Inspection Reports for
Utica Rehabilitation & Nursing Center
2535 Genesee Street, Utica, NY, 13501
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
24 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
371% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 35
Date: Feb 11, 2025
Visit Reason
Complaint Survey with 12 health and 23 life safety citations including immediate jeopardy for accident hazards and abuse reporting; all deficiencies corrected by April 2025.
Findings
Complaint Survey with 12 health and 23 life safety citations including immediate jeopardy for accident hazards and abuse reporting; all deficiencies corrected by April 2025.
Deficiencies (35)
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Grievances
Infection prevention & control
Nutrition/hydration status maintenance
Pharmacy srvcs/procedures/pharmacist/records
Posted nurse staffing information
Provided diet meets needs of each resident
Required postings
Right to survey results/advocate agency info
Safe/clean/comfortable/homelike environment
Building construction type and height
Building rehabilitation
Cooking facilities
Corridor - doors
Corridor - openings
Doors with self-closing devices
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Electrical systems - other
Ep training program
Fire drills
Hazardous areas - enclosure
Hvac
Illumination of means of egress
Maintenance, inspection & testing - doors
Means of egress - general
Portable fire extinguishers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subsistence needs for staff and patients
Utilities - gas and electric
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Feb 11, 2025
Visit Reason
The recertification survey was conducted to assess compliance with state and federal regulations for nursing home operations and resident care.
Findings
The facility had multiple deficiencies including failure to post required grievance and survey information, unsafe environment issues such as accessible operational stove knobs, unclean medical equipment, unsecured enabler bars, failure to develop comprehensive care plans for residents with complex needs, immediate jeopardy due to residents being served cleaning solution, failure to maintain accurate medication records and counts, failure to post nurse staffing information, expired medications in medication carts, missing meal items for residents, unclean kitchen and kitchenette areas, and inadequate infection prevention and control practices.
Deficiencies (13)
F 0575: The facility failed to post names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups in a manner accessible to residents and representatives.
F 0577: The facility failed to post the results of the most recent Federal and State surveys in a readily accessible place for residents and others.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment; issues included an accessible operational stove, unclean feeding pole, and unsecured enabler bar for residents.
F 0585: The facility failed to ensure residents knew who the grievance officer was or how to file grievances; signage and communication were inadequate.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for residents with diabetes, anticoagulant use, and psychotropic medications.
F 0689: Immediate jeopardy due to residents being served cleaning solution stored in an unlabeled pitcher in the kitchenette refrigerator, resulting in physical and psychosocial harm.
F 0692: The facility failed to ensure residents maintained acceptable nutritional status; Resident #6 was not reassessed after significant weight changes and Resident #31's feeding tube water flushes were not provided as ordered.
F 0732: The facility failed to post daily nurse staffing information and resident census in a prominent location accessible to residents and visitors for multiple days.
F 0755: The facility failed to maintain accurate controlled substance records and secure narcotic keys; narcotic counts were not performed between shift changes and keys were left unsecured.
F 0761: The facility failed to ensure drugs and biologicals were labeled with opened dates and stored properly; expired medications and unlabeled medication cups were found in medication carts.
F 0800: Resident #24 was not provided their preferred meal choices; missing items on meal trays and lack of posted menus limited resident choice.
F 0812: The facility failed to maintain food service areas and equipment in a clean and sanitary condition; unclean surfaces, moldy bread, and inaccurate thermometers were observed in kitchen and kitchenettes.
F 0880: The facility failed to establish and maintain an infection prevention and control program; missing precaution signage and personal protective equipment stations, improper use of PPE during gastrostomy care, and unsanitary suction equipment were observed.
Report Facts
Residents served cleaning solution: 3
Weight loss: 29.7
Weight gain: 31.4
Medication count discrepancy: 1
Staff education completion: 85
Temperature out of range: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #13 | Named in medication labeling and expired medication findings. | |
| Licensed Practical Nurse #1 | Named in narcotic count and key transfer findings. | |
| Licensed Practical Nurse #2 | Named in narcotic count and key transfer findings. | |
| Licensed Practical Nurse Unit Manager #15 | Named in care plan, feeding tube care, and narcotic key transfer findings. | |
| Licensed Practical Nurse Infection Preventionist | Named in infection control and PPE findings. | |
| Dietetic Technician #29 | Named in nutritional assessment and weight monitoring findings. | |
| Food Service Aide #34 | Named in immediate jeopardy chemical incident investigation. | |
| Dietary Cook/Supervisor #35 | Named in immediate jeopardy chemical incident investigation. | |
| Administrator | Named in immediate jeopardy incident and corrective action. | |
| Medical Director | Named in immediate jeopardy incident and resident monitoring. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jan 14, 2025
Visit Reason
Complaint Survey with 2 health citations including immediate jeopardy for free from abuse and neglect and reporting of alleged violations; deficiencies corrected by March 2025.
Findings
Complaint Survey with 2 health citations including immediate jeopardy for free from abuse and neglect and reporting of alleged violations; deficiencies corrected by March 2025.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 2
Date: Jan 14, 2025
Visit Reason
The abbreviated survey was conducted due to allegations of staff-to-resident abuse involving Resident #1. The facility was investigated for failure to protect residents from abuse and failure to timely report the abuse incident to administration, the State Agency, and law enforcement.
Findings
The facility failed to ensure residents were free from abuse when Certified Nurse Aide #8 was witnessed slapping Resident #1 and the incident was not reported for three days. Multiple staff had knowledge of the abuse but failed to report it timely. The facility also failed to report the abuse to the State Agency and law enforcement within required timeframes. Immediate Jeopardy was identified and later removed after corrective actions including termination of involved staff and education of all staff.
Deficiencies (2)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Certified Nurse Aide #8 slapped Resident #1 on the face and the incident was not reported timely by staff who witnessed or knew of the abuse.
F 0609: The facility failed to timely report suspected staff abuse to the State Agency and law enforcement. The abuse incident involving Resident #1 was reported to administration three days late and law enforcement was not notified until after survey.
Report Facts
Residents affected: 1
Residents in facility: 104
Staff education completion: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Certified Nurse Aide | Named in abuse incident involving Resident #1 and subsequent termination |
| Dietary Aide #4 | Dietary Aide | Witnessed abuse and reported incident to Director of Nursing |
| Director of Nursing | Director of Nursing | Notified of abuse incident, conducted assessments, and involved in corrective actions |
| Administrator | Facility Administrator | Notified of abuse incident and involved in investigation and corrective actions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Oct 7, 2024
Visit Reason
Complaint Survey with 6 health citations including immediate jeopardy for free from abuse and neglect and quality of care; multiple deficiencies corrected by November 2024.
Findings
Complaint Survey with 6 health citations including immediate jeopardy for free from abuse and neglect and quality of care; multiple deficiencies corrected by November 2024.
Deficiencies (6)
Administration
Care plan timing and revision
Free from abuse and neglect
Investigate/prevent/correct alleged violation
Provision of medically related social service
Quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Oct 7, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of sexual abuse, review resident care plans, treatment, and social services related to behavioral health and safety concerns.
Findings
The facility failed to protect residents from sexual abuse, did not timely assess or intervene after incidents, and did not notify appropriate parties timely. Care plans were not updated to address ongoing sexually inappropriate behaviors and risks. Medically related social services were inadequate, and licensed social work consultation was not utilized. Treatment and care were not consistently provided according to professional standards, including delayed assessments and lack of monitoring for wounds and medication administration. Facility administration failed to ensure quality of care and thorough investigations.
Deficiencies (6)
F 0600: The facility failed to protect residents from sexual abuse and did not implement timely interventions or notifications after incidents involving Residents #4 and #5.
F 0610: The facility failed to respond appropriately to alleged violations, including delayed assessments after incidents involving Residents #4, #5, #6, and #9, and allowed unqualified staff to administer vaccinations.
F 0657: The facility failed to develop and revise individualized comprehensive care plans for Residents #4, #5, and #13 to address sexually inappropriate behaviors and risks of abuse.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, including delayed assessment and notification for Resident #3's bleeding, inadequate wound monitoring for Resident #2, and failure to administer Resident #1's Lidocaine Pain Patch timely.
F 0745: The facility failed to provide medically related social services to maintain residents' highest practicable well-being, including inadequate behavioral health interventions and failure to consult licensed social work for Resident #5's high-risk behaviors.
F 0835: The facility failed to administer in a manner that ensured appropriate quality of care, including failure to protect residents from sexual abuse, failure to revise care plans, failure to provide treatment and care according to professional standards, and failure to provide adequate social services.
Report Facts
Residents affected by sexual abuse incident: 114
Staff education completion: 83
Staff education completion: 100
Behavioral contract date: May 27, 2024
Resident cognitive function score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #25 | Nurse Practitioner | Documented Resident #5's sexually inappropriate behaviors and ongoing issues. |
| Psychiatric Nurse Practitioner #24 | Psychiatric Nurse Practitioner | Documented Resident #5's history of sexually inappropriate behaviors and provided recommendations. |
| Director of Social Services | Director of Social Services | Responsible for behavioral care planning; acknowledged lack of interventions and consultation for Resident #5. |
| Registered Nurse Supervisor #12 | Registered Nurse Supervisor | Notified of sexual abuse incident on 12/30/2023; documented notifications and assessments. |
| Certified Nurse Aide #15 | Certified Nurse Aide | Observed and reported sexual abuse incident involving Residents #4 and #5. |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Notified of sexual abuse incident and reported observations. |
| Licensed Practical Nurse Manager #3 | Licensed Practical Nurse Manager | Aware of Resident #5's behaviors and concerns; raised issues with Director of Social Services. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Administered injection to Resident #9 without qualification; suspended pending investigation. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Directed Certified Nurse Aide #1 to administer injection to Resident #9. |
| Licensed Master Social Worker #36 | Licensed Master Social Worker Consultant | Contracted consultant not contacted by facility for Resident #5's behavioral concerns. |
| Psychologist #26 | Psychologist | Evaluated Resident #5 and provided recommendations not implemented by facility. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 27, 2024
Visit Reason
Complaint Survey with 1 life safety code citation for sprinkler system out of service; deficiency corrected by April 2024.
Findings
Complaint Survey with 1 life safety code citation for sprinkler system out of service; deficiency corrected by April 2024.
Deficiencies (1)
Sprinkler system - out of service
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network; deficiency not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 23, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's pest control program and ensure it effectively prevents and deals with pests such as mice and insects.
Findings
The facility failed to maintain an effective pest control program, as fruit flies were observed in the 2nd floor kitchenette and 2nd floor Teresian room despite no documentation of such sightings in pest control records. A leaking handwash sink contributed to the pest problem, and staff failed to report the issue properly.
Deficiencies (1)
F 0925: The facility did not maintain an effective pest control program, with fruit flies observed in the 2nd floor kitchenette and 2nd floor Teresian room. The handwash sink in the Teresian room was leaking water onto the shelf and floor, contributing to the pest issue.
Report Facts
Fruit flies observed: 25
Fruit flies observed: 75
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Mar 8, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, updating comprehensive care plans for residents, providing adequate assistance with activities of daily living, ensuring food safety and palatability, implementing infection prevention and control practices, and maintaining an effective pest control program.
Deficiencies (6)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with unclean and damaged floors, walls, ceilings, and fixtures across multiple floors and resident rooms.
F 0657: The facility failed to review and revise comprehensive care plans for 2 residents, including lack of interventions to prevent resident-to-resident abuse and omission of protective boots in care plans.
F 0677: The facility failed to provide necessary assistance with activities of daily living for 3 residents, including failure to reposition, set up meals, and maintain personal hygiene.
F 0804: The facility failed to ensure food was served at palatable and safe temperatures, with hot food items served below 140°F on multiple occasions.
F 0880: The facility failed to implement infection prevention and control practices, including failure of a nurse to perform hand hygiene and change gloves between wound dressing treatments on a resident with multidrug-resistant organisms.
F 0925: The facility failed to maintain an effective pest control program, with fruit fly infestations observed in multiple areas including the kitchen, resident rooms, and nursing stations.
Report Facts
Fruit flies observed: 10
Fruit flies observed: 30
Fruit flies observed: 10
Fruit flies observed: 10
Fruit flies observed: 4
Fruit flies observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Failed to perform hand hygiene and change gloves between wound dressing treatments on Resident #84 |
| CNA #22 | Certified Nurse Aide | Witnessed resident-to-resident incident involving Residents #74 and #78 |
| SW #26 | Social Worker | Followed up on resident-to-resident incident and documented care plan updates |
| RN #9 | Registered Nurse | Assessed resident after resident-to-resident incident and commented on care plan omissions |
| Food Service Director | Reported on food temperature standards and pest control issues | |
| Housekeeping Supervisor #48 | Housekeeping Supervisor | Described environmental reporting and maintenance communication |
| LPN #39 | Licensed Practical Nurse | Reported on environmental damage and maintenance reporting |
| RN MDS Coordinator #25 | Registered Nurse MDS Coordinator | Discussed care plan responsibilities and protective booties use |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Mar 8, 2023
Visit Reason
The inspection was a recertification and abbreviated survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident rights, medication administration, advance directives, environment cleanliness and maintenance, care planning, activities of daily living assistance, medication storage and labeling, food service safety and allergy accommodations, infection control practices, and pest control.
Deficiencies (13)
F 0550: The facility failed to provide keys for locked drawers to 3 residents who requested them, violating residents' rights to privacy and personal belongings.
F 0554: The facility failed to ensure self-administration of medications was clinically appropriate for 1 resident who had medications left at bedside without assessment or order.
F 0578: The facility failed to ensure a resident's advance directive was accurately documented and honored, with conflicting orders for CPR and DNR status.
F 0582: The facility failed to provide required notices of Medicare non-coverage and potential financial liability to 2 residents discharged from Medicare Part A services.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment with multiple areas of uncleanliness, damage, and disrepair across resident rooms, common areas, and nursing units.
F 0657: The facility failed to review and revise comprehensive care plans for 2 residents, including lack of interventions to prevent resident-to-resident abuse and omission of protective boots for pressure ulcer prevention.
F 0677: The facility failed to provide necessary assistance with activities of daily living for 3 residents, including failure to reposition, set up meals, and maintain personal hygiene.
F 0761: The facility failed to label and store medications properly, including an insulin pen without date opened or expiration date.
F 0804: The facility failed to ensure food was served at safe and appetizing temperatures for 2 meals, with hot foods served below 140°F.
F 0806: The facility failed to ensure residents received food accommodating allergies and preferences, serving eggs to a resident allergic to eggs and green beans to a resident allergic to beans.
F 0812: The facility failed to maintain food service safety and sanitation in the kitchen, including improper cooling of soup, unclean equipment and surfaces, leaking faucet, and use of dented cans.
F 0880: The facility failed to implement infection prevention and control practices during wound and gastrostomy care, with staff not performing hand hygiene or changing gloves between dressing changes.
F 0925: The facility failed to maintain an effective pest control program, with fruit fly infestations observed in multiple areas including kitchen, resident rooms, and nursing stations.
Report Facts
Deficiencies cited: 12
Food temperature: 108
Food temperature: 119
Food temperature: 117
Food temperature: 107
Food temperature: 104
Fruit flies observed: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Named in infection control deficiency for improper hand hygiene during wound care |
| LPN #29 | Licensed Practical Nurse | Named in medication administration deficiency for leaving medications at bedside |
| LPN Unit Manager #12 | Licensed Practical Nurse Unit Manager | Named in medication administration deficiency for supervising medication safety |
| RN #9 | Registered Nurse Unit Manager | Named in advance directive and allergy food service deficiencies |
| CNA #15 | Certified Nurse Aide | Named in ADL assistance deficiency for not setting up resident for meals |
| Food Service Director | Named in food service deficiencies including food temperature, sanitation, and pest control | |
| Dietary Aide #40 | Named in food allergy deficiency for plating incorrect food | |
| Registered Dietitian #41 | Named in food allergy deficiency for confirming allergy documentation | |
| Infection Control Preventionist Nurse #19 | Named in infection control deficiency for explaining proper hand hygiene | |
| Maintenance Director | Named in environmental and maintenance deficiencies | |
| Social Worker #26 | Named in care planning deficiency related to resident-to-resident abuse | |
| LPN Unit Manager #17 | Licensed Practical Nurse Unit Manager | Named in ADL assistance and care planning deficiencies |
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Sep 17, 2020
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including inadequate supervision and assistance to prevent accidents leading to aspiration pneumonia, failure to maintain residents' nutritional status, improper labeling and storage of medications, serving food at unsafe temperatures, unclean food storage areas, and lack of a working call system for a resident.
Deficiencies (6)
F 0689: The facility failed to ensure adequate supervision and assistance devices to prevent accidents for 2 of 5 residents, resulting in aspiration pneumonia due to incorrect food consistency and lack of supervision during meals.
F 0692: Resident #24 experienced significant weight loss and was not reassessed timely to address weight loss, decreased meal intake, and difficulty chewing.
F 0761: The facility did not ensure drugs and biologicals were labeled with the date opened for 1 of 3 medication carts and 1 of 2 medication storage rooms observed.
F 0804: Food and drink were not served at palatable and safe temperatures during meal service for 2 of 2 meal trays tested.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards; the kitchen and nourishment refrigerators were soiled and contained unlabeled food.
F 0919: The facility did not provide a working call system in the bathroom and bathing area for Resident #7; the call system unit was not operational and no call cord was installed.
Report Facts
Weight change: 8.36
Weight change: 5.92
Food temperature: 125.8
Food temperature: 95.2
Food temperature: 53.7
Food temperature: 123
Food temperature: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #11 | Certified Nursing Assistant | Reported finding resident with wrong food consistency tray and partially eaten food leading to aspiration incident |
| LPN #15 | Licensed Practical Nurse | Last nurse on shift who was unaware of resident receiving wrong food consistency until late |
| RNS #10 | Registered Nurse Supervisor | Completed resident assessment after aspiration incident and notified physician |
| Director of Nursing | Director of Nursing | Reported care plan violation and staff discipline related to resident supervision and meal care |
| SLP #6 | Speech Language Pathologist | Provided recommendations for aspiration precautions and supervision during meals |
| Food Service Director | Food Service Director | Reported food temperature issues and nourishment refrigerator cleaning responsibilities |
| Director of Environmental Services | Director of Environmental Services | Reported unawareness of missing call cord and nonfunctional call system for resident #7 |
| RN Unit Manager #4 | Registered Nurse Unit Manager | Unaware of call system issues for resident #7 |
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