Inspection Reports for Menorah Park of Central New York
4101 E Genesee St, Syracuse, NY 13214, United States, NY, 13214
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
14.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
184% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of practice related to foot care and treatment for residents, specifically focusing on podiatry care for residents with medical conditions such as diabetes and peripheral vascular disease.
Findings
The facility failed to ensure proper foot care and treatment for one of three residents reviewed, specifically Resident #3, who did not receive routine podiatry care for eight months despite recommendations. The facility lacked a documented policy on scheduling podiatry consults and responsibility for arranging appointments, resulting in delayed nail care and wound management.
Deficiencies (1)
Failure to provide appropriate foot care and treatment in accordance with professional standards, including lack of routine podiatry care for Resident #3 for eight months.
Report Facts
Residents affected: 3
Residents affected: 1
Months without podiatry care: 8
Ulcer size: 0.5
Podiatrist visit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #7 | Registered Nurse Manager | Provided information about podiatry scheduling process and facility practices |
| Wound Nurse Practitioner #9 | Wound Nurse Practitioner | Provided wound care and recommended podiatry visits; interviewed about resident care |
| Physician #10 | Physician | Provided vascular consult documenting wounds and need for podiatry follow-up |
| Chief Nursing Officer #3 | Chief Nursing Officer | Discussed lack of documented scheduling process and plans to update policy |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Renewal
Capacity: 60
Deficiencies: 12
Date: Apr 16, 2025
Visit Reason
12 violations related to resident services, personnel, environmental standards, medication management, admission and retention standards, and records and reports.
Findings
12 violations related to resident services, personnel, environmental standards, medication management, admission and retention standards, and records and reports.
Deficiencies (12)
402.5(c) — Requirements before submitting a request for a criminal history record check
487.7 (d) (1) (iv) — Resident services
487.7 (d) (8) — Resident services
487.7 (f) (8) — Resident services
487.9 (a) (3) — Personnel
487.9 (a) (8) — Personnel
487.9 (a) (15) — Personnel
487.11 (i) (1) — Environmental standards
1001.7 (k) (5) — Admission and retention standards
1001.10 (i) (5-8) — Resident services
1001.10 (l)(1) — Medication management
1001.12 (b) (1-7) — Records and reports
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Annual Inspection
Deficiencies: 16
Date: May 23, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements and investigate specific complaints and concerns.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, notification of significant changes to resident representatives, maintaining a safe and homelike environment, investigation of alleged violations, development and implementation of comprehensive care plans, assistance with activities of daily living, provision of meaningful activities, pressure ulcer care, bed rail assessments and consents, medication storage and labeling, infection prevention and control, food service safety, and call light accessibility.
Deficiencies (16)
Residents were not treated with respect and dignity; staff were observed speaking loudly about a resident's urinary device and using personal communication devices during work hours.
Resident's representative was not notified of significant changes in condition requiring treatment for wounds.
Facility did not ensure a safe, clean, comfortable, and homelike environment; issues included unclean wheelchairs, damaged flooring and countertops, sticky floors, and self-locking spa doors.
Facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for two residents.
Facility did not ensure development and implementation of a comprehensive person-centered care plan for a resident with an indwelling urinary catheter.
Residents who were unable to carry out activities of daily living did not receive necessary services to maintain grooming and personal hygiene.
Facility did not ensure ongoing provision of programs to support each resident in their choices of activities designed to meet their interests and well-being.
Residents at risk for pressure ulcers did not receive necessary treatment and services to prevent new ulcers and promote healing; incontinence care was not provided routinely as planned.
Residents were not assessed for risk of entrapment from bed rails prior to installation, risks and benefits were not reviewed with residents or representatives, and informed consent was not obtained.
Drugs and biologicals were not labeled and stored in accordance with professional principles; medication carts were left unlocked and unattended; alcoholic beverages were stored improperly.
Facility did not establish and maintain an infection prevention and control program; staff failed to use appropriate personal protective equipment and hand hygiene during care of residents on precautions.
Facility did not ensure planned menus were followed; residents did not receive menu items as planned per their individual meal tickets.
Facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards; issues included missing grease trap, stained ceiling tiles, holes with exposed wiring, disrepair of freezer floor, and expired or undated food.
Facility did not ensure food and drink were palatable, attractive, and at safe and appetizing temperatures; multiple food items served below palatable temperatures.
Resident call systems were not accessible to call for staff assistance; call lights were out of reach or residents were left alone without access to call lights.
Facility did not maintain an effective pest control program; evidence of drain flies and fruit flies on first and second floors.
Report Facts
Residents affected: 13
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 8
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 2
Nursing floors affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #36 | Certified Nurse Aide | Named in dignity and respect deficiency for speaking loudly about resident's urinary device |
| Registered Nurse Manager #14 | Registered Nurse Manager | Interviewed regarding dignity, cell phone use, and falls investigation |
| Licensed Practical Nurse Unit Manager #1 | Licensed Practical Nurse Unit Manager | Interviewed regarding cell phone use, falls investigation, and infection control |
| Certified Nurse Aide #32 | Certified Nurse Aide | Observed and interviewed regarding cell phone use and bed rail use |
| Licensed Practical Nurse Unit Manager #17 | Licensed Practical Nurse Unit Manager | Interviewed regarding falls investigation, infection control, and toileting |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding notification of family, infection control, and wound care |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding cleanliness, pest control, and bed rail installation |
| Certified Nurse Aide #7 | Certified Nurse Aide | Interviewed regarding cleanliness of wheelchairs and personal care |
| Licensed Practical Nurse #18 | Licensed Practical Nurse | Observed and interviewed regarding incontinence care and infection control |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed and interviewed regarding medication cart security |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Observed and interviewed regarding medication cart security and infection control |
| Certified Nurse Aide #10 | Certified Nurse Aide | Observed and interviewed regarding infection control |
| Certified Nurse Aide #11 | Certified Nurse Aide | Observed and interviewed regarding infection control |
| Certified Nurse Aide #13 | Certified Nurse Aide | Observed and interviewed regarding infection control |
| Licensed Practical Nurse Manager #26 | Licensed Practical Nurse Unit Manager | Interviewed regarding personal hygiene care |
| Certified Nurse Aide #22 | Certified Nurse Aide | Interviewed regarding falls reporting and toileting care |
| Nurse Practitioner #35 | Nurse Practitioner | Interviewed regarding falls investigation and wound care |
| Director of Therapy | Director of Therapy | Interviewed regarding bed enabler devices and safety |
| Registered Nurse Unit Manager #14 | Registered Nurse Unit Manager | Interviewed regarding bed enabler devices and falls |
| Certified Nurse Aide #33 | Certified Nurse Aide | Interviewed regarding bed enabler device incident |
| Director of Maintenance | Director of Maintenance | Interviewed regarding bed enabler device removal |
| Licensed Practical Nurse Manager #1 | Licensed Practical Nurse Unit Manager | Interviewed regarding infection control and contact precautions |
| Licensed Practical Nurse Manager #24 | Licensed Practical Nurse | Interviewed regarding medication room alcohol storage |
| Food Service Director | Food Service Director | Interviewed regarding food service safety and pest control |
| Certified Nurse Aide #12 | Certified Nurse Aide | Interviewed regarding call light accessibility and infection control |
| Certified Nurse Aide #27 | Certified Nurse Aide | Interviewed regarding resident left alone in shower room |
| Licensed Practical Nurse Unit Manager #6 | Licensed Practical Nurse Unit Manager | Interviewed regarding personal hygiene care |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: May 23, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements and investigate specific complaints and concerns.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, notification of resident representatives, safe and homelike environment, investigation of alleged violations, assistance with activities of daily living, pressure ulcer care, infection prevention and control, food service safety, and nurse staffing postings. Several residents were not provided adequate care or protections as required by regulations.
Deficiencies (11)
Staff did not ensure residents were treated with respect and dignity; staff used personal communication devices during working hours and spoke loudly about residents in public areas.
Resident's representative was not notified of significant changes in treatment, including new wounds requiring care.
Facility did not ensure a safe, clean, comfortable, and homelike environment; issues included unclean wheelchairs, damaged flooring and countertops, sticky floors, and self-locking spa doors.
Facility did not thoroughly investigate alleged violations involving abuse, neglect, or mistreatment for some residents with falls and injuries of unknown origin.
Residents who were unable to perform activities of daily living did not consistently receive necessary assistance with grooming, personal hygiene, and toileting.
Residents at risk for pressure ulcers did not consistently receive necessary treatment and services to prevent new ulcers and promote healing; incontinence care was not provided routinely as planned.
Facility did not post daily nurse staffing information including current resident census and actual hours worked by licensed and unlicensed nursing staff per shift.
Planned menus were not followed; residents did not receive menu items as indicated on their individual meal tickets.
Food was not served at palatable and safe temperatures for lunch meals observed; hot foods were below recommended temperatures and cold foods were above recommended temperatures.
Food was not stored, prepared, distributed, and served in accordance with professional standards; issues included missing grease trap in kitchen hood, stained ceiling tiles, hole with exposed wiring in kitchen wall, disrepair of freezer floor, and expired and undated food in main kitchen and unit kitchenette.
Infection prevention and control program was not effectively implemented; staff failed to wear required personal protective equipment and perform hand hygiene when providing care to residents on contact or enhanced barrier precautions; urinary catheter drainage bag was lying on the floor without a barrier.
Report Facts
Residents affected: 13
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 1
Days: 4
Residents affected: 2
Meals: 2
Staff: 8
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #36 | Observed speaking loudly about resident's urinary drainage device | |
| Registered Nurse Manager #14 | Interviewed about staff use of cell phones and resident dignity | |
| Licensed Practical Nurse Unit Manager #1 | Interviewed about cell phone policy and resident privacy | |
| Certified Nurse Aide #32 | Observed using personal cell phone in resident care area | |
| Licensed Practical Nurse Unit Manager #17 | Interviewed about family notification of resident condition changes | |
| Assistant Director of Nursing | Interviewed about family notification and wound care | |
| Licensed Practical Nurse Unit Manager #6 | Interviewed about wheelchair cleaning responsibilities | |
| Certified Nurse Aide #7 | Interviewed about wheelchair cleaning and resident care | |
| Director of Environmental Services | Interviewed about environmental maintenance and safety | |
| Registered Nurse #30 | Documented resident fall and follow-up care | |
| Nurse Practitioner #35 | Provided medical care and follow-up for resident with fall and fractured rib | |
| Licensed Practical Nurse #41 | Documented resident fall and care | |
| Certified Nurse Aide #22 | Interviewed about fall reporting and toileting care | |
| Licensed Practical Nurse #18 | Observed and interviewed regarding wound care and infection control | |
| Certified Nurse Aide #20 | Observed providing incontinence care without proper infection control | |
| Certified Nurse Aide #21 | Observed providing incontinence care without proper infection control | |
| Licensed Practical Nurse #8 | Observed not wearing gloves or hand hygiene during medication administration | |
| Certified Nurse Aide #10 | Observed not wearing personal protective equipment for resident on contact precautions | |
| Certified Nurse Aide #11 | Observed not wearing personal protective equipment for resident on contact precautions | |
| Certified Nurse Aide #13 | Observed not wearing personal protective equipment for resident on contact precautions | |
| Licensed Practical Nurse Unit Manager #26 | Interviewed about resident shower schedule and personal hygiene | |
| Food Service Director | Interviewed about food service and kitchen conditions | |
| Housekeeper #5 | Interviewed about floor cleaning and maintenance | |
| Certified Nurse Aide #12 | Interviewed about infection control precautions |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 9, 2024
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Follow-Up
Capacity: 60
Deficiencies: 0
Date: Mar 7, 2024
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 8, 2024
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Renewal
Capacity: 60
Deficiencies: 2
Date: Oct 24, 2023
Visit Reason
Two violations related to environmental standards and resident services.
Findings
Two violations related to environmental standards and resident services.
Deficiencies (2)
487.11 (k) (1-3) — Environmental standards
1001.10 (i) (5-8) — Resident services
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect and failure to provide necessary care to Resident #4, who was found on the floor for approximately two and a half hours without assessment and subsequently expired.
Complaint Details
The complaint investigation revealed that Resident #4 fell from a partition and remained on the floor for approximately two and a half hours while multiple staff members walked by without providing assistance or notifying a registered nurse. The resident was assisted into a wheelchair without assessment and expired shortly thereafter. The facility failed to report the incident and did not conduct a thorough investigation. Additional concerns included failure to administer medications as ordered, failure to notify providers of critical blood glucose levels, and failure to respond appropriately to seizure activity.
Findings
The facility failed to protect Resident #4 from neglect when staff walked by the resident on the floor without providing assistance or notifying a registered nurse. The resident fell from a partition, remained on the floor for hours, and was assisted into a wheelchair without proper assessment. The facility also failed to report the incident as required. Additionally, the facility did not ensure appropriate treatment and care according to medical orders, including medication administration and seizure management.
Deficiencies (4)
Failure to protect resident from neglect when staff did not attend to resident on floor for approximately two and a half hours and failed to notify registered nurse for assessment.
Failure to thoroughly investigate allegations of neglect and abuse, including incomplete review of video surveillance and failure to identify neglect and discrepancies in staff statements.
Failure to provide treatment and care according to medical orders, including administration of antipsychotic medication (Seroquel) in excess of ordered doses, failure to notify provider of low blood glucose, and failure to administer seizure medication or call 911 during prolonged seizure.
Failure of facility administration to ensure residents were free from neglect, complete thorough investigations, remove staff from resident access during investigations, and report neglect to state authorities.
Report Facts
Duration resident remained on floor: 2.5
Height of partition resident fell from: 27
One-time dose of Seroquel administered in addition to routine dose: 6
Blood glucose reading: 64
Seizure duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Notified of resident on floor but did not assess or notify RN; administered medications incorrectly; failed to call RN or 911 during seizure. |
| RNS #4 | Registered Nurse Supervisor | Arrived several minutes after resident was assisted off floor and pronounced resident deceased. |
| CNA #1 | Certified Nurse Aide | Reported resident on floor and notified LPN #5; statement discrepancies noted compared to video. |
| Resident Helper #27 | Resident Helper | Assisted resident off floor without RN assessment; not authorized to transfer residents. |
| DON | Director of Nursing | Completed investigation but did not review entire video; unaware of resident helper assisting resident off floor; did not report neglect. |
| NP #3 | Nurse Practitioner | Notified of resident death; reviewed video and expressed concern about delay in assistance; ordered seizure and hypoglycemia protocols. |
| LPN #8 | Licensed Practical Nurse | Witnessed seizures; unaware of rectal diazepam order and failure to call 911. |
| LPN #13 | Licensed Practical Nurse | Documented low blood glucose but did not notify medical provider. |
| CEO | Chief Executive Officer | Had access to video; did not have hands-on role in investigation; relied on others for review and reporting. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Mar 8, 2022
Visit Reason
The inspection was a recertification survey conducted from 3/1/22 to 3/8/22 to assess compliance with federal and state regulations for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to post survey results, unsafe and unclean environment, improper use of restraints, incomplete care planning, inadequate assistance with activities of daily living, improper pressure ulcer care, failure to maintain nutritional status, unsafe food service practices, inadequate infection control practices, and failure to ensure staff COVID-19 vaccination compliance.
Deficiencies (10)
Failed to post survey results and plan of correction from the most recent Life Safety Code Federal survey conducted on 9/11/19.
Failed to ensure residents had a safe, clean, comfortable, and homelike environment including unclean rolling window shades, torn fall mat, damaged ceiling and walls, and unclean wheelchairs and scoot chairs.
Failed to ensure least restrictive use of physical restraints and ongoing re-evaluation for Resident #48 with an alarming wheelchair seat belt.
Failed to ensure participation of Resident #50 in comprehensive care plan meetings.
Failed to provide timely toileting assistance and care planning for residents #100 and #253, resulting in undignified care and unmet behavioral needs.
Failed to provide appropriate pressure ulcer care for Resident #79, resulting in a deep tissue injury progressing to a Stage IV pressure ulcer with actual harm.
Failed to maintain acceptable nutritional status for Resident #97 with significant weight loss, inconsistent weekly weights, and delayed nutritional interventions.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including damaged sinks, unclean floors, soiled equipment, improperly stored food scoops, missing ceiling tiles, and uneven floor surfaces.
Failed to establish and maintain an infection prevention and control program including staff wearing masks inappropriately or masks of unsuitable materials.
Failed to ensure all staff, including contract security guards, were fully vaccinated for COVID-19 and maintain documentation or contingency plans for non-vaccinated employees.
Report Facts
Weight loss percentage: 18.6
Pressure ulcer size: 4
Pressure ulcer size: 4.5
Weight loss percentage: 15
Weight loss percentage: 10.25
Weight loss percentage: 9.23
Weight loss percentage: 4.85
Weight loss percentage: 4.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Unit Manager #21 | Registered Nurse Unit Manager | Observed wearing mask below nose and named in infection control deficiency |
| CNA #17 | Certified Nurse Aide | Named in toileting assistance deficiency for Resident #100 |
| CNA #18 | Certified Nurse Aide | Named in toileting assistance deficiency for Resident #100 |
| CNA #19 | Certified Nurse Aide | Named in toileting assistance deficiency for Resident #100 |
| RN #3 | Registered Nurse | Named in restraint use deficiency for Resident #48 |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Named in restraint use deficiency for Resident #48 and toileting behavior deficiency for Resident #253 |
| Support RN #3 | Support Registered Nurse | Named in restraint use deficiency for Resident #48 and toileting behavior deficiency for Resident #253 |
| CNA #5 | Certified Nurse Aide | Named in toileting behavior deficiency for Resident #253 and pressure ulcer care |
| CNA #14 | Certified Nurse Aide | Named in toileting behavior deficiency for Resident #253 |
| LPN #15 | Licensed Practical Nurse | Named in toileting behavior deficiency for Resident #253 |
| RN Supervisor #9 | Registered Nurse Supervisor | Named in pressure ulcer care deficiency |
| LPN #6 | Licensed Practical Nurse | Named in pressure ulcer care deficiency |
| Wound RN #7 | Wound Registered Nurse | Named in pressure ulcer care deficiency |
| RD #25 | Registered Dietitian | Named in nutritional status deficiency |
| Food Service Director | Named in food service safety deficiency | |
| Maintenance Director | Named in food service safety deficiency | |
| Maintenance worker #22 | Named in food service safety deficiency | |
| Receptionist #31 | Named in infection control deficiency for improper mask use | |
| Security guard #27 | Named in infection control and COVID-19 vaccination deficiencies | |
| Activity aide #30 | Named in infection control deficiency for improper mask use | |
| Director of Nursing | DON | Named in pressure ulcer care deficiency |
| Director of Rehabilitation | Named in restraint use deficiency | |
| Director of Social Services | Named in care plan participation deficiency | |
| Administrator | Named in COVID-19 vaccination deficiency | |
| Physician #32 | Named in pressure ulcer care deficiency | |
| Physician Assistant | PA | Named in pressure ulcer care deficiency |
| RN Unit Manager #2 | Registered Nurse Unit Manager | Named in pressure ulcer care deficiency |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 1, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
487.10 (e) (2) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 21, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 14, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 7, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 30, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Aug 16, 2021
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 29, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Jun 30, 2021
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Renewal
Capacity: 60
Deficiencies: 7
Date: Jun 9, 2021
Visit Reason
Seven violations related to resident services, personnel, environmental standards, medication management, and records and reports.
Findings
Seven violations related to resident services, personnel, environmental standards, medication management, and records and reports.
Deficiencies (7)
487.7 (f) (1-4) — Resident services
487.9 (a) (15) — Personnel
487.11 (f) (19) — Environmental standards
487.11 (k) (1-3) — Environmental standards
1001.10 (i) (5-8) — Resident services
1001.10 (l)(1) — Medication management
1001.11 (c) (2) (i-iv) — Personnel
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Sep 11, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements and investigate specific complaints and concerns related to resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, medication self-administration assessments, personal funds management, cleanliness and maintenance of the environment, investigation of alleged abuse and neglect, development and implementation of person-centered care plans, provision of activities of daily living assistance, hearing aid provision, food safety and temperature control, infection prevention and control, and pest control.
Deficiencies (16)
Resident #122 was not served his meal timely after his tablemates had been served, violating resident dignity.
Resident #25 was observed with medicated cream without physician order or interdisciplinary team determination for self-administration.
Resident #14 did not receive quarterly personal account statements as requested, violating personal funds management policies.
Facility did not maintain a clean and home-like environment; sticky floors and unclean walls were observed on multiple units.
Facility failed to thoroughly investigate allegations of abuse, neglect, or mistreatment for residents with falls, lacking witness statements and complete investigations.
Residents #25 and #107 did not have person-centered comprehensive care plans addressing mental and psychosocial needs and behaviors.
Resident #14 was not involved in developing or making decisions about her care plan; no documentation of invitation or attendance at care plan meetings.
Resident #52 was not provided timely personal hygiene and toileting assistance; was observed in soiled brief during meal.
Resident #22 was not provided bilateral hearing aids as care planned; Resident #107 requested hearing aids but audiology consult was not initiated.
Resident #106 with limited range of motion was observed without recommended rolled wash cloth in contracted hand.
Resident #29 was not provided necessary behavioral health care and services; lacked psychological counseling and individualized care plan for mood and behavioral symptoms.
Facility failed to maintain food at safe and appetizing temperatures during meals; multiple food items served below required temperatures.
Facility did not store, prepare, distribute and serve food in accordance with professional standards; spoiled food found in walk-in cooler and soiled pots and pans on clean drying rack.
Facility did not ensure services were provided in compliance with applicable laws for advance directives; MOLST forms completed by health care proxy without required determination of incapacity by physician or nurse practitioner.
Improper infection control technique observed during pressure ulcer treatment; no PPE available in laundry wash area; washers and dryers not maintained per manufacturer's guidelines.
Facility did not maintain an effective pest control program; small flies observed on multiple units and in main kitchen.
Report Facts
Deficiencies cited: 16
Fall bruise size: 10
Fall bruise size: 10
Food temperature: 47
Food temperature: 121
Food temperature: 99
Food temperature: 59.9
Food temperature: 58.3
Food temperature: 107
Food temperature: 111
Drink temperature: 65.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding meal service delay and resident dignity |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding meal service delay and resident dignity |
| RN Unit Manager #3 | Registered Nurse Unit Manager | Interviewed regarding meal service delay and resident dignity |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding medication self-administration and hearing aids |
| CNA #6 | Certified Nurse Aide | Observed assisting resident and interviewed regarding meal service |
| Receptionist #23 | Receptionist | Interviewed regarding personal funds statements |
| Comptroller #24 | Comptroller | Interviewed regarding personal funds statements |
| RN Unit Manager #8 | Registered Nurse Unit Manager | Interviewed regarding abuse investigations and behavioral health care |
| CNA #26 | Certified Nurse Aide | Interviewed regarding abuse investigations and behavioral health care |
| LPN #25 | Licensed Practical Nurse | Interviewed regarding abuse investigations and behavioral health care |
| CNA #20 | Certified Nurse Aide | Mentioned in fall investigation for Resident #99 |
| RNS #15 | Registered Nurse Supervisor | Interviewed regarding fall investigations |
| CNA #33 | Certified Nurse Aide | Interviewed regarding fall investigations |
| LPN #17 | Licensed Practical Nurse | Interviewed regarding fall investigations |
| RN Supervisor #18 | Registered Nurse Supervisor | Interviewed regarding fall investigations |
| RN #8 | Registered Nurse | Interviewed regarding behavioral health care |
| Social Worker #34 | Social Worker | Interviewed regarding behavioral health care |
| Nurse Practitioner #36 | Nurse Practitioner | Interviewed regarding behavioral health care |
| Family Services Counselor #39 | Family Services Counselor | Interviewed regarding behavioral health care |
| Food Service Supervisor #5 | Food Service Supervisor | Interviewed regarding food temperature and food service |
| Dietary Aide #4 | Dietary Aide | Interviewed regarding food service and drink temperature |
| RN Unit Manager #12 | Registered Nurse Unit Manager | Interviewed regarding infection control and advance directives |
| Director of Social Services #13 | Director of Social Services | Interviewed regarding advance directives |
| LPN #22 | Licensed Practical Nurse | Observed and interviewed regarding wound care infection control |
| Infection Control RN #40 | Infection Control Registered Nurse | Interviewed regarding wound care infection control |
| Director of Facilities | Director of Facilities | Interviewed regarding laundry PPE and pest control |
| Laundry Room Worker #41 | Laundry Room Worker | Interviewed regarding laundry PPE |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding laundry PPE and pest control |
| Operations Manager | Operations Manager | Interviewed regarding pest control |
| Food Service Worker #29 | Food Service Worker | Interviewed regarding pest control |
| Food Service Worker #28 | Food Service Worker | Interviewed regarding pest control |
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