Inspection Reports for Van Duyn Center for Rehabilitation and Nursing
5075 W Seneca Turnpike, Syracuse, NY 13215, United States, NY, 13215
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 15, 2025, identified deficiencies related to resident dignity and respect, housekeeping and maintenance, treatment and care, food service, and environmental cleanliness. Earlier inspections showed a pattern of issues including inadequate pest control, failure to protect residents from abuse, medication delays, and problems with care planning, supervision, and discharge procedures. Complaint investigations substantiated a sexual abuse incident and unsafe discharge practices that posed immediate jeopardy to resident safety. Enforcement actions such as immediate jeopardy findings were noted in prior reports, but no fines or license suspensions were listed in the available reports. The facility’s deficiencies have persisted over time with recurring themes in resident care, environment, and safety, indicating ongoing challenges without clear improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
318% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 15, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements related to resident rights, environment, treatment and care, food service, and safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate housekeeping and maintenance resulting in unsanitary conditions, failure to provide appropriate treatment and care according to orders, serving food that was not palatable or at safe temperatures, and failure to maintain a safe, clean, and comfortable environment due to strong urine odors and other issues.
Deficiencies (5)
Failure to ensure residents were treated with respect and dignity; staff used foul language, ethnic slurs, and laughed at residents.
Failure to provide effective housekeeping and maintenance services; strong urine odors, soiled toilets, broken fixtures, stained bedding, and unclean floors observed.
Failure to provide appropriate treatment and care according to orders; a resident had an old bandage with no documented orders or treatment records.
Failure to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures; multiple residents complained about cold and poor quality food.
Failure to maintain a safe, functional, sanitary, and comfortable environment; strong urine odors detected in multiple areas.
Report Facts
Residents affected: 7
Residents affected: 5
Residents affected: 1
Meals reviewed: 2
Residents affected: 7
Resident units affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #6 | Named in finding related to use of ethnic slur and foul language | |
| Certified Nurse Aide #7 | Named in finding related to laughing at confused resident | |
| Licensed Practical Nurse #6 | Interviewed regarding staff behavior and dignity issues | |
| Registered Nurse #4 | Interviewed regarding staff behavior and dignity issues | |
| Administrator #1 | Administrator | Provided information on re-education related to code of conduct |
| Director of Environmental Services #1 | Director of Environmental Services | Interviewed regarding housekeeping and maintenance deficiencies and odor investigation |
| Assistant Administrator #1 | Assistant Administrator | Interviewed regarding housekeeping audits and resident preferences |
| Licensed Practical Nurse #1 | Interviewed regarding bandage care and documentation | |
| Registered Nurse #1 | Interviewed regarding expectations for dressing orders | |
| Registered Nurse #2 | Interviewed regarding bandage removal and notification of skin issues | |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding reporting of skin issues and dressing orders |
| Certified Nurse Aide #14 | Present during food temperature testing and meal replacement | |
| Dietary Technician #1 | Dietary Technician | Present during food temperature testing and meal replacement |
| Certified Nurse Aide #15 | Reported resident complaints about food temperature | |
| Licensed Practical Nurse #14 | Reported resident complaints about food temperature and tray accuracy | |
| Food Service Director #1 | Food Service Director | Interviewed regarding food temperature issues and equipment problems |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jul 14, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with pharmaceutical services requirements, specifically to ensure that routine and emergency medications and biologicals were provided timely to meet the needs of residents.
Findings
The facility failed to provide timely medications for two residents reviewed, resulting in a low Lithium blood level for Resident #3 due to delayed Lithium refills caused by a pharmacy computer error, and delayed administration of cinacalcet and Sevelamer for Resident #4 due to medication availability issues related to dialysis and insurance problems. These delays posed minimal harm or potential for actual harm to the residents.
Deficiencies (2)
Failure to provide or obtain routine and emergency medications timely for Resident #3, resulting in low Lithium blood level due to pharmacy computer error rejecting refill requests.
Failure to administer cinacalcet and Sevelamer timely to Resident #4 due to medication availability issues related to dialysis and insurance, resulting in delayed medication delivery.
Report Facts
Lithium tablets delivered: 180
Lithium blood level: 0.3
Medication doses not administered: 11
Medication doses not administered: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Documented Lithium not administered on 11/18 and 11/19/2024; interviewed about medication administration | |
| Licensed Practical Nurse #8 | Registered Nurse | Documented family call about Lithium toxicity symptoms; nursing note on 11/18/2024; Lithium level drawn on 11/19/2024 |
| Pharmacist #11 | Quality Assurance Pharmacist | Interviewed regarding pharmacy delivery and refill system error causing Lithium delay; also interviewed about medication dispensing machine and delays for Resident #4 |
| Registered Nurse Manager #21 | Registered Nurse Manager | Interviewed about medication refill procedures and notification expectations for missing medications |
| Licensed Practical Nurse #10 | Interviewed about medication administration delays and communication with dialysis and pharmacy for Resident #4 | |
| Licensed Practical Nurse #19 | Reported medications not available on 6/14 and 6/15/2025 for Resident #4 | |
| Licensed Practical Nurse #16 | Interviewed about medication ordering and notification procedures | |
| Registered Nurse Manager #6 | Registered Nurse Manager | Interviewed about medication order processing and communication with dialysis and pharmacy regarding medication availability for Resident #4 |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Apr 18, 2025
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' dignity and respect, communication access for Deaf residents, environmental cleanliness, protection from misappropriation of property, provision of activities of daily living care, wound care, medication administration, dental care, food service, and pest control.
Deficiencies (11)
Residents #170 and #335 were continent but were placed in incontinence briefs and told to urinate/defecate in them instead of using the toilet, causing psychosocial harm.
Residents #50 and #162 were Deaf and not provided their preferred communication method, resulting in psychosocial harm to Resident #50 and immediate jeopardy.
Several residents' rooms and common areas were unclean with odors, soiled linens on floors, dirty furniture, and trash.
Activity Aide #5 had possession of Resident #50's money and did not return the full amount promptly; Resident #102 had deposit cans removed without receiving money.
Facility did not complete a timely investigation of alleged misappropriation of Resident #50's money and failed to report to the state as required.
Residents #160 and #336 were not provided with oral hygiene or hair care as required.
Resident #461 did not receive timely follow-up care for dehisced surgical wound; Resident #274 was not provided wound vacuum or backup dressing as ordered.
Resident #1098 was administered lispro insulin without being provided food, risking hypoglycemia.
Residents #102 and #336 did not receive timely dental care; Resident #336 did not receive dentures as planned and Resident #102 was not scheduled for tooth extraction.
Residents #306, #336, and #740 frequently had missing food items including nutritional supplements at meals.
Facility did not maintain an effective pest control program; fruit flies were observed in multiple areas and mice were reported in resident rooms.
Report Facts
Amount of money held by Activity Aide #5: 1000
Amount of money missing: 181
Number of residents reviewed for communication deficiency: 3
Number of residents with environmental deficiencies: 6
Number of residents with oral hygiene and hair care deficiencies: 2
Number of residents with wound care deficiencies: 2
Number of residents with medication errors: 1
Number of residents with dental care deficiencies: 2
Number of residents with food service deficiencies: 3
Number of residents reporting missing food items: 5
Number of residents reporting pest sightings: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Aide #5 | Activity Aide | Held Resident #50's money and was involved in misappropriation investigation. |
| Certified Nurse Aide #43 | Certified Nurse Aide | Named in dignity and respect deficiency related to toileting assistance for Resident #335. |
| Certified Nurse Aide #45 | Certified Nurse Aide | Named in dignity and respect deficiency related to toileting assistance for Resident #335. |
| Certified Nurse Aide #44 | Certified Nurse Aide | Named in dignity and respect deficiency related to toileting assistance for Resident #335. |
| Licensed Practical Nurse Assistant Unit Manager #46 | Licensed Practical Nurse Assistant Unit Manager | Named in dignity and respect deficiency related to toileting assistance for Resident #335. |
| Assistant Director of Nursing #47 | Assistant Director of Nursing | Named in dignity and respect deficiency related to toileting assistance for Resident #335. |
| Nurse Practitioner #48 | Nurse Practitioner | Named in dignity and respect deficiency related to toileting assistance for Resident #335. |
| Medical Director | Medical Director | Named in dignity and respect deficiency related to toileting assistance for Resident #335. |
| Deaf Services Manager #18 | Deaf Services Manager | Named in communication deficiency for Resident #50. |
| Certified Nurse Aide #4 | Certified Nurse Aide | Named in communication deficiency for Resident #50. |
| Certified Nurse Aide #19 | Certified Nurse Aide | Named in communication deficiency for Resident #50. |
| Certified Nurse Aide #20 | Certified Nurse Aide | Named in communication deficiency for Resident #50. |
| Licensed Practical Nurse #21 | Licensed Practical Nurse | Named in communication deficiency for Resident #50. |
| American Sign Language Interpreter #53 | Interpreter | Named in communication deficiency for Resident #50. |
| Administrator | Administrator | Named in communication deficiency for Resident #50. |
| Assistant Administrator | Assistant Administrator | Named in communication deficiency for Resident #50. |
| Licensed Practical Nurse Assistant Unit Manager #40 | Licensed Practical Nurse Assistant Unit Manager | Named in communication deficiency for Resident #162. |
| Social Worker #121 | Social Worker | Named in misappropriation and communication deficiencies. |
| Director of Social Work | Director of Social Work | Named in misappropriation and communication deficiencies. |
| Certified Nurse Aide #54 | Certified Nurse Aide | Named in activities of daily living care deficiency for Resident #336. |
| Licensed Practical Nurse #52 | Licensed Practical Nurse | Named in activities of daily living care deficiency. |
| Certified Nurse Aide #169 | Certified Nurse Aide | Named in activities of daily living care deficiency for Resident #160. |
| Licensed Practical Nurse Unit Manager #9 | Licensed Practical Nurse Unit Manager | Named in wound care deficiency. |
| Licensed Practical Nurse Assistant Unit Manager #7 | Licensed Practical Nurse Assistant Unit Manager | Named in wound care deficiency. |
| Nurse Practitioner #48 | Nurse Practitioner | Named in wound care deficiency. |
| Wound Care Registered Nurse #128 | Wound Care Registered Nurse | Named in wound care deficiency. |
| Wound Care Registered Nurse #136 | Wound Care Registered Nurse | Named in wound care deficiency. |
| Licensed Practical Nurse #26 | Licensed Practical Nurse | Named in medication administration deficiency. |
| Certified Nurse Aide #27 | Certified Nurse Aide | Named in medication administration deficiency. |
| Registered Nurse Manager #30 | Registered Nurse Manager | Named in medication administration deficiency. |
| Clerk #110 | Clerk | Named in medication administration deficiency. |
| Certified Nurse Aide #109 | Certified Nurse Aide | Named in medication administration deficiency. |
| Licensed Practical Nurse Unit Manger #72 | Licensed Practical Nurse Unit Manager | Named in food service deficiency. |
| Food Service Director | Food Service Director | Named in food service deficiency. |
| Licensed Practical Nurse Unit Manager #40 | Licensed Practical Nurse Unit Manager | Named in pest control deficiency. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as an abbreviated survey following a complaint investigation regarding the facility's failure to protect a resident from sexual abuse by another resident.
Complaint Details
The complaint investigation substantiated that Resident #5 was sexually assaulted by Resident #4. The facility failed to protect Resident #5's right to be free from sexual abuse. Resident #4 was placed under arrest and discharged to the Sheriff's department. The incident was reviewed in Quality Assurance meetings and corrective actions were implemented.
Findings
The facility failed to protect Resident #5, who was cognitively impaired, from sexual abuse by Resident #4. The incident involved Resident #5 being found unclothed with Resident #4, who admitted to attempting sexual intercourse. The resident was transported to the hospital for evaluation and the accused resident was taken into police custody. The facility implemented corrective actions including staff education and ongoing monitoring.
Deficiencies (1)
Failure to protect residents from all types of abuse including sexual abuse, resulting in actual harm to Resident #5.
Report Facts
Residents affected: 5
Residents affected: 1
Dates of incident: Aug 17, 2024
Dates of corrective action: Aug 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #9 | Registered Nurse Supervisor | Documented incident, assessment, and coordinated response including notifying physician, administrator, and police. |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Reported removal of Resident #5 from Resident #4's room and assisted with care post-incident. |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Assisted with care of Resident #5 and notified Registered Nurse Supervisor #9. |
| Certified Nurse Assistant #10 | Certified Nurse Assistant | Reported finding Residents #4 and #5 unclothed together and called for help. |
| Certified Nurse Assistant #12 | Certified Nurse Assistant | Assigned to care for Residents #4 and #5 on the day of the incident and provided observations. |
| Director of Nursing | Director of Nursing | Provided information on Resident #5's behavioral assessment and staff education post-incident. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 26, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate the facility's pest control program and ensure the facility was free of pests, specifically focusing on the 4th and 5th nursing floors.
Findings
The facility failed to maintain an effective pest control program on the 4th and 5th floors, with multiple observations of live and dead cockroaches in resident rooms and utility areas. Pest control vendor service reports and housekeeping interviews revealed inconsistent cleaning and pest control inspections, with some resident rooms not serviced or inspected timely.
Deficiencies (1)
Failure to maintain an effective pest control program resulting in evidence of cockroaches on the 4th and 5th floors.
Report Facts
Cockroach sightings: 20
Live cockroaches: 5
Live cockroaches: 5
Live cockroaches: 1
Pest control service dates: 4
Pest control service dates: 3
Pest control service dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Director | Interviewed regarding cleaning schedules and pest control vendor inspections | |
| Assistant Administrator | Interviewed about pest sighting logs and vendor inspection frequency | |
| Administrator | Interviewed regarding pest sightings, vendor inspections, and resident COVID precautions |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was conducted as an abbreviated complaint survey triggered by concerns about the facility's failure to provide timely notification to the State Long Term Care Ombudsman and to ensure safe and orderly discharges for residents, specifically regarding two residents discharged without proper planning or notification.
Complaint Details
The complaint investigation revealed that two residents were discharged without proper notification to the Ombudsman and without safe discharge plans. Resident #1 was discharged to a DSS building without money, identification, or shelter, resulting in homelessness and lack of medications. Resident #2 was discharged similarly and was refused re-entry to the facility, also ending up homeless without medications or permanent housing. Immediate jeopardy was identified and removed after corrective actions including postponing discharges and staff education.
Findings
The facility failed to notify the State Long Term Care Ombudsman of resident discharges at least 30 days prior, and failed to provide safe and orderly discharges for two residents who were discharged to Department of Social Services (DSS) buildings without shelter, medications, or proper discharge plans, resulting in immediate jeopardy to resident health and safety.
Deficiencies (2)
Failure to provide timely notification to the resident representative and ombudsman before transfer or discharge.
Failure to prepare residents for a safe transfer or discharge, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents affected: 2
Facility total capacity: 376
Medications listed for Resident #2: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator #7 | Assistant Administrator | Directed discharge of Resident #1 and expected social worker to document discharge plans. |
| Director of Social Work | Director of Social Work | Involved in discharge process and interviews regarding discharge planning and deficiencies. |
| Social Worker #2 | Social Worker | Interviewed regarding discharge procedures and involvement with Resident #1. |
| Social Worker #3 | Social Worker | Documented progress notes and discharge planning for Resident #2. |
| Nurse Practitioner #8 | Nurse Practitioner | Interviewed about understanding of discharge plans for Residents #1 and #2. |
| Administrator | Administrator | Interviewed regarding discharge decisions and facility policies. |
| Facility Ombudsman | Ombudsman | Reported not receiving discharge notices and lack of communication about discharges. |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jul 28, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for nursing home care, including resident rights, safety, care, and environment.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified care, inadequate hygiene and bathing assistance, unsafe and unclean environment, failure to investigate and resolve grievances, inadequate supervision to prevent abuse and smoking, incomplete care plans, failure to provide nourishing and palatable diets with adaptive equipment, and failure to maintain essential equipment and pest control.
Deficiencies (10)
Failure to honor residents' rights to a dignified existence, including proper hygiene and clothing for residents #62 and #410.
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple unclean areas, foul odors, and disrepair on Units 3, 4, 5, and 7.
Failure to ensure residents' right to voice grievances and make prompt efforts to resolve them, specifically for Resident #113 with missing personal items not investigated.
Failure to timely report suspected abuse, neglect, or theft and to thoroughly investigate incidents of resident-to-resident physical altercations involving Resident #198.
Failure to develop and implement a comprehensive person-centered care plan for Resident #326, including addressing frequent removal of wander alert device and inconsistent documentation of device checks.
Failure to provide care and assistance to perform activities of daily living for Residents #277, #408, and #410, including inadequate shaving, showering, toileting, and barrier cream application.
Failure to ensure adequate supervision to prevent accidents and unsafe behaviors related to smoking for Residents #42, #198, and #204, and failure to supervise Resident #763 to prevent elopement, resulting in Immediate Jeopardy.
Failure to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, including missing food items, lack of adaptive equipment, and improper food temperatures for multiple residents.
Failure to keep all essential equipment working safely, including a malfunctioning steamer and clogged sink in the main kitchen, and multiple equipment issues in the 7th floor kitchenette.
Failure to maintain an effective pest control program, resulting in presence of fruit flies, cockroaches, mice, and dead pests on multiple floors and resident units.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 5
Residents affected: 10
Residents affected: 14
Residents affected: 3
Residents affected: 2
Residents affected: 7
Residents affected: 4
Incident reports: 4
Smoking incidents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #10 | Certified Nursing Assistant | Named in hygiene and dignity deficiencies for Resident #410 |
| LPN #17 | Licensed Practical Nurse | Named in hygiene and dignity deficiencies for Resident #410 |
| RNS #22 | Registered Nurse Supervisor | Named in hygiene and dignity deficiencies for Resident #410 |
| CNA #6 | Certified Nursing Assistant | Named in hygiene deficiencies for Resident #62 |
| RN Unit Manager/ADON #4 | Registered Nurse Unit Manager/Assistant Director of Nursing | Named in hygiene and abuse supervision deficiencies |
| SW #3 | Social Worker | Named in grievance and smoking deficiencies |
| SW #81 | Social Worker | Named in grievance deficiencies for Resident #113 |
| RN #22 | Registered Nurse | Named in grievance deficiencies for Resident #113 |
| LPN #1 | Licensed Practical Nurse | Named in smoking supervision deficiencies |
| NP #46 | Nurse Practitioner | Named in smoking supervision deficiencies |
| CNA #31 | Certified Nursing Assistant | Named in ADL care deficiencies for Resident #277 |
| LPN #30 | Licensed Practical Nurse Assistant Unit Manager | Named in ADL care deficiencies for Resident #277 |
| CNA #84 | Certified Nursing Assistant | Named in diet and adaptive equipment deficiencies for Resident #79 |
| Dietary Supervisor #94 | Dietary Supervisor | Named in diet and adaptive equipment deficiencies |
| COTA #93 | Certified Occupational Therapy Assistant | Named in diet and adaptive equipment deficiencies for Resident #79 |
| RA #98 | Resident Assistant | Named in diet deficiencies for Resident #90 |
| DT #99 | Dietary Technician | Named in diet deficiencies |
| Clinical Nutritional Manager #9 | Clinical Nutritional Manager | Named in diet deficiencies |
| SLP #39 | Speech Language Pathologist | Named in diet and adaptive equipment deficiencies for Resident #764 |
| Dietary Aide #91 | Dietary Aide | Named in diet deficiencies |
| Dietary Aide #92 | Dietary Aide | Named in diet deficiencies |
| Housekeeping Manager | Housekeeping Manager | Named in pest control deficiencies |
| Director of Plant Operations #112 | Director of Plant Operations | Named in pest control deficiencies |
| Director of Nursing | Director of Nursing | Named in abuse and smoking supervision deficiencies |
| Administrator | Administrator | Named in smoking supervision deficiencies |
Inspection Report
Annual Inspection
Census: 358
Deficiencies: 14
Date: Jul 28, 2023
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility had multiple deficiencies including failure to ensure residents' rights to dignified care, safe and clean environment, proper grievance handling, prevention of abuse, comprehensive care planning, adequate assistance with activities of daily living, provision of activities, supervision to prevent accidents, proper medication storage, nourishing diet provision, maintenance of equipment, and pest control.
Deficiencies (14)
Failure to honor residents' rights to dignified existence and personal care, including hygiene and appropriate clothing.
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple unclean areas, foul odors, and disrepair on several nursing units.
Failure to ensure residents' right to voice grievances with prompt investigation and resolution, specifically for a resident with missing personal belongings.
Failure to timely report suspected abuse and thoroughly investigate incidents of resident-to-resident physical altercations.
Failure to develop and implement comprehensive person-centered care plans addressing residents' needs, including frequent removal of wander alert devices and inconsistent documentation.
Failure to provide care and assistance to perform activities of daily living for residents unable to do so, including bathing, shaving, toileting, and application of barrier cream.
Failure to provide ongoing activities to meet residents' interests and needs, including lack of individualized programming and failure to provide adaptive equipment for activities.
Failure to ensure adequate supervision to prevent accidents, specifically related to residents smoking in the facility and elopement risk.
Failure to ensure feeding tubes are used appropriately with proper administration of tube feedings and notification of missed feedings to medical team.
Failure to ensure drugs and biologicals are stored and labeled in accordance with professional principles, including unclean medication room refrigerator and unlocked medication carts accessible to residents.
Failure to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, including missing food items, lack of adaptive equipment, and improper food temperatures.
Failure to keep all essential equipment working safely, including a malfunctioning steamer, clogged sink, and unmaintained equipment in the 7th floor kitchenette.
Failure to maintain an effective pest control program, with presence of fruit flies, cockroaches, mice, and bed bugs on multiple floors and resident units.
Failure to verify nurse aide certification before allowing work, with a CNA working with an expired certificate.
Report Facts
Census: 358
Tube feeding missed doses: 26
Weight loss percentage: 4.1
Number of smoking incidents documented: 15
Number of turkey breasts improperly cooled: 9
Temperature of pureed pork: 127
Number of medication carts unlocked: 2
Number of medication rooms with unclean refrigerator: 1
Number of residents with missing adaptive equipment: 2
Number of residents with missing food items on trays: 5
Number of pest sightings: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #10 | Certified Nursing Assistant | Named in findings related to Resident #410 hygiene and care |
| LPN #17 | Licensed Practical Nurse | Named in findings related to Resident #410 hygiene and tube feeding |
| RNS #22 | Registered Nurse Supervisor | Named in findings related to Resident #410 hygiene and care |
| SW #3 | Social Worker | Named in grievance and smoking investigations |
| RN Unit Manager/ADON #4 | Registered Nurse Unit Manager/Assistant Director of Nursing | Named in abuse investigation and smoking supervision |
| DON | Director of Nursing | Named in abuse investigation and smoking supervision |
| NP #21 | Nurse Practitioner | Named in tube feeding and smoking care |
| CNA #29 | Certified Nursing Assistant | Named for working with expired certification |
| Director of Dining Services #114 | Director of Dining Services | Named in food service temperature and kitchen maintenance |
| Corporate Dietary Consultant #109 | Corporate Dietary Consultant | Named in food service temperature and pest control |
| Regional Foodservice Director #123 | Regional Foodservice Director | Named in food service temperature and dishwashing |
| Dietary Supervisor #94 | Dietary Supervisor | Named in food service and kitchenette maintenance |
| Housekeeping Manager | Named in pest control program | |
| Director of Plant Operations #112 | Director of Plant Operations | Named in pest control and maintenance |
Inspection Report
Annual Inspection
Deficiencies: 18
Date: Jun 21, 2021
Visit Reason
The recertification survey was conducted to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified care, informed consent and communication, safe and clean environment, investigation of alleged violations, timely notification of transfers, care planning participation, maintenance of residents' abilities in activities of daily living, provision of necessary care for residents unable to perform ADLs, nutritional status maintenance, food palatability and temperature, infection prevention and control, equipment maintenance, and pest control.
Deficiencies (18)
Failed to ensure residents' right to a dignified existence for 4 of 7 residents reviewed, including inappropriate dressing and feeding practices and staff not adhering to cell phone policy.
Did not ensure residents were fully informed and understood their health status, including failure to provide translation services for a non-English speaking resident.
Did not maintain a safe, clean, comfortable, and homelike environment; multiple physical environment issues including damaged sinks, broken electrical outlets, cluttered resident rooms, and stained wheelchair cushions.
Did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment were thoroughly investigated and reported, specifically an injury of unknown origin was not fully investigated or reported.
Failed to send timely notice of resident facility-initiated discharges/transfers to the Office of the State Long-Term Care Ombudsman for 2 residents transferred to hospital.
Did not ensure participation of resident or representative in development of comprehensive care plan for 1 resident who expressed interest in attending care plan meeting.
Did not ensure residents were provided necessary care and services to maintain or improve ability to perform activities of daily living including dressing, eating, and bathing for 4 residents reviewed.
Did not ensure residents unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 residents reviewed.
Did not ensure a resident with pressure ulcers received necessary treatment and services, including provision of an ordered alternating air mattress.
Did not ensure the resident environment remained free of accident hazards; specifically, no plan to evacuate a bariatric resident in an emergency.
Did not provide a service by a person or agency outside the facility when the facility did not employ a qualified professional; specifically, missed scheduled appointment due to lack of transportation.
Did not label drugs and biologicals in accordance with professional standards and did not store expired medications properly; expired medications and vaccines found in medication carts, rooms, and refrigerators.
Did not ensure provision of food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 of 3 meals observed; food served cold or at improper temperatures and some food items overcooked or dry.
Did not conduct and document a facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies; specifically, did not include bariatric population needs.
Did not ensure the New York State Department of Health was notified of a loss of service; specifically, commercial dishwasher outage and water leak between resident rooms were not reported.
Did not establish and maintain an infection prevention and control program to prevent COVID-19 transmission; staff observed wearing masks improperly and drinking without masks near residents.
Did not maintain all mechanical, electrical, and patient care equipment in safe operating condition; main kitchen equipment and unit kitchenette coffee makers not working, and electrical supply issues in Unit 3 kitchenette.
Did not maintain an effective pest control program; cockroaches observed in main kitchen and Unit 3 and Unit 5 kitchenettes.
Report Facts
Weight loss: 11.2
Weight loss: 9
Weight loss: 4.2
Weight: 700
Pressure ulcer size: 2.2
Pressure ulcer size: 3
Pressure ulcer size: 3
Temperature: 108
Temperature: 110
Temperature: 56
Temperature: 107
Temperature: 99
Temperature: 59
Temperature: 61
Temperature: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical therapy aide #5 | Physical therapy aide | Stated residents should be dressed for physical therapy |
| Registered nurse Unit Manager #1 | Registered nurse Unit Manager | Stated residents should be dressed for physical therapy and urine bags covered |
| Certified nurse aide #7 | Certified nurse aide | Stated residents should be dressed prior to physical therapy and urine bags covered |
| Director of Nursing | Director of Nursing | Stated residents may wear gowns if preferred and urine bags should be covered |
| Certified nurse aide #54 | Certified nurse aide | Stated Resident #58 needed cues and supervision with eating |
| Occupational therapist #57 | Occupational therapist | Stated Resident #58 required staff assistance with meals |
| Registered nurse Unit Manager #34 | Registered nurse Unit Manager | Stated staff should not wear airpods and should be able to hear knocks |
| Certified nurse aide #92 | Certified nurse aide | Was observed wearing airpods while feeding Resident #165 |
| Social worker #73 | Social worker | Stated phone translation service was available but not used for Resident #297 |
| Physician #73 | Physician | Stated resident did not speak English and communicated via son |
| Maintenance Director | Maintenance Director | Stated physical environment issues were not known prior to survey |
| Housekeeping Director | Housekeeping Director | Stated Resident #243 refused deep cleaning of room |
| Assistant Director of Nursing | Assistant Director of Nursing | Documented Resident #250 fall and facial bruising |
| Director of Social Services | Director of Social Services | Stated Ombudsman was not notified of resident transfers |
| Certified nurse aide #4 | Certified nurse aide | Stated Resident #146 was not assisted timely with dressing |
| Licensed practical nurse #3 | Licensed practical nurse | Stated CNA was assisting another resident and not available to assist Resident #146 |
| Certified nurse aide #54 | Certified nurse aide | Stated Resident #58 required supervision and cueing with meals |
| Occupational therapist #57 | Occupational therapist | Stated Resident #58 required staff to cue and redirect for meals |
| Acting registered nurse Manager #1 | Acting registered nurse Manager | Stated Resident #84 required assistance with dressing and to be dressed for therapy |
| Certified nurse aide #7 | Certified nurse aide | Stated CNAs were to assist residents as much as needed |
| Temporary nurse aide #76 | Temporary nurse aide | Stated Resident #290 had beard and nails trimmed |
| Certified nurse aide #77 | Certified nurse aide | Stated Resident #290 refused assistance with toothbrushing |
| Registered nurse Manager #79 | Registered nurse Manager | Stated care included cleaning and trimming nails and shaving |
| LPN #36 | Licensed practical nurse | Observed expired medications and vaccines in medication storage |
| LPN #38 | Licensed practical nurse | Observed expired medication on medication cart |
| Food Service Director | Food Service Director | Stated food temperatures were not acceptable and food was overcooked or cold |
| Maintenance technician #48 | Maintenance technician | Described water leak incident from one resident room to another |
| Registered nurse Infection Preventionist | Registered nurse Infection Preventionist | Stated masks should be worn properly and staff should not drink near residents |
| Food service worker #39 | Food service worker | Observed mask below nose and described pest control issues |
| Director of Housekeeping | Director of Housekeeping | Stated pest control vendor treated facility weekly |
| Unit Clerk #70 | Unit Clerk | Responsible for scheduling transportation and appointments |
| Unit Clerk #71 | Unit Clerk | Responsible for scheduling transportation and appointments |
| RN Manager #69 | Registered nurse Manager | Stated transportation was not rescheduled when facility bus was down |
| Director of Operations | Director of Operations | Stated facility did not allow food deliveries for residents |
| Diet technician #24 | Diet technician | Stated residents could receive mail food packages but not food deliveries |
| RD #33 | Registered dietitian | Stated resident was a picky eater and needed PEG tube |
| RN Manager #34 | Registered nurse Manager | Stated resident was followed by psychology and PEG tube consult was pending |
| Administrator | Administrator | Stated dishwasher outage was not reported to NYSDOH |
| Maintenance Director | Maintenance Director | Described dishwasher outage and electrical issues in Unit 3 kitchenette |
| Food Service Director | Food Service Director | Described dishwasher outage and electrical issues in Unit 3 kitchenette |
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