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 Cooperstown Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to prevent resident-to-resident abuse, with multiple incidents involving aggressive behaviors among residents. A resident hit another with a walker, causing bruising, and engaged in altercations with others, resulting in injuries. Another resident exhibited aggressive behavior, hitting and threatening others. The facility's care plans and interventions were insufficient to prevent these incidents, leading to repeated abuse and inadequate protection for residents.
The facility failed to submit timely 5-day investigative reports to the NY State Department of Health for multiple resident altercations, resulting in injuries. The Director of Nursing could not explain the delays or omissions, indicating non-compliance with state reporting requirements.
The facility failed to maintain resident dignity, as several residents were observed in hospital gowns due to clothing shortages and miscommunication about available donated clothing. Additionally, a nurse was seen standing over a resident while assisting with a meal, contrary to guidelines. Staff interviews revealed systemic issues with laundry and clothing management.
The facility was cited for environmental deficiencies, including chipped paint, scuff marks, and visible dirt across all units. Interviews with the Director of Maintenance and the Administrator revealed challenges in maintaining the facility due to limited staff and overwhelming workload. Both acknowledged the need for additional staff to address these issues.
The facility failed to maintain sufficient nursing staff on the 3rd floor Dementia Unit, as required by their staffing grid. Staffing schedules for early 2024 showed frequent shortages of CNAs, with only 2 or 3 present during shifts instead of the required 5. Staff interviews revealed challenges due to call-outs and inadequate staffing, leading to unsanitary conditions for residents. The DON acknowledged staffing issues, including CNAs being pulled for appointments, despite some improvements.
The facility's assessment failed to include unit-specific staffing requirements necessary for competent resident care. Although the assessment listed overall staff needs, it did not specify the number of staff required per unit per shift. The Administrator was unaware of the need to include these details.
A resident with severe cognitive impairment and existing wounds developed a Stage 3 pressure ulcer due to the facility's failure to provide necessary care and documentation. The resident, dependent on staff for all care, did not have a documented physician order for turning and positioning, and staff failed to assist with bed mobility on numerous occasions.
The facility failed to ensure proper labeling and storage of medications, including missing open/expiration dates, unsecured controlled substances, and expired medications. Staff interviews revealed non-compliance with the facility's Medication Administration Policy.
The facility experienced significant staffing shortages, leading to delayed responses to resident needs and an increase in falls. Residents reported long waits for assistance, and staff interviews revealed that nurses and aides were often overworked, sometimes working alone or with minimal support. Despite efforts by the DON to address the issue, the facility documented 34 falls in one month, highlighting the impact of inadequate staffing on resident care.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with issues including improper sanitizing solution concentration, uncalibrated thermometers, and soiled surfaces in the main kitchen and 7 of 10 kitchenettes.
A resident with multiple health conditions fell out of bed when a CNA, not adhering to the care plan requiring two staff for bed mobility, attempted to change bed sheets alone. The resident, who had impaired cognition, was sent to the hospital after complaining of pain. The facility's neglect policy was not followed, as the CNA did not review the care Kardex.
A resident with multiple health conditions fell out of bed when a CNA failed to follow the care plan requiring two staff for bed mobility. The incident was not reported to the Department of Health as required, despite the resident being sent to the emergency room. The facility's policy mandates immediate reporting of such incidents, but this was not followed.
A facility failed to readmit a resident who was hospitalized for aggressive behaviors and later medically cleared for discharge. The resident, with a history of dementia and depression, was not allowed to return due to the facility's concerns about managing potential agitation and danger to self and others. The facility's policy required readmission once deemed safe by the hospital, but the facility cited a lack of resources for one-on-one supervision as a reason for refusal.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse, as evidenced by multiple incidents involving aggressive behaviors among residents. Resident #2 was involved in several altercations, including hitting Resident #5 with a walker, resulting in bruising, and engaging in a physical altercation with Resident #4, causing lacerations to both residents. Despite being cognitively intact, Resident #2's care plan did not adequately address the risk of involvement in resident-to-resident altercations, and interventions were insufficient to prevent further incidents. Resident #6 also exhibited aggressive behavior, hitting Resident #9 and threatening Resident #7. The facility's care plan for Resident #6 acknowledged the risk of harm to others but failed to implement effective interventions to prevent these incidents. The facility's policy on abuse and neglect was not effectively enforced, as evidenced by the repeated altercations involving Resident #6 and the lack of adequate measures to separate residents with known aggressive behaviors. The facility's failure to implement effective interventions and adequately monitor residents with aggressive behaviors led to multiple incidents of resident-to-resident abuse. The care plans for residents involved in these altercations were not consistently updated or revised to reflect the incidents, and the facility did not ensure that residents were kept separate to prevent further altercations. The lack of effective monitoring and intervention contributed to an environment where residents were not adequately protected from abuse.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to submit the required 5-day investigative conclusion reports to the New York State Department of Health within the mandated timeframe for incidents involving resident-to-resident altercations. Specifically, the facility did not submit the reports on time for incidents involving two residents who engaged in physical altercations on multiple occasions. These incidents resulted in injuries such as bruising, lacerations, and scratches. The facility's failure to submit timely reports was noted for incidents occurring on 3/28/2024, 5/2/2024, 11/2/2024, 11/7/2024, and 11/22/2024, with delays ranging from several days to over a week. The Director of Nursing was unable to provide a clear explanation for the delays or the lack of submission for some incidents. The incidents involved residents who were cognitively intact and required supervision for various activities. Despite the facility's internal documentation of these altercations and the injuries sustained, the required reports were either submitted late or not at all, indicating a lapse in compliance with state reporting requirements.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure the residents' right to a dignified existence, as evidenced by observations and interviews during an abbreviated survey. On the 6th floor, four residents were observed seated in the hallway dressed in hospital gowns, which is contrary to the facility's policy that residents should be well-groomed and dressed appropriately. These residents had varying degrees of cognitive impairment and required different levels of assistance with daily activities. The facility's care plans for these residents indicated that staff assistance was necessary to meet their daily needs, including being dressed appropriately. Additionally, in the 5th floor dining room, a registered nurse was observed standing over a resident while assisting them with their meal, which is not in line with the facility's guidelines for maintaining resident dignity during mealtime. The resident in question had moderate cognitive impairment and required assistance with eating, among other activities of daily living. The registered nurse acknowledged awareness of the inappropriate nature of standing over residents during meals. Interviews with staff revealed systemic issues contributing to the deficiency. Certified Nurse Assistants reported that some residents lacked personal clothing due to issues with laundry and housekeeping, and there was confusion about the availability and location of donated clothing. The Director of Nursing and the Director of Housekeeping outlined processes for addressing clothing shortages, but these were not effectively communicated or implemented, leading to residents being dressed in hospital gowns. The facility administrator confirmed the availability of donated clothing and the expectation that no resident should be dressed in hospital gowns.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility was found to have multiple environmental deficiencies during an abbreviated survey. Observations revealed chipped paint, scuff marks, visible dirt, and stains on walls and floors across all units. Baseboards were chipped and coming off the walls, holes were present in the walls, tiles were chipped, and ceiling tiles were caving. Foul odors were also noted. Specific issues included a light bulb out on the third floor, a bathroom with visible dirt and chipped paint, and a radiator with chipped paint. Additionally, there were improper ceiling tile repairs, holes in walls, and duct tape holding a paper towel dispenser together. Interviews with the Director of Maintenance and the Administrator highlighted challenges in maintaining the facility. The Director of Maintenance, responsible for repairs and maintenance, stated that they have limited staff and experience challenges in completing tasks promptly. They mentioned that tasks are usually completed within a day, but some require more time if additional items are needed. The Administrator, who has been with the facility since earlier in the year, conducts environmental rounds at least weekly and communicates issues to the maintenance department. Both the Director of Maintenance and the Administrator acknowledged the need for additional staff to address the overwhelming workload.
Insufficient Staffing on Dementia Unit
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents on the 3rd floor Dementia Unit, as determined by the facility's staffing grid and Provider Average Ratio (PAR) levels. The staffing policy required sufficient nursing staff with appropriate competencies to ensure resident safety and well-being. However, the review of staffing schedules for January, February, and March 2024 revealed that the number of certified nurse assistants (CNAs) scheduled was often below the required levels. For instance, during the day shift, there were multiple instances where only 2 or 3 CNAs were present instead of the required 5, and similar shortages were noted during evening and night shifts. Interviews with staff members highlighted the challenges faced due to staffing shortages. The Staffing Coordinator acknowledged frequent call-outs and the difficulty in maintaining adequate staffing levels, despite attempts to schedule additional staff and use agency staff. Certified Nurse Assistants reported starting shifts with fewer staff than scheduled, leading to situations where only one CNA and a nurse were available for 35 to 40 residents. This resulted in residents being left in unsanitary conditions, such as being saturated with feces and urine, particularly on the 3rd floor dementia unit where residents tend to wander. The Director of Nursing (DON) confirmed that staffing was a challenge, with issues such as lateness and call-outs affecting the ability to meet the documented PAR levels. The DON noted that CNAs were sometimes pulled from units to accompany residents to appointments, further impacting staffing levels. Despite improvements from earlier in the year, the facility continued to struggle with maintaining adequate staffing to meet the needs of its residents.
Facility Assessment Lacks Unit-Specific Staffing Requirements
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care. The assessment, last updated on November 7, 2024, and reviewed by the quality assurance and improvement committee on September 18, 2023, did not include specific staffing requirements by unit per shift. This omission was identified during a review on December 19, 2024, which revealed that the assessment lacked details on the number of staff needed for each unit to adequately care for residents. During an interview, the Administrator acknowledged that while the facility assessment listed the staff required to care for residents, it did not specify staffing requirements by unit, which they were unaware needed to be included.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, resulting in the development of a Stage 3 pressure ulcer. The resident, who was dependent on staff for all care, including bed mobility, was admitted with severe cognitive impairment, impaired vision, and was bedbound with existing wounds. Despite these conditions, there was no documented physician order for turning and positioning the resident, and the Braden scale assessments did not classify the resident's risk for developing pressure ulcers. The facility's records showed that the resident required maximal assistance with rolling left and right, yet there was no documented evidence of staff providing this assistance on multiple occasions. A Registered Nurse's assessment later documented the development of a Stage 3 pressure ulcer on the resident's left hip. The Director of Nursing confirmed that if tasks were not documented, they were not completed, indicating a failure in the facility's care practices and documentation processes.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, opened medications had no open and/or expiration dates, controlled substances were not kept secured in a double-locked cabinet, expired medications were present, and medications were left unattended on top of the medication cart. These deficiencies were observed in 3 out of 10 medication carts and 2 out of 5 medication storage rooms reviewed. For example, multiple insulin pens and eye drop solutions were found without open or expiration dates, and a tuberculin purified protein derivative bottle was found in the medication room refrigerator past its discard date. Controlled substances were not properly secured, as evidenced by a narcotic lock box with only one functioning lock and discrepancies in the narcotic book. An LPN was observed administering Oxycodone without immediately updating the narcotic book, resulting in a discrepancy in the count of oxycodone tablets. Additionally, expired medications, such as an Epinephrine pen, were found in the medication storage room, and medications were left unattended on top of the medication cart. Interviews with staff revealed a lack of adherence to the facility's Medication Administration Policy and Procedure. One LPN admitted to not knowing the facility's policy for narcotic medication administration and stated that their system worked for them. Another LPN was unsure of what to do with expired medications and left them out for pharmacy pick-up. The Director of Nursing stated that the facility had completed a full staff medication administration training the previous month, and each nurse completed competencies for medication administration upon hire and annually.
Staffing Shortages Lead to Delayed Care and Increased Falls
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of all residents, as evidenced by delayed responses to call lights and a high number of falls. Observations and interviews revealed that residents experienced long waits for assistance, with some waiting over an hour for critical needs such as oxygen concentrator changes. The facility's staffing levels were consistently below the required numbers, particularly for Certified Nurse Aides and Medication Nurses, across various shifts and dates. Interviews with staff highlighted the challenges faced due to understaffing. Certified Nurse Aides and Licensed Practical Nurses reported working extended hours, often alone or with minimal support, which impacted their ability to complete tasks timely. The shortage of staff led to situations where nurses had to manage multiple responsibilities, such as handling medication carts for multiple units, which further strained their capacity to provide adequate care. The facility's Director of Nursing acknowledged the staffing issues and mentioned efforts to mitigate them, such as leadership stepping in to assist and reaching out to agency staff. However, these measures were insufficient to prevent the documented 34 falls in April 2024, indicating a significant impact on resident safety and care quality due to the staffing deficiencies.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and 7 of 10 kitchenettes. Specifically, the concentration of quaternary ammonium compound used in the final sanitizing rinse sink of the 3-compartment sink was measured at 0 parts per million, contrary to the required 200-400 parts per million. Additionally, two food temperature thermometers were found to be out of calibration, and various surfaces, including the serving line reach-down refrigerator and utensil drawers, were soiled with food residue or broken. In the kitchenettes, several issues were observed, including split and uncleanable freezer door gaskets, and floors and cabinets soiled with food particles. These observations were made in the Hollyhock Way, Gardenia Way, Whispering Way, Star Haven, Emerald Way, [NAME] Glen, [NAME] Creek, and Oak Creek kitchenettes. Interviews with the Food Service Director and the Administrator confirmed that staff education on proper sanitizing solution concentration and thermometer calibration had been initiated, and some cleaning and repairs had been conducted.
Neglect Due to Inadequate Staff Assistance for Bed Mobility
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by an incident involving Certified Nurse Aide #4, who did not adhere to the resident's Comprehensive Care Plan. The plan specified that two staff members were required for bed mobility assistance. On the day of the incident, the aide attempted to change the resident's bed sheets alone, resulting in the resident rolling out of bed and onto the floor. This incident occurred because the aide did not review the resident's care Kardex, which documented the need for two staff members for bed mobility. The resident involved in the incident had a history of hypertensive heart disease, chronic obstructive pulmonary disorder, and morbid obesity, with moderately impaired cognition. Following the fall, the resident complained of head and body pain and was sent to the hospital for further evaluation. Interviews with other staff members confirmed that the requirement for two staff members for bed mobility was clearly documented and should have been followed. The facility's policy on neglect defines it as the failure to provide necessary goods and services to avoid physical harm, which was not adhered to in this case.
Failure to Report Resident Fall Due to Non-Compliance with Care Plan
Penalty
Summary
The facility failed to report an incident involving a resident who fell out of bed due to a Certified Nurse Aide (CNA) not following the resident's care plan. The resident, who had diagnoses including hypertensive heart disease, chronic obstructive pulmonary disorder, and morbid obesity, required the assistance of two staff members for bed mobility as documented in their Comprehensive Care Plan. On the day of the incident, the CNA attempted to change the resident's sheets without assistance, resulting in the resident rolling out of bed and complaining of head and body pain. This incident was not reported to the New York State Department of Health as required by the facility's policy and state regulations. The facility's policy mandates that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but this was not adhered to in this case. The Director of Nursing and the interdisciplinary team were responsible for reporting such incidents but failed to do so, as they believed the lack of injury negated the need for reporting. Interviews with staff revealed that the CNA did not review the resident's care Kardex before providing care, which contributed to the incident. Despite the resident being sent to the emergency room for evaluation, the incident was not reported to the Department of Health, highlighting a lapse in following established reporting procedures.
Facility Refusal to Readmit Medically Cleared Resident
Penalty
Summary
The facility failed to ensure that a resident, who was hospitalized for evaluation of behaviors, was allowed to return to the facility after being medically cleared. Resident #165, who had diagnoses of dementia, diffuse traumatic brain injury, and depression, was sent to the hospital due to aggressive behaviors and was medically cleared for discharge. However, the facility refused to accept the resident back, citing concerns about the resident's potential for agitation and danger to self and others. The facility's policy required them to readmit residents once they were deemed safe to return by the hospital. Despite this, the facility did not conduct a comprehensive assessment of the resident and relied on previous aggressive behavior as justification for refusal. The Director of Nursing stated that the facility lacked the resources for one-on-one supervision necessary to manage the resident's behaviors safely. The refusal to readmit the resident was based on the fear of potential agitation, despite the resident being calm during the transfer to the hospital.
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What surveyors actually found near you
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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 Cooperstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aurelia Osborn Fox Memorial Hospital | 14.3 mi | ★★★★★ | 0 | 0 |
| Chestnut Park Rehabilitation And Nursing Center | 16.4 mi | ★★★★★ | 4 | 1 |
| Chasehealth Rehab And Residential Care | 19.4 mi | ★★★★★ | 0 | 0 |
| Robinson Terrace | 24 mi | ★★★★★ | 6 | 0 |
| The Grand Rehabilitation And Nursing At Mohawk | 24.7 mi | ★★★★★ | 3 | 1 |
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