Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alice Hyde Medical Center during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse by not adequately updating and implementing behavior care plans and 15‑minute safety checks for residents with known sexually inappropriate and aggressive behaviors. One resident with dementia and Parkinson’s disease had a long history of sexually inappropriate comments, gestures, and physical contact toward staff and intrusive wandering into others’ rooms, yet their care plan was not consistently revised to add interventions to reduce these behaviors or protect others. This resident was later found in bed with another cognitively impaired resident, partially undressed, while the other resident was crying and unable to explain what happened. In a separate case, a resident with Alzheimer’s disease and documented wandering and physically and verbally abusive behaviors was placed on 15‑minute checks after multiple altercations, but staff did not perform or document these checks during a meal period and later found the resident wandering into another resident’s room, demonstrating a failure to carry out required monitoring.
A resident with Parkinson’s disease, dementia, and known behavioral issues was sent to a hospital after being found in another resident’s room and had a care plan including 1:1 interventions and 15‑minute checks. After the transfer, the MD and SW informed the family that the facility could no longer meet the resident’s needs and would discharge the resident, directing the family to the hospital SW for alternative placement and discussing packing belongings and benefit redirection. The DON stated the resident required a locked unit due to exit‑seeking, that 15‑minute checks had failed, and that the facility chose not to readmit the resident while its investigation was ongoing. The family reported they were told the resident would not be accepted back, were not met with regarding discharge, and were not given alternative placement options, and the resident was instead sent to another hospital unit used to hold behaviorally complex residents while awaiting nursing home placement.
Three residents with cognitive and physical impairments experienced falls after staff failed to follow care plans, including not providing scheduled toileting, not using required two-person transfers, and not activating a bed alarm. These lapses in care led directly to resident injuries.
A facility failed to develop and implement complete person-centered care plans for two residents with significant cognitive impairment and behavioral or safety needs. One resident’s activities plan did not include documented diversional interventions for wandering or evidence that planned one-to-one visits were provided, while another resident’s restraint plan did not include the use of a lap belt or instructions for managing it, despite staff stating the belt was released every 2 hours and during care and meals.
Activities program deficiencies were cited for three residents with significant cognitive impairment and dementia-related diagnoses. Residents were observed sitting or pacing alone while scheduled unit activities were not occurring, and there was no documented evidence of activities provided in the EMR. Care plans referenced one-to-one visits, music, outdoor visits, and other individualized supports, but staff reported low staffing, reliance on volunteers, and limited one-to-one activity time.
A nurse administered seven medications to a resident that were prescribed for another individual, failing to verify the resident's identity and not following the required medication administration protocols. The resident, who had dementia and severe cognitive impairment but could usually state their name, received the wrong medications due to the nurse's failure to perform the five rights of medication administration.
A resident with dementia, heart failure, anxiety, and moderate cognitive impairment was observed multiple times in a wheelchair with a lap belt/seat belt in place, and staff were unable to confirm the resident could self-release it. The chart lacked a physician order for the belt and did not show quarterly reassessment or interdisciplinary documentation for its continued use, despite prior PT documentation that it had been intended as a self-releasing seat belt.
A resident with severe cognitive impairment and Alzheimer's was left unattended and fell, despite requiring staff assistance for ambulation. The incident was not reported to the Department of Health until the following day, violating facility policy and state regulations.
The facility failed to implement comprehensive care plans for five residents, resulting in unwitnessed falls and minor injuries due to missed 15-minute safety checks, improper bed positioning, and missing bed alarms.
A resident with multiple diagnoses was found on the floor with the bed not in a low position, the call light not within reach, and without socks on. The CNA responsible did not follow the care plan, which included a low bed and appropriate footwear. The CNA received education on following care plans after the incident.
Failure to Protect Residents From Sexual Abuse and to Implement 15-Minute Safety Checks
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically sexual abuse and resident-to-resident aggression, and to implement and follow behavior care plans and safety interventions such as 15‑minute checks. One resident with Alzheimer’s disease, paralysis on one side, and aphasia had a care plan noting combative and resistant behaviors, weepiness, and attempts to self‑transfer, with goals that they would not be a victim or aggressor and interventions to monitor behaviors and escalations. Another resident with Parkinson’s disease, dementia with anxiety, and heart disease had a behavior care plan documenting a tendency to be sexually inappropriate, to wander, and to stay awake at night. The care plan for this resident initially focused on inviting them to activities, assessing for behaviors, and monitoring cognitive status, and was later updated to include diversion, 1:1 supervision, television, and 15‑minute checks. Despite this, between two specified dates there were 26 nursing notes documenting this resident’s sexually inappropriate comments, gestures, propositions, and physical contact with staff, including grabbing a staff member’s breast, without corresponding updates to the behavior care plan to add interventions to reduce sexually inappropriate behaviors or to protect other residents and staff. Physician notes over time documented that the sexually inappropriate behaviors continued daily, with staff reporting increased sexually inappropriate comments and attempts at touching staff. The notes described multiple medication adjustments in response to ongoing sexual disinhibition, agitation, anxiety, hallucinations, and mood swings, and family concerns about the resident’s behavior. A prior incident was documented in which this resident was found in another resident’s room, in their wheelchair next to the sleeping resident’s bed, appearing to watch them sleep, and insisting that the sleeping resident was their spouse. Subsequent nursing documentation described the resident intrusively wandering into other rooms, stating other residents were their spouse, asking staff if they were married, and being difficult to redirect. Staff interviews indicated that 15‑minute checks were used for behaviors and resident‑to‑resident altercations, that all nursing staff were responsible for performing these checks, and that there was little or no specific training on managing sexually inappropriate resident behaviors beyond general dementia training and diversion tactics. The deficiency culminated in an incident where the cognitively impaired resident with Alzheimer’s disease was found in their room with the sexually disinhibited resident. A family member entered the room and found the second resident lying on their side in the first resident’s bed with their pants and brief pulled down to their knees, while the first resident was in a t‑shirt and intact brief, with their left breast exposed according to witness statements. The first resident was crying and shaking and unable to communicate what had happened due to dementia. Facility documentation and hospital records indicated no penetration and no immediate physical injury, though later notes described small bruises on the resident’s leg and thigh of uncertain origin. Observation sheets showed that the sexually disinhibited resident was documented as being in their own room on 15‑minute checks during the time of the incident, despite being found in another resident’s bed. Interviews with the DON and other staff acknowledged that 15‑minute checks had failed to prevent the resident from entering other residents’ rooms and that staff were not able to keep residents safe under the existing interventions. A separate but related deficiency involved another resident with Alzheimer’s disease, major depressive disorder, and severe cognitive impairment, who had a behavior care plan documenting wandering, verbally and physically abusive behavior, intrusive wandering, exit‑seeking, and aggressive behaviors such as kicking, hitting, abusive language, threatening behavior, resisting care, and striking or shoving other residents. The care plan included diversion activities and repeated use of 15‑minute checks after multiple incidents, including unsafe wandering, striking a resident on the head, shoving a resident to the floor, kicking a resident, and hitting a resident in the chest and face. On one date, a care plan note documented that this resident was agitated, pushed a staff member, could not be redirected or calmed, and was given intramuscular Haldol and placed on 15‑minute checks. However, on a later date, surveyor observations and record review showed that although the resident was listed on the unit 15‑minute check list, the check sheets were not signed from 11:45 a.m. through 12:30 p.m., and staff reported they were assisting with lunch and did not complete or document the checks during that period. During that same timeframe, the resident with aggressive behaviors was observed in their room watching television, and later was found wandering into another resident’s room and had to be redirected back to their own room. An LPN subsequently signed all residents’ 15‑minute check sheets while speaking with the surveyor and stated they documented that the aggressive resident was wandering for all the missing time slots based on finding them in another resident’s room at 1:04 p.m. Staff interviews revealed confusion about why this resident was on 15‑minute checks, with one RN stating there was no note explaining the reason and that staff had the checks stopped when they could not determine the rationale. The DON stated that 15‑minute checks were typically used for 72 hours and then reassessed, and that the need for checks should be reflected in the care plan, care cards, electronic notes, and shift‑to‑shift communication, with all staff responsible for performing and documenting the checks. The failure to consistently implement and document the ordered 15‑minute checks for this resident with a history of aggressive and abusive behaviors placed other residents at risk for abuse.
Failure to Allow Hospitalized Resident to Return and Inadequate Discharge Process
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident, who had been transferred to a hospital, to return to their previous room or to the facility upon bed availability, contrary to the facility’s transfer and discharge rights policy and regulatory requirements. The resident had diagnoses including Parkinson’s disease with dyskinesia, unspecified dementia with anxiety, and atherosclerotic heart disease, and was assessed as significantly cognitively impaired but usually able to understand others and make themselves understood. The resident’s comprehensive care plan included a behavior focus with interventions such as diversion, redirection, 1:1 supervision, television, and 15‑minute checks. According to progress notes, the resident was transported to a hospital after being found in another resident’s room. The Medical Director documented that, although they had previously told the family that the facility could manage the resident’s behaviors, the events leading to the hospital transfer changed the situation, and the facility informed the family that they could not meet the resident’s needs for discharge back from the hospital. The Social Worker documented informing the family that the facility would need to discharge the resident because it was unable to meet the resident’s needs at that time, and directed the family to the hospital social worker/discharge planner for assistance with alternative placement. The Social Worker also discussed packing the resident’s belongings and provided contact information for the facility biller when the family inquired about redirecting the resident’s benefits. In interviews, the DON stated that after the resident was found in another resident’s room, the resident was placed on consistent 15‑minute checks and that the resident had to be on a locked unit due to known exit‑seeking behaviors. The DON further stated the facility chose not to take the resident back when they were cleared for discharge because the facility had not concluded its investigation and believed it could not continue 1:1 supervision after 15‑minute checks had failed. The family member reported being told by the emergency room physician, based on information from the facility, that the resident would not be welcomed back, and stated that facility staff never met with them regarding discharge, did not provide options for alternative placements, and that the resident was instead sent to another hospital unit designed to hold residents with behaviors while awaiting nursing home placement. The Administrator confirmed that this other hospital unit was used for residents who were hard to place, usually due to behaviors.
Failure to Follow Care Plans Results in Resident Falls Due to Neglect
Penalty
Summary
Three residents experienced neglect due to staff failing to follow established care plans and facility policies. One resident with severe cognitive impairment and a history of dementia was not offered toileting opportunities every two hours as required by their care plan. Documentation showed that the resident was only offered toileting once per shift, and there was no evidence of two-hourly toileting prior to the incident. This failure led to the resident attempting to toilet themselves, resulting in a fall and bruising. Another resident, also with severe cognitive impairment and multiple diagnoses including vascular dementia and Alzheimer's disease, required two-person assistance for transfers according to their care plan. Despite this, a Certified Nurse Aide attempted to transfer the resident alone, which resulted in the resident being lowered to the floor due to non-compliance with directions and improper body mechanics. The care plan specifically indicated the need for two-person assistance with a mechanical lift, which was not followed. A third resident, diagnosed with Parkinson's disease and dementia, was at high risk for falls and required a bed alarm as part of their fall prevention interventions. After being put back to bed by staff, the bed alarm was not activated as required by the care plan. The resident was subsequently found on the floor next to their bed, and documentation confirmed that the bed alarm was not in place at the time of the fall. In all three cases, the failure to adhere to individualized care plans directly contributed to resident falls.
Incomplete Person-Centered Care Plans for Activities and Restraint Use
Penalty
Summary
The facility did not develop and implement a comprehensive person-centered care plan for residents with identified medical, nursing, mental, and psychosocial needs. The deficiency involved two residents out of 24 reviewed. The facility’s policy stated that care plans were to be person-centered, based on individual treatment plans, and monitored and updated quarterly and with changes in status, with problems, goals, and interventions documented. One resident was admitted with unspecified dementia, generalized anxiety disorder, and major depressive disorder. The resident’s MDS documented significant cognitive impairment and wandering behavior that intruded on the privacy or activities of others. The Activities care plan documented limited participation related to mood and confusion and stated the resident participated in music, one-to-one visits, and outdoor visits, along with family visits and trips. However, the care plan did not include documented person-centered diversional activities or interventions to address undesirable behaviors, and there was no documented evidence that one-to-one visits were provided as planned. During observations, the resident was sitting in a wheelchair in the hallway, and staff interviews stated one-to-one visits were not consistently provided because of low staffing. Another resident was admitted with dementia, ventricular tachycardia, and anxiety. The resident’s MDS documented severe cognitive impairment and daily use of a trunk restraint when in a chair or out of bed. The restraint care plan addressed safety and least restrictive device use, but it did not include the resident’s lap belt or instructions for managing it. The resident was observed in a wheelchair with a lap belt in place on two occasions, and a CNA stated lap belts were released every two hours and at mealtimes. Nursing and rehabilitation staff stated lap belts should be released every two hours and with transfers, toileting, and meals, and that therapy recommendations were communicated verbally, but the resident’s care plan did not reflect the lap belt use.
Activities Program Did Not Meet Residents’ Needs
Penalty
Summary
The facility did not ensure an ongoing activities program that supported residents’ choices and met their interests and cognitive abilities for three residents reviewed. The cited policy stated the facility would provide opportunities for residents to use their mental and physical capabilities through recreational, social, or other meaningful activities, and that cognitively impaired residents would have structured therapeutic recreational activities based on individual assessments. However, the survey found no documented evidence that activities were actually provided for the three residents in the electronic medical record. Resident #17 had diagnoses including unspecified dementia with agitation, Alzheimer’s disease with early onset, and hypertensive chronic kidney disease. The MDS documented severe cognitive impairment, and during observations the resident was seen ambulating alone or sitting alone in a common area, was unresponsive to communication attempts, and was pacing the hall while the unit activity listed noodle ball but no activity was observed. The care plan stated the resident would accept one-to-one visits and observe unit activities, with interventions such as lower-level activities, one-to-one visits, monthly calendars, and stimulation with radio or television, but there was no documented evidence of activities being done with the resident. Resident #79 had diagnoses including unspecified dementia, Alzheimer’s disease with late onset, and a left femur neck fracture. The MDS documented the resident was rarely or never understood and severely cognitively impaired. The resident was observed sitting in a wheelchair in the common area, unresponsive to communication attempts, and at the time of the scheduled unit activity no activity was observed; the resident was sitting, mumbling to themselves, and picking at a lap blanket. Resident #81 had diagnoses including unspecified dementia with agitation, generalized anxiety disorder, and major depressive disorder, and the MDS documented significant cognitive impairment. The resident was observed sitting in a wheelchair in the hallway, and the care plan documented limited participation with music, one-to-one visits, outdoor visits, family visits, and trips with family, but there was no documented evidence of activities being done with the resident. Staff interviews stated one-to-one visits were limited by staffing, residents needed more stimulation, and the activity department relied heavily on volunteers and budget constraints limited hiring.
Significant Medication Error Due to Failure in Resident Identification
Penalty
Summary
A deficiency occurred when a nurse administered seven medications to a resident that were actually prescribed for another individual. The facility's medication administration policy required nurses to verify the resident's identity, check the drug label multiple times, and ensure the five rights of medication administration, including right resident, right drug, right dose, right route, and right time. Despite these protocols, the nurse failed to verify the correct resident and did not administer the medications at the ordered time, resulting in the resident receiving medications not intended for them. The resident involved had diagnoses of dementia, hyperlipidemia, and anxiety, with severe cognitive impairment documented. However, the resident was generally able to state their name when asked, and staff confirmed that the resident could usually identify themselves. The error was discovered after the nurse realized the mistake and reported it. Interviews with staff confirmed that the nurse did not follow the required procedures for resident identification and medication administration. The facility's investigation found that the nurse did not practice safe medication administration and failed to perform the five rights. The incident was considered a significant medication error, and the nurse responsible was terminated. The event was documented through interviews, record reviews, and direct observation of the resident, who appeared alert and engaged following the incident.
Unordered wheelchair lap belt used without documented reassessment
Penalty
Summary
The facility did not ensure that a resident was free from a physical restraint that was not supported by a physician order or documented ongoing reassessment. Resident #82, who had diagnoses including unspecified dementia with mood disturbance, hypertensive heart disease with heart failure, and anxiety disorder, was assessed as having moderate cognitive impairment and required a wheelchair for locomotion, with dependence on staff for transfers, toileting, and bathing. The resident’s care plan included fall-related interventions and noted a self-releasing seat belt in the wheelchair, but the record also reflected a restraint care plan entry related to a low bed and lack of safety awareness. During multiple observations, Resident #82 was seen in a wheelchair with a lap belt/seat belt in place. On one observation, a CNA asked the resident to release the belt and the resident was unable to do so. On another observation, an RN asked the resident to release the seat belt and the resident again was unable to do so, after which the RN removed it. CNA documentation for November and December 2025 recorded wheelchair restraint/lap belt use while the resident was out of bed, and treatment records for December 2025 also reflected the belt’s use. The record did not contain a physician order for seat belt use. The resident’s chart also lacked evidence of quarterly assessment or evaluation of the continued need for the belt as a restraint, and there was no documented evidence of interdisciplinary team discussion about its continued use. A prior PT note documented that the resident had been care planned for a self-releasing seat belt and was able to self-release, so the belt was not considered a restraint at that time. However, facility staff interviews stated that if a resident could not self-release, a physician order, consent, care plan update, and quarterly re-evaluation would be needed. Staff also stated lap belts should be released every two hours and that residents using them should be able to self-release if the belt was not to be considered a restraint.
Failure to Report Resident Fall and Injury Timely
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source, were immediately reported to the State Agency. Specifically, a resident with severe cognitive impairment, Alzheimer's disease, unspecified dementia with behavioral disturbance, and type 2 diabetes was left unattended and fell while ambulating, despite their care plan requiring staff assistance for transfers and ambulation. The incident occurred on 2/29/2024, but was not reported to the Department of Health until 3/01/2024. The facility's policies required that Safe Events Reports be completed and referred to the appropriate personnel and reviewed with the Interdisciplinary Team. However, the Registered Nurse on duty was unaware that the Certified Nurse Aide had violated the care plan by allowing the resident to ambulate independently. The Certified Nurse Aide was also unaware of the resident's care plan requirements. This lack of awareness and failure to report the incident promptly led to the deficiency identified during the survey.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility did not ensure the implementation of a comprehensive person-centered care plan for five residents. Specifically, for three residents, 15-minute safety checks were not completed as required by their care plans. One resident was found after an unwitnessed fall with no documentation of 15-minute checks being done from 2:00 AM to 6:00 AM. Another resident had no documentation for 15-minute safety checks between 2:00 PM and 7:00 PM and was found after an unwitnessed fall, requiring hospital evaluation. The third resident was found on the floor after an unwitnessed fall, with no 15-minute safety checks documented during the specified period. These lapses in safety checks led to unwitnessed falls and minor injuries for the residents involved. Additionally, the facility failed to ensure that specific interventions were in place for two other residents. One resident's bed was not in a low position, and appropriate footwear was not on the resident, as required by their care plan. Another resident's bed alarm was not in place before the resident was put to bed, leading to an unwitnessed fall. These deficiencies were identified through record reviews, progress notes, and staff interviews, which confirmed that the required interventions were not consistently implemented, resulting in care plan violations.
Failure to Ensure Resident Safety and Adherence to Care Plan
Penalty
Summary
The facility did not ensure the resident's environment remained as free of accident hazards as possible for one resident reviewed for accidents. Specifically, Resident #15, who had diagnoses of heart failure, type 2 diabetes mellitus, and end-stage renal disease, was found on the floor with the bed not in a low position, the call light not within reach, and without socks on. The resident's care plan included interventions such as a low bed and appropriate footwear, which were not followed by the Certified Nurse Aide (CNA) responsible for the resident's care. The facility's investigation revealed that the CNA did not place a bed alarm on the resident's bed, did not ensure the resident had non-skid socks on, and did not place the call light within reach. Interviews with facility staff confirmed that the CNA was aware of the care plan requirements but failed to follow them. The CNA received education on following care plans to prevent falls and injuries after the incident. Other staff members also acknowledged the importance of adhering to safety instructions and completing required safety checks to prevent such incidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Malone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Country Nursing & Rehabilitation Center | 29.5 mi | ★★★★★ | 24 | 0 |
| Massena Rehabilitation & Nursing Center | 30.6 mi | ★★★★★ | 39 | 1 |
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