard Health Citation — quality of care
Nutrition/hydration Status Maintenance: Standard Health Citation — quality of care
Reporting Of Alleged Violations: Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors: Standard Health Citation — quality of care
Sufficient Nursing Staff: Standard Health Citation — quality of care
Reporting - National Health Safety Network: Standard Health Citation — quality of care
Reporting - National Health Safety Network: Standard Health Citation — quality of care
Free From Abuse And Neglect: Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care
Infection Control: Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation: Standard Health Citation — quality of care
Notify Of Changes (injury/decline/room, Etc. ): Standard Health Citation — quality of care
Definitions: Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care
Infection Control: Standard Health Citation — quality of care
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 46
Inspections with violations: 6
Inspections without violations: 1
On-site complaint inspections: 3
Total complaints: 32
Total enforcement actions: 1
Total fines: 8000
Citations from complaints: 12
Inspection Report — Jan 25, 2024
Abbreviated Survey CMS
Date: Jan 25, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of neglect, insufficient care planning, inadequate nutrition and hydration, insufficient staffing, medication errors, and lack of a completed facility assessment.
Findings
The facility failed to timely report an incident of neglect, did not develop and implement comprehensive care plans for residents, failed to maintain adequate nutrition and hydration for a resident, had insufficient nursing staff to meet resident needs, administered medications late without proper notification to physicians, and lacked a completed facility-wide assessment to determine necessary resources.
Citations (6)
F0609: The facility did not timely report an alleged neglect incident involving Resident #1 who fell from bed and sustained injury; the incident was reported 5 days late to the State Survey Agency.
F0656: The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives for Residents #1 and #3, resulting in inadequate assistance during bed mobility and lack of nutrition and hydration interventions.
F0692: The facility did not ensure Resident #3 received adequate nutrition and hydration, failed to monitor and document intake properly, and did not respond timely to signs of dehydration and poor intake, resulting in hospitalization for acute kidney injury.
F0725: The facility did not provide sufficient nursing staff to meet resident needs, resulting in delayed care, missed showers, long waits for assistance, and inadequate supervision.
F0760: The facility failed to ensure residents were free from significant medication errors, including late administration of medications for Residents #3, #4, and #11, and lack of physician notification for late or missed doses.
F0838: The facility did not complete or maintain a facility-wide assessment to determine necessary resources to competently care for residents during day-to-day operations and emergencies.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 3
Minimum staffing requirement: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in medication error finding for not administering Metoprolol on 9/2/2023 |
| Director of Nursing #1 | Director of Nursing | Named in staffing and medication error findings |
| Registered Nurse Manager #1 | Registered Nurse Manager | Named in nutrition and staffing findings |
| Medical Director #1 | Medical Director | Named in medication error and nutrition findings |
Inspection Report — Jun 17, 2022
Abbreviated Survey CMS
Date: Jun 17, 2022
Visit Reason
The inspection was a recertification and abbreviated survey conducted to assess compliance with regulations related to resident safety and accident prevention.
Findings
The facility failed to ensure adequate supervision and interventions to prevent falls for Resident #144, who experienced five falls between 9/29/2021 and 10/16/2021. The facility did not follow its policy for accident and incident reporting, including failure to identify root causes and implement timely interventions or update care plans accordingly.
Citations (1)
F 0689: The facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #144 fell five times without documented interventions or updated care plans to prevent recurrence.
Report Facts
Number of falls: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated incident reports should have documented a plan to prevent recurrence and care plans should have been updated |
| Registered Nurse Manager #1 | Registered Nurse Manager | Stated incident reports need better documentation and care plans should be updated immediately after falls |
| Administrator | Administrator | Reported staff re-education on incident reports and described the process for updating care plans and incident reports |
Inspection Report — Nov 21, 2019
Annual Inspection CMS
Date: Nov 21, 2019
Visit Reason
The inspection was a 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 housekeeping, care plan documentation, accident prevention, nutritional care, dialysis communication, medication regimen review, psychotropic medication management, menu nutritional adequacy, staffing plan updates, and medical record maintenance.
Citations (11)
F 0584: The facility did not provide effective housekeeping services; floors were not clean on 2 of 2 resident units.
F 0655: The facility did not provide a written summary of the baseline care plan to 10 residents and their representatives within 48 hours of admission.
F 0656: The facility did not develop comprehensive care plans with measurable objectives and timeframes for 6 residents to address medical, nursing, and psychosocial needs.
F 0689: The facility did not ensure adequate supervision and individualized care plans for smoking for 1 resident, including smoking assessments and safety measures.
F 0692: The facility did not ensure nutritional status was maintained for 1 resident by failing to verify severe weight loss and consistently provide finger foods and extensive assistance with eating.
F 0698: The facility did not ensure ongoing communication, collaboration, and physician orders for dialysis care for 1 resident receiving dialysis.
F 0756: The facility did not have timeframes established in the medication regimen review policy for pharmacist and facility actions when irregularities were identified.
F 0758: The facility did not consistently document physician-ordered gradual dose reductions for psychotropic medications for 2 residents.
F 0803: The facility menus did not meet nutritional needs by providing insufficient fruits and vegetables and were not reviewed for adequacy after changes.
F 0838: The facility assessment was not reviewed and updated annually to ensure sufficient qualified staff were available to meet resident needs; staffing did not meet the documented plan.
F 0842: The facility did not maintain medical records in accordance with accepted standards for 3 residents, including wound assessment documentation, quarterly elopement risk assessments, and physician notification of abnormal vital signs.
Report Facts
Residents reviewed for baseline care plan summary: 10
Residents reviewed for comprehensive care plans: 13
Residents reviewed for accident prevention: 1
Residents reviewed for nutrition: 2
Residents reviewed for dialysis care: 1
Residents reviewed for medication regimen review: 2
Residents reviewed for medical record maintenance: 13
Weight loss percentage: 8.37
Medication regimen review recommendations: 3
Blood pressure readings below ordered parameters: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNUM #1 | Registered Nurse Unit Manager | Named in multiple interviews related to care plan deficiencies, accident prevention, wound care, and physician notification |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan summaries, smoking assessments, dialysis communication, medication regimen review, and staffing |
| RN #3 | Registered Nurse | Interviewed regarding dialysis communication |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding weight monitoring and feeding assistance |
| RD #7 | Registered Dietitian | Interviewed regarding nutritional adequacy of menus and feeding assistance |
| Social Worker #6 | Social Worker | Interviewed regarding discharge care planning |
| Pharmacist | Consultant Pharmacist | Interviewed regarding medication regimen review and gradual dose reductions |
| Medical Director | Medical Director | Interviewed regarding medication regimen review and physician notification |
| Kitchen Aide #10 | Kitchen Aide | Interviewed regarding meal preparation and finger food errors |
| Kitchen Cook #9 | Kitchen Cook | Interviewed regarding meal preparation and finger food errors |
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