Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Champlain Valley Physicians Hosp Med Ctr S N F during CMS and state inspections, most recent first.
The facility's emergency preparedness plan was found deficient as it lacked documentation on resident populations at risk during emergencies and the services to address their vulnerabilities. The plan did not identify the resident population, strategies for their needs, or how to maintain continuity of care during emergencies. This deficiency could affect all residents. The Director of Emergency Management acknowledged the need for updates.
The facility did not ensure that 18 of 63 staff received annual training in emergency preparedness policies and procedures, as identified during a recertification survey. There was no documented evidence of training completion for these staff members, which could affect all residents. A registered nurse acknowledged the issue and planned to consult with the Organizational Development Coordinator.
The facility failed to provide emergency lighting in the activities room and dining room, as required by NFPA 101 Life Safety Code. The absence of automatic emergency lighting along the means of egress was confirmed by the Associate Vice President of Patient Care Operations, who stated that installation would occur in the skilled nursing unit.
The facility's emergency preparedness plan was found deficient as it did not include strategies for addressing the loss of call bell, loss of emergency generator, and cyber-attack. This was identified during a recertification survey through record review and an interview with the Director of Emergency Management and Life Safety.
A facility failed to protect residents from abuse and neglect, resulting in incidents involving three residents. A resident with quadriplegia reported wrist twisting by a nurse, leading to bruising. Another resident with dementia fell due to a lack of required assistance and bed bolster, and a third resident suffered a skin tear when a CNA failed to follow the care plan for resistive behavior. These incidents highlight the facility's failure to adhere to care plans and protect residents' rights.
The facility was cited for not marking empty oxygen cylinders in the Clean Supply room as required by NFPA 99 standards. During a survey, it was observed that four empty cylinders were unmarked, and an LPN confirmed the status of three tanks. This non-compliance was noted during a recertification survey.
The facility did not provide required training on the risks and proper handling of pressurized oxygen cylinders to 19 out of 63 employees, including those in the physical therapy and medical treatment sections, as per NFPA 99 standards. This deficiency was identified during a recertification survey through record review and staff interviews.
A resident with impaired vision and cognitive intactness did not receive optometry consultations or a care plan for vision needs. Despite using corrective lenses, there were no records of optometry visits since admission. The resident expressed the need for a new prescription, and a nurse confirmed the absence of an eye doctor visit, stating a request was made to add the resident to the optometry list.
The facility did not adhere to professional standards for food service safety, as cleaning chemicals were improperly stored, equipment was not maintained, and proper testing equipment for sanitizing solutions was unavailable. Additionally, certain areas were found to be unclean, and the administrator acknowledged these issues.
A facility failed to report an alleged physical abuse incident involving a resident with dementia within the required 2-hour timeframe. The incident, which resulted in a skin tear, was observed by staff but not reported to the New York State Department of Health until the following day. The facility's administrator acknowledged the delay in reporting, which violated the facility's policy on timely reporting of incidents involving bodily injury.
A facility failed to immediately remove a CNA from resident care following an abuse allegation involving a resident with dementia. The CNA, who did not follow the care plan requiring two staff during behavioral episodes, caused a skin tear on the resident's hand. Despite the incident being documented, the CNA continued working until the end of their shift, and the incident was not promptly reported to the Administrator or DON.
A resident with dementia and epilepsy, requiring two-person assistance, fell out of bed when a CNA provided care alone without using a bed bolster, contrary to the care plan. The incident was witnessed, and the CNA confirmed acting alone. No injuries were reported.
The facility did not have a facility Authorized Person sign the necessary forms for criminal history checks before requesting them for five new employees, including a CNA and three Nutrition Service Workers, as required by regulations.
Two residents experienced delayed reporting of abuse allegations in an LTC facility. One resident with cognitive impairment was allegedly struck by a CNA, while another resident faced inappropriate behavior from a different CNA. In both cases, the witnessing CNA delayed reporting due to fear of retaliation and uncertainty about the process, leading to a failure to meet the facility's immediate reporting policy.
Emergency Preparedness Plan Lacks Critical Resident Information
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. The deficiency was identified through a record review, which revealed that the facility's emergency plan, dated 03/31/2024, lacked documentation regarding the resident populations at risk during an emergency and the specific services in place to address their unique vulnerabilities. The plan did not include identification of the resident population served, strategies to address their needs, a description of services the facility could provide during an emergency, or how continuity of care would be maintained to protect residents' health and safety if normal operations were disrupted. This deficiency could potentially affect all residents at the facility. During an interview, the Director of Emergency Management and Life Safety acknowledged the need to update the emergency preparedness plan to include this critical information.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 1. Champlain Valley Physicians Hospital will revise that the Emergency Operations Plan includes all Skilled Nursing Unit residents and addresses the unique needs of the population. A. Strategies the facility had put in place to address the needs of the population, B. Description of the types of services the facility could provide in the event of an emergency, and C. How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. Review will be conducted by (MONTH) 15, 2025. 2. All skilled nursing facility residents have the potential to be affected by alleged deficient practice. 3. The Skilled Nursing Facility staff will be educated on the revised Emergency Operations Plan annually and as needed. 4. The Director of Emergency Management will conduct one policy audit per quarter, and as needed, to confirm: - Identification of the resident population served and their unique needs, - Strategies the facility had put in place to address the needs of the population, - Description of the types of services the facility could provide in the event of an emergency, and - How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. All revisions to the Emergency Operations Plan will be reviewed at Skilled Nursing Facility Quality Assurance Committee for recommendations and approval. 5. Director of Life Safety & Emergency Management.
Emergency Preparedness Training Deficiency
Penalty
Summary
The facility failed to ensure that 18 out of 63 staff members received annual training in emergency preparedness policies and procedures. This deficiency was identified during a recertification survey through record review and interviews. There was no documented evidence to confirm that these staff members had completed the required training in the emergency plan. During an interview, a registered nurse acknowledged the oversight and mentioned consulting with the Organizational Development Coordinator to address the training gap. This deficiency could potentially affect all residents in the facility.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 1. There were eighteen (18) staff identified as not having completed annual Emergency Preparedness Education. B. Any staff member who was identified as incomplete will complete the annual Emergency Preparedness Training prior to 3/04/2025. Any staff who did not complete the Emergency Preparedness Training by 03/04/2025 will be removed from the schedule and unable to work on Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. B. All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Organizational Development Coordinator will run completion reports. An Educational report for completion status of the Emergency Preparedness Training will be reviewed monthly to ensure all staff are compliant with Emergency Preparedness Training. 4. Completion report of the Emergency Preparedness Training will be reviewed at the monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee
Deficiency in Emergency Lighting in Resident Areas
Penalty
Summary
The facility was found to be deficient in providing emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. During a recertification survey, it was observed that the activities room and dining room did not have emergency lighting that would operate automatically without manual intervention along the means of egress to the public way. This deficiency was confirmed during an interview with the Associate Vice President of Patient Care Operations, who acknowledged the absence of emergency lighting in these areas and stated that it would be installed in the skilled nursing unit.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 1. Lighting controls within the Dining and Activity rooms will be changed to maintain constant illumination within the Dining and Activity Room per NFPA 101: 7.8. Specific fixtures identified will be connected to emergency power circuits. 2. Facilities will verify the lights operate continuously and cannot be turned off with a wall switch. Facilities will survey all other areas of the Skilled Nursing Unit and the adjacent, 5 Main East wing to verify that the emergency lighting system conditions are in compliance with NFPA 101: 7.8. This survey will be completed by (MONTH) 10, 2025. 3. The Environment of Care Checklist will be modified to include evaluation of emergency lighting to ensure conformance with NFPA 101: 7.8. This will be completed by (MONTH) 10, 2025. 4. The Facility currently conducts checks of all emergency lighting on the Skilled Nursing Unit on a monthly frequency. Documentation is maintained by Facilities. 5. Associated Vice President of Facilities
Emergency Preparedness Plan Lacks Key Strategies
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the facility's emergency preparedness plan lacked documented strategies for addressing certain emergency events identified in the facility's risk assessment. These missing strategies included plans for the loss of call bell, loss of emergency generator, and cyber-attack. This deficiency was identified through record review and an interview with the Director of Emergency Management and Life Safety, who acknowledged the absence of these plans in the emergency preparedness documentation.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 1. The Emergency Preparedness Plan will be reviewed and revised. B. The Emergency Preparedness plan will be revised to include response actions that address loss of generator, loss of nurse call, cyber-attack, and missing residents specific to the Skilled Nursing Facility. Review of the Emergency Preparedness Plan will be complete by (MONTH) 15, 2025. 2. The skilled nursing facility will review and revise the Emergency Operations Plan to ensure compliance with all emergency preparedness requirements. 3. The Skilled Nursing Facility staff will be educated on the policies for loss of generator, loss of nurse call, cyber-attack, and missing residents on an annual basis and with any changes to the Emergency Preparedness plan. 4. The Director of Life Safety and Emergency Preparedness Plan will review the Emergency plan annually at a minimum and as needed to ensure all emergency events in the facility risk assessment are addressed. B. The Emergency Preparedness plan will be presented quarterly at the skilled nursing facility Quality Assurance and Performance Improvement committee and as needed for approval. 5. The Director of Life Safety & Emergency Management.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect Resident #1 from abuse when a staff member, Registered Nurse #2, allegedly twisted the resident's wrist and removed their call light. Resident #1, who has quadriplegia and is cognitively intact, reported the incident, which resulted in a reddened area and bruising on their wrist. The care plan for Resident #1 included ensuring the call bell was within reach and temporarily interrupting care if the resident became verbally abusive, which was not followed by the staff member involved. Resident #14, who has severe cognitive impairment due to dementia, experienced neglect when a Certified Nurse Aide provided care without the required assistance of a second staff member, as outlined in the resident's care plan. This neglect led to a fall from the bed because the bed bolster was not in place, although no injuries were reported. The care plan specified the use of posey rolls and a two-person assist for bed mobility, which were not adhered to during the incident. Resident #23, also severely cognitively impaired, suffered a skin tear on their hand due to the actions of Certified Nurse Aide #3, who failed to follow the care plan requiring two staff members to assist when the resident was resistive to care. The aide was observed grabbing the resident's hands, leading to the injury. The care plan emphasized allowing time for the resident to de-escalate and re-approaching if agitated, which was not followed, resulting in the resident's injury.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #1 had a skin check completed by registered nurse. Skin check revealed reddened area to wrist on 6/23/2024. Director of Nursing was notified on 6/23/2024. Administrator was notified per policy on 6/23/2024. Registered Nurse #2 was immediately placed on administrative leave and removed from facility pending investigation on 6/23/2024. Department of Health notified on 6/23/2024. Provider ordered diagnostic studies on 6/24/2024 which revealed no fractures. Registered Nurse #2 was terminated from employment on 6/26/2024 and Office of Professions notified of incident. B. Resident #14 had a recorded witnessed fall on 12/22/2024 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024. Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024. Resident #14 sent to emergency room on [DATE] and returned on 12/22/2024 with no findings. Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investigation. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. C. Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024. Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024. Registered Nurse #4 was educated/reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. Certified Nurse Assistant was placed on administrative leave on 12/25/2024. Certified Nurse Assistant was terminated on 12/27/2024. 2. Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency. A review of all residents with behavior care plans was completed on 02/21/2025. One additional resident was identified as requiring 2 assists with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention, Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18, 2025. Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. The Abuse Reporting and Investigation policy was reviewed on 2/10/2025 with no changes. C. There were no system changes as this alleged deficient practice was related to one noncompliant staff member, Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee.
Unmarked Empty Oxygen Cylinders in Clean Supply Room
Penalty
Summary
The facility failed to protect pressurized oxygen cylinders in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition. During an observation, four empty oxygen cylinders in the Clean Supply room were not marked as required. A Licensed Practical Nurse confirmed that three of the oxygen tanks in the unmarked rack were empty. This deficiency was identified during a recertification survey, and the facility was found to be non-compliant with the relevant regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were four (4) oxygen cylinders identified in the alleged deficient practice. B. The oxygen tank racks were inspected, and empty cylinders were moved to the empty cylinder rack at the time of the survey. C. Signage on the racks was updated to reflect the clean and empty racks and signs were secured to racks. 2. All residents with Oxygen Orders have the potential to be affected by this alleged deficient practice. B. All Current Skilled Nursing Facility staff will be educated on Compressed Gas. The Compressed Gas Training includes proper storage and placement of Oxygen Cylinders. C. All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Day shift Charge Nurse will complete daily inspection of compressed gas racks on the Skilled Nursing Unit to ensure signage is in place and cylinders are suitably stored. The inspection will be documented on the Environment of Care log. 4. Scheduled [MEDICATION NAME] and Environment of Care rounds are in place to document compliance with compressed gas storage. B. Results of daily Compressed Gas Storage and monthly Environmental Rounds will be reviewed at the monthly Quality Assurance Performance Improvement Committee for further recommendations. 5. Associate Vice President of Facilities.
Deficiency in Oxygen Cylinder Handling Training
Penalty
Summary
The facility failed to manage pressurized oxygen cylinders in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1. Specifically, 19 out of 63 employees who handle oxygen cylinders did not receive the required education on the risks associated with their handling and use. This deficiency was identified through record review and interviews during a recertification survey. It was noted that there was no documented evidence of periodic training for these employees, including those working in the physical therapy department and the medical treatment section. A registered nurse confirmed that staff in these areas had not received the necessary training on the risks and proper handling of oxygen cylinders.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were nineteen (19) staff identified as not having completed annual Compressed Gas Education. B. Any staff member who was identified as incomplete including staff in [MEDICAL TREATMENT] and Physical Therapy will complete the annual Compressed Gas Training prior to 3/04/2025. C. Any staff who did not complete the Compressed Gas Training by 03/04/2025 will be removed from the schedule and unable to work on the Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. 3. The Organizational Development Coordinator will provide an Education report for completion status of the Compressed Gas Training. This will be reviewed monthly to ensure all staff of the Skilled Nursing Facility are compliant with Compressed Gas Training. Education will be documented in the facility electronic education software or on the education sign-in sheet. Staff who are not compliant will be removed from the schedule until verification of completion. All other staff working in the Skilled Nursing Facility will be reviewed for the required training, and those that have not will receive the training. 4. Completion Report of the Compressed Gas will be audited monthly, with audit results reviewed at the Monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee
Failure to Provide Vision Services for a Resident
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain the vision ability for a resident with impaired vision. The resident, who was admitted with chronic obstructive pulmonary disease, hypertension, and dementia, was documented as being cognitively intact and using corrective lenses. However, there were no records of optometry consultations or a comprehensive care plan addressing the resident's vision needs. During interviews, the resident expressed the need for a new prescription and confirmed not having seen an eye doctor since admission. A registered nurse acknowledged the lack of an optometry consultation and stated that a request had been made to place the resident on the optometry list.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. Resident #28 A. An eye examination is scheduled for (MONTH) 14, 2025. 2. Other residents with visual deficits have the potential to be affected by this alleged deficient practice. A full house audit of all residents was completed on 2/18/2025 by the Intake Manager to identify residents with visual impairment. Each current resident identified as having visual impairment was offered an eye examination on 2/21/2025. The resident representative was contacted for all residents identified with visual impairment, who cannot make their own decisions on 2/21/2025. There were 15 additional residents identified with visual impairment whose last eye exam was over 1 year. 5 of the 15 residents and the other 10 declined. 3. The policy Vision and Hearing was created by the Director of Nursing on 2/18/2025. The Vision and Hearing Policy will include required consult documentation and comprehensive care plan development for Vision and hearing. B. All Nursing staff and the administrator will be educated on the Vision and Hearing Policy. Staff will complete a written post test to ensure comprehension of the policy. Education will be completed prior to 3/4/2025. 4. All current resident's Minimum Data Set Assessments will be reviewed to identify vision and or hearing needs. Residents identified as having vision or hearing needs will have consultations scheduled and upon admission for new residents then as needed. 5. A monthly audit will be completed for all residents to ensure vision appointments have been offered per policy. All Audit results will be reported to the monthly Quality Committee until three consecutive months of compliance is achieved then at the direction of the committee. 6. Director of Nursing / Designee
Deficiencies in Food Service Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations, it was noted that cleaning chemicals, specifically glass cleaner, were improperly stored above a food processor. Additionally, the warewashing area had a spray hose nozzle hanging below the sink flood rim, which was in contact with water, posing a risk of back-siphonage. The facility lacked the correct test papers to accurately measure the concentration of the sanitizing solution, as the available test papers did not show the required range of 150 to 400 parts per million of quaternary ammonium compound, as specified by the sanitizer concentrate label. Furthermore, the deli station's reach-down refrigerator door gasket was split and uncleanable, and various areas, including the underside of the floor mixer and floors under the baker's worktable and sink, were soiled with food particles or dirt. During an interview, the facility's administrator acknowledged the issues identified, including the improper storage of glass cleaner, the absence of appropriate sanitizer test papers, the spray hose's potential for back-siphonage, and the need for cleaning in specific areas.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 F812 (483.60) Spray hose and potential back siphonage issue with hose being too long and resting in standing pot water in pot room. 1. Work order placed by supervisor on duty 1/13/25 asking for shorter spray hose to be installed. Work order (# 5) completed on 1/19, issue permanently fixed. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the spray hose length is appropriate to prevent potential back siphonage. 3. Nutrition Services and Facilities team made aware that hose must be short and not rest in water. 4. Scheduled kitchen mock surveys in place to document compliance with spray hose length. If non-compliance is discovered a separate work order will be generated and issued to Facilities. 5. Target date for corrective action was 1/19/25. Director Nutrition Services is the responsible party. F812 (483.60) Deli Cooler Gasket was split and uncleanable. 1. Work order submitted on 1/13/25 requesting gasket replacement. Work order (# 1) completed on 1/18/25. 2. All residents have potential to be affected by this alleged deficient practice. 3. Cooler gasket checks have been added to routine cooler preventive maintenance schedule. Deli cleaning and closing checklist revised to add gasket cleaning. Deli staff will be educated on this revised cleaning list, understanding and awareness will be confirmed via employee sign off on this education. 4. Scheduled kitchen mock surveys in place to document compliance with gaskets in main kitchen, deli and SNF kitchen. If non-compliant gaskets are discovered a separate work order will be generated and issued to Facilities. 5. Target date for corrective action was 1/18/25. Director Nutrition Services is the responsible party. F812 (483.60) Incorrect sanitizer test strips used in ware washing sanitizer sink. 1. Ecolab rep called immediately and delivered a supply of QT-40 test strips in less than one hour. All Qt-10 Test strips on site were immediately discarded. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the QT-40 test strips are the only strips available and in use for testing PPM of sanitizing solution. 3. Electronic order guide updated to remove QT-10 and replace with appropriate Qt-40 test strip to help prevent the inappropriate test strip from being ordered. Education developed to include manufacturer recommendations for type of test strip to be used to test sanitizer ppm as well as target ppm range. This education will be provided bi-annually. 4. Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5. Target date for corrective action was 1/13/25 when all QT-10 were discarded and steps implemented as per above. Director Nutrition Services is the responsible party. F812 (483.60) Chemicals not stored properly. Spray bottle of glass cleaner left on windowsill in food prep area near equipment. 1. Spray bottle in question immediately removed from food prep area and stored properly. Inspection of other areas of kitchen revealed no other non-compliant chem storage issues. Staff working in impacted area made aware of non-compliance and reminded of proper storage. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor the department for compliance with proper chemical storage. 3. Nutrition Service leadership will provide initial and then bi-annual training on proper storage of chemicals. 4. Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5. Target date for corrective actions is 90 days from survey. Director Nutrition Services is responsible party. Audits and surveys will be shared with SNF QAPI monthly. F812 (483.60) Underside of the floor mixer, floor under the baker’s worktable and bakers sink were soiled. 1. Area under baker’s worktable and pots sink was swept/cleaned immediately by staff members. Work order # 3 submitted requesting removal of the mixer assembly on the underside of the floor mixer for proper cleaning. 2. All residents have the potential to be impacted by this alleged deficient practice. 3. Daily cleaning and closing checklist to be signed off on daily by staff/leader to ensure floors are appropriately cleaned along with other equipment in this area. Mixing assembly removed at underside of floor mixer and sent for cleaning, sanding, repainting. 4. Any non-compliance found daily during cleaning sign off will be addressed in real time. Trends in non-compliance with specific staff will be reviewed weekly when cleaning lists are reviewed prior to scanning into e-file. Non-compliance will be addressed with retraining and job performance disciplines as warranted. Scheduled kitchen mock surveys in place to document compliance with workstation and mixer cleanliness. 5. Target date for corrective action is 90 days from survey. Director Nutrition Services is the responsible party. Daily cleaning sign off and surveys will be shared with SNF Quality Assurance Performance Improvement monthly meeting.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident within the required timeframe. On December 25, 2024, at 2:00 AM, a staff member observed a Certified Nurse Aide (CNA) improperly handling a resident, resulting in a skin tear on the resident's right hand. The resident, who was admitted with dementia, atrial fibrillation, and anxiety disorder, was severely cognitively impaired and rarely understood by others. Despite the incident being documented in an accident report, it was not reported to the New York State Department of Health until December 26, 2024, at 3:19 PM, exceeding the mandated 2-hour reporting window for incidents involving bodily injury. The facility's policy on abuse prevention, investigation, and reporting, revised in August 2024, requires that incidents resulting in bodily injury be reported within 2 hours. However, the incident was not brought to the attention of the facility's administrator until 2:30 PM on December 25, 2024, and the CNA involved was subsequently suspended. The delay in reporting was acknowledged by the administrator during an interview, who stated that they should have been informed sooner. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to regulatory requirements.
Plan Of Correction
Plan of Correction: Approved February 6, 2025 1. Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand. Registered Nurse #4 applied steri strips to skin tear on right hand. Registered Nurse #4 was reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. 2. Other residents do have the potential to be affected by alleged deficiency. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff will be educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education will include a posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. C. The Abuse Prevention, Reporting and Investigation Policy was reviewed. There were no system changes as this alleged deficient practice was related to one noncompliant staff member, Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee
Failure to Immediately Remove CNA After Abuse Allegation
Penalty
Summary
The facility failed to ensure the immediate removal of a Certified Nurse Aide (CNA) from resident care following an allegation of physical abuse involving a resident with dementia, psychotic disturbance, and anxiety disorder. The incident occurred when the CNA did not adhere to the resident's Comprehensive Care Plan, which required two staff members to be present during behavioral episodes. This resulted in a skin tear on the resident's hand. Despite the incident being documented in an accident report, the CNA was allowed to continue working until the end of their shift, contrary to the facility's policy on abuse prevention and investigation. The deficiency was further compounded by a lack of timely communication and action from the Nursing Supervisor, who failed to report the incident to the Administrator or Director of Nursing immediately. The incident was only discovered during a daily review of reports, leading to a delay in the suspension of the CNA. The facility's investigation substantiated the abuse allegation, and the CNA was eventually terminated. However, the initial failure to remove the CNA from resident care and report the incident promptly constituted a breach of the resident's right to be free from potential abuse.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024. Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024. Registered Nurse #4 was educated reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. Certified Nurse Assistant was placed on administrative leave on 12/25/2024. Certified Nurse Assistant was terminated on 12/27/2024. 2. Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency. A review of all residents with behavior care plans was completed on 02/21/2025. One additional resident was identified as requiring 2 assist with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18 2025. Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. The abuse Reporting and investigation policy was reviewed on 2/10/2025 with no changes. Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee
Inadequate Supervision and Assistive Devices Lead to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for a resident who required two caregivers for care. Specifically, the resident, who was diagnosed with dementia, epilepsy, and major depressive disorder, was assisted by only one caregiver, and a bed bolster was not in place, resulting in the resident rolling out of bed. The resident was severely cognitively impaired and required total dependence with a two-person physical assist for bed mobility, as documented in their comprehensive care plan. An accident/incident report documented that the resident had a witnessed fall out of bed while personal care was being completed by a Certified Nurse Aide (CNA) alone, contrary to the care plan's requirement for a two-person assist. The CNA provided a written statement confirming they had provided care without additional assistance. The Director of Nursing confirmed that the CNA had received education on following the care plan to prevent accidents and injuries. The incident did not result in any injuries to the resident.
Plan Of Correction
Plan of Correction: Approved February 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #14 had a recorded witnessed fall on 12/22/24 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024. Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024. Resident #14 sent to emergency room on [DATE] and returned on 12/22/2024 with no findings. Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investigation. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. 2. All residents who have Activity of Daily Living care plans for bed mobility requiring 2-person assistance have the potential to be affected by this alleged deficient practice. A. A review of all current residents' Activity of Daily Living care plans was completed to identify all residents requiring two-person assistance with bed mobility on 2/21/2025. B. Twelve additional residents were identified as being care planned for 2-person assist for bed mobility. C. A review of all incident and accident reports since 12/22/2024 was completed on 2/21/2025 with no other incidents/accidents attributed to bed mobility care plan violations. 3. The incident and accident policy was reviewed by the Director of Nursing with no revisions made. A. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. B. All current Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, and therapy staff will be educated on Activity of Daily Living care plans to include bed mobility requiring 2 assists. C. All new Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, and Physical Therapy staff will be educated at new employee orientation. 4. A random weekly visual audit of 10% (4) residents of the in-house census will be completed to ensure that staff are following compliance with the level of assistance identified in the care plan. A. Audit will be completed weekly by the Director of Nursing or designee and will include day, evening, and night shifts. B. Audit results will be reported to the monthly Quality Committee until 100% compliance is maintained for 3 consecutive months and then at the recommendation of the committee. 5. Responsible Party: Director of Nursing/Designee
Failure to Sign Required Forms for Criminal History Checks
Penalty
Summary
The facility failed to comply with the requirements for obtaining criminal history information for new employees, as mandated by 10 New York Codes, Rules, and Regulations section 402.5(c). Specifically, the facility did not have a facility Authorized Person sign the Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information before requesting criminal history record checks. This deficiency was identified for five new employees, including a Certified Nurse Aide and three Nutrition Service Workers. The lack of documented evidence of the required signatures was confirmed during a recertification survey, and the Director of Employee Relations acknowledged the oversight during an interview.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 1. No resident was affected by alleged deficient practice. 2. Other residents have the potential to be affected by alleged deficient practice. 3. All prior Criminal History Record Check forms have been audited for signature. Those without signature are being reviewed with signatory for correction. B. Workflow and Human Resource system configuration has been updated to require written signature. C. Policy updated to highlight signature requirement. Authorized Human Resource employee who completed task has been reeducated by Human Resource Director. Two additional Human Resource employees have been set up with access through Criminal History Record Check and trained by Human Resource Director to support this work. D. A check system has been put in place, completed by a second person, to ensure all forms are verified for accuracy. 4. Human Resource Director will audit 100% of completed forms for past three months and for new hires. B. The results of all audits will be presented at the monthly Skilled Nursing Facility Quality Assurance Performance Improvement for further recommendations. 5. Human Resource Director is responsible for the accuracy of the process. HR Position Coordinators are responsible for completing the task.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required timeframe. Resident #1, who had severe cognitive impairment, was allegedly struck on the hand by a Certified Nurse Aide (CNA) after the resident grabbed the aide's wrist. The incident occurred in the evening, but the CNA who witnessed it did not report it until the following morning, citing fear of retaliation and uncertainty about the reporting process. The Director of Nursing and Administrator were not informed until later, resulting in a delay in reporting the incident to the Department of Health. In another incident, Resident #3, who was cognitively intact, was allegedly subjected to inappropriate behavior by another CNA. The CNA reportedly squished their breasts together and made inappropriate comments to the resident. The witnessing CNA delayed reporting the incident due to fear of retaliation, although they eventually informed a Registered Nurse Unit Manager. The Director of Nursing confirmed that the witnessing CNA had expressed fear of retaliation as a reason for the delay in reporting. The facility's policy requires immediate reporting of abuse allegations, with a two-hour window for notifying the Department of Health in cases of serious bodily injury. However, in both cases, the staff failed to adhere to these guidelines, resulting in delayed reporting of the incidents. The facility's administration acknowledged the lapses in timely reporting and the need for staff to feel comfortable reporting such incidents without fear of retaliation.
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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 Plattsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Healthcare | 0.4 mi | ★★★★★ | 0 | 0 |
| Plattsburgh Rehabilitation And Nursing Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Clinton County Nursing Home | 1.4 mi | ★★★★★ | 0 | 0 |
| Elderwood At Burlington | 16.3 mi | ★★★★★ | 15 | 0 |
| Birchwood Terrace Rehab & Healthcare | 16.3 mi | ★★★★★ | 2 | 0 |
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