Below 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 Highlands Living Center during CMS and state inspections, most recent first.
Failure to report newly identified hip fracture after resident altercation. A resident with dementia and moderate cognitive impairment was pushed to the floor by another resident and initially sustained a humeral fracture. After returning from the hospital, staff documented worsening hip pain, an x-ray showed an acute femoral neck fracture, and the resident later underwent a hemiarthroplasty. The incident report and DOH submission included the altercation and arm fracture but did not include the hip fracture, hospitalization, or surgery; the RN mgr stated no additional incident report was completed, and the DON stated the hip fracture should have been reported to the State Survey Agency.
Failure to Investigate Resident Injury After Altercation: A resident with dementia, pulmonary fibrosis, and anxiety was pushed to the floor by another resident and sustained a humeral fracture. After returning from the hospital, the resident later developed worsening hip pain, was found to have an acute femoral neck fracture, and underwent hemiarthroplasty. The facility did not complete an incident report or a thorough investigation to determine the cause of the fracture or whether it was related to the earlier altercation.
The facility failed to thoroughly investigate alleged violations of abuse, neglect, or mistreatment for several residents. A resident with severe cognitive impairment suffered a shoulder dislocation, but the investigation was incomplete. Another resident with Alzheimer's was found with bruising, yet the investigation lacked staff statements and failed to rule out mistreatment. A cognitively intact resident reported rough handling and verbal abuse, but the investigation did not include witness statements. Additionally, a resident experienced a medical incident where necessary medication was unavailable, and the investigation did not identify involved staff or reasons for the unavailability.
The facility's nurse call system on two resident-use floors was found to be malfunctioning, preventing effective communication between residents and staff. Observations revealed that call lights failed to alert staff, with some lights not functioning in the hallway or at the nurses' station. Staff confirmed the issues, and some call lights required multiple resets. Additionally, disconnected call cords were not indicated by the system, highlighting a significant deficiency in maintaining the call system.
A recertification survey identified deficiencies in the facility's environment, including cold water from handwashing sinks in the kitchen, a non-functional sink in the beauty salon, and dirty footrest trays on stand assist lifts across all floors. These issues indicate a failure to maintain a functional and sanitary environment.
A Life Safety Code Survey identified unsealed openings in the elevator shaft on the first floor of a facility. Observations showed openings around electrical raceways and hydraulic lines extending through the concrete block wall into the shaft. A Maintenance Staff Member noted that elevator upgrades were done a few months earlier.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident receiving oxygen therapy did not have it included in their care plan, another with a right-hand splint order was observed without it, and a third resident's care plan lacked interventions for multiple health issues.
A resident with right-sided hemiplegia and cognitive impairment did not receive necessary nail care, resulting in long, debris-filled fingernails. Despite the facility's policy requiring nail care on shower days, observations showed the resident eating with unclean nails, and interviews confirmed the care was not provided as needed.
A survey revealed a 12.5% medication error rate in an LTC facility, where two residents received medications improperly. An LPN crushed enteric-coated and extended-release medications labeled 'Do Not Crush' and administered cardiovascular drugs without checking vital signs as required. Staff interviews confirmed these actions were errors.
A resident with atrial fibrillation and hypertension received cardiovascular medications without the required vital sign checks, and an extended-release tablet was crushed against pharmacy instructions. The LPN did not follow physician orders or facility policy, leading to significant medication errors.
A facility failed to implement its Infection Control Program by not ensuring proper PPE use during wound care for a resident on Enhanced Barrier Precautions. The resident, with a history of stroke and an unstageable pressure ulcer, required daily wound care. An LPN was observed performing wound care without a gown, despite signage indicating the need for gloves and a gown. Staff interviews confirmed the oversight, acknowledging the necessity of gowns to prevent infection spread.
The facility failed to properly store oxygen cylinders, leaving them exposed to inclement weather. A large rack with 77 full E-size oxygen cylinders and an uncovered cart with 10 cylinders were found outside, accumulating snow and melting snow. The Director of Facilities acknowledged the issue and suggested relocating the tanks to a more protected area.
The facility did not comply with emergency preparedness requirements by failing to update emergency contact information in the New York State Health Commerce System. The 24/7 Facility Contact, Director of Nursing, Emergency Medical Supplies Receiving Office, and Office of the Administrator had outdated information. The Director of Nursing's contact details were particularly outdated, listing a former employee's email. The Administrator acknowledged the issue and stated they would update the information.
Failure to Report Newly Identified Hip Fracture After Resident Altercation
Penalty
Summary
The facility failed to timely report a suspected injury of unknown source after a resident-to-resident altercation resulted in a right humeral fracture and later a right femoral neck fracture. The facility policy required any injury of unknown source to be investigated and reported immediately or within two hours to the Department of Health. Resident #2 had diagnoses including dementia, pulmonary fibrosis, and anxiety, and was documented as having moderate cognitive impairment and using a four-wheeled walker for ambulation. On 09/18/2025, Resident #2 was pushed to the floor by another resident while walking in the hallway and landed on the right side, with pain to the right shoulder and elbow. The facility reported the altercation and right humeral fracture, and the resident was transferred to the hospital. After the resident returned, therapy and provider notes documented right lower extremity resistance, grimacing with right hip flexion, and worsening right hip pain. An x-ray identified an acute right femoral neck fracture, and the resident was transferred again for hospital evaluation and later underwent a right hip hemiarthroplasty. The investigative report submitted to the Department of Health included the altercation and humeral fracture but did not include the hip fracture, hospitalization, or surgery. During interview, the RN manager stated the facility assumed the hip fracture was related to the altercation and no additional incident report was completed after the fracture was identified; the DON stated the right hip fracture should have been reported to the State Survey Agency.
Failure to Investigate Resident Injury After Altercation
Penalty
Summary
The facility failed to ensure an alleged resident-to-resident altercation resulting in a serious injury was thoroughly investigated for Resident #2. Resident #2 had diagnoses including dementia, pulmonary fibrosis, and anxiety, and the MDS dated 09/24/2025 showed moderate cognitive impairment and one fall with major injury since the prior assessment. An incident report dated 09/18/2025 documented that Resident #2 was pushed to the floor by another resident while walking in the hallway and sustained a right humeral fracture, requiring transfer to the hospital. After treatment, Resident #2 returned to the facility. Following return to the facility, therapy documentation on 09/23/2025 noted resistance to range of motion of the right lower extremity and grimacing with right hip flexion. A provider note on 09/24/2025 documented worsening right hip pain, and an x-ray identified an acute right femoral neck fracture, leading to hospital transfer and later right hip hemiarthroplasty on 09/25/2025. Facility records showed no incident report was completed after the hip fracture was identified, and no documented investigation was completed to determine the cause of the fracture, whether it was related to the earlier altercation, whether signs or symptoms of injury were missed after the incident, or whether additional corrective actions were needed.
Inadequate Investigation of Alleged Violations in LTC Facility
Penalty
Summary
The facility failed to ensure thorough investigations of alleged violations of abuse, neglect, or mistreatment for several residents. Resident #63, who had severe cognitive impairment and was dependent on staff for care, suffered a left shoulder dislocation. The investigation into this injury was incomplete, lacking staff statements and failing to rule out abuse, neglect, or mistreatment. The Director of Nursing acknowledged the investigation's inadequacy, noting that the x-ray results were misread, leading to a delay in addressing the injury. Resident #47, with severe cognitive impairment due to Alzheimer's disease, was observed with bruising on the face and neck. The facility's investigation did not include staff statements or determine if abuse, neglect, or mistreatment occurred. The Director of Nursing was not informed of the incident until 11 days later, indicating a significant lapse in communication and investigation procedures. Resident #81, who was cognitively intact but required assistance for daily activities, reported rough handling and verbal abuse by a Certified Nursing Assistant. The investigation did not include witness statements or follow-up with the resident, leaving the allegations unresolved. Additionally, Resident #80 experienced a medical incident where necessary medication was unavailable, and the investigation failed to identify involved staff or reasons for the medication's unavailability, highlighting a lack of thoroughness in addressing potential neglect.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. Immediate assessment of all residents involved to ensure safety. Residents' allegations were ruled out of neglect: mistreatment or potential abuse for residents #1, #63, #81, #80, and #103. No other residents were affected after the assessment. Injuries of Unknown Origin: Education a. Review of all reportable events. b. What is reportable? c. Process of report to DON/Administrator. 2. Process Change I. The nurse manager/nursing supervisor will obtain all statements when the event is noted. II. Discussion regarding the report done by DON and Administrator. III. The report made. IV. Investigation completed. V. A and I committee scheduled before the 5th business day to review the statement, lab, x-ray results, care plan, care card, and other potential process issues. VI. Recommendations made a. Small subgroup will meet and adjust policies and procedures as needed. b. The final report will be placed in the folder with the reportable based on the recommendations made. Review and update facility Abuse, Neglect, and Mistreatment Prohibition, Investigation, and Reporting policy. The staff has been educated regarding the process that should be taken when the emergency medication box keys concerning resident #80 or any other resident. Discussions with the Lead Pharmacist and the Consultant Pharmacist have led us to discover that some processes need to be reviewed. This meeting will occur at 11 AM on Thursday, (MONTH) 19. The agenda items include but are not limited to the following things A. What is in the current e-box for resident changes in orders? A new list will be placed in the pharmacy book that sits on each unit. B. The Narcotic E box will list available items for the provider to order and nurses to use in an emergent situation. C. Addition of the most current policies regarding the pharmacy and obtaining medication after hours. D. Update of all 3 Pharmacy books and Education will be provided to all the Nursing staff on all three units. 3. Implemented mandatory training for all unit managers and clinical coordinators on reporting and proper investigation procedures. Established a dedicated investigative team chaired by the Administrator to handle all abuse, neglect, and mistreatment investigations. The committee will recommend education based on the nature of the inquiry; all education will be completed in 30 days. The facility will initiate an investigation checklist. 4. All investigation checklists will be audited monthly for three months and presented to the QAPI committee. The committee will determine the frequency of the audit thereafter. Responsible Party: Director of Nursing
Deficient Nurse Call System Functionality
Penalty
Summary
The facility failed to maintain a properly functioning nurse call system on two of its three resident-use floors, as observed during a recertification survey. The nurse call system, which is supposed to allow residents to call for staff assistance from their bedside and bathroom facilities, was found to be malfunctioning. Specifically, the call system lights were not functioning properly, preventing calls from being relayed to staff members or centralized work areas. The manufacturer's specification manual for the Ascom nurse call system outlines that the system should emit tones and illuminate lights to indicate active calls, but these features were not working as intended. During the survey, several instances were observed where residents attempted to use the call system, but the system failed to alert staff. For example, a resident pressed their bedside call button, which resulted in two beeps being heard in the room, but no light was observed outside the room, and no alert was sent to the staff. Certified Nursing Assistants and Registered Nurses confirmed that the system was not functioning correctly, with some call lights not lighting up in the hallway or at the nurses' station. In some cases, call lights needed to be reset multiple times, and staff were unaware of the malfunctions until they were pointed out by the surveyor. The survey also revealed that some call lights were not connected properly, and the system did not indicate when a call cord was disconnected. For instance, a resident was found with their call light cord not attached to the wall, and the system did not show any activation or alert. Staff members, including Registered Nurses, acknowledged the issues and stated that they would inform maintenance to address the problems. However, the persistent malfunctions of the nurse call system indicate a significant deficiency in the facility's ability to ensure residents can effectively communicate their need for assistance.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. Immediately inspected and tested all nurse call systems in the facility. All non-functional call lights were replaced, and all nurse call panels were reset. 2. Conducted a facility-wide audit to check the functionality of all nurse's calls in all residents’ rooms. 3. Established a daily check by staff to ensure all call lights are operational. Implemented a preventive maintenance schedule for routine inspections and testing of the nurse call system. Training for nursing and maintenance staff on the importance of the nurse call system and how to report, reset, and escalate malfunctions to the facilities director will begin on 03/10/2025. Training will include video in-service training provided by the nurse call system company for all nursing and maintenance staff. 4. Weekly nurse call audits will be conducted on all units. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Responsible party: Director of Nursing
Deficiencies in Sanitation and Functionality of Facility Equipment
Penalty
Summary
During a recertification survey conducted from February 11 to February 19, 2025, several deficiencies were identified in the facility's environment, impacting both residents and staff. On the initial tour of the main kitchen, it was observed that two self-dispensing motion-activated handwashing sinks dispensed only cold water, with one sink measuring 43 degrees Fahrenheit. A dining services worker confirmed that the water typically comes out cold. Additionally, a handwash sink in the third-floor beauty salon was found to be non-functional, as it did not dispense water. The Director of Facilities later stated that the water to this sink was turned off, despite the room being used for hair and grooming services for multiple residents. Further observations revealed that several stand assist lifts across all three resident-use floors had dirty footrest trays with an accumulation of crumbs and debris. Specifically, manual stand aid lifts on the second and third floors, as well as two stand assist lifts on the first floor, were noted to have dirty footrests. An electric sit-to-stand lift on the first floor was also found with a dirty footrest tray. These findings indicate a failure to maintain a functional and sanitary environment, as required by the relevant health regulations.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. All manual stand-aid lifts were immediately cleaned. The sink mixing valve in the kitchen was replaced on 02/13/2025, and the beauty shop water was turned back on. 2. All sinks in the facility were checked and are in working order. Both hand-washing sinks provide adequate hot water on 02/13/2025. 3. The director of facilities educated the beautician on the importance of not turning the sink water off. 4. Weekly cleaning audits for footrests on all manual and electrical residents' stand-assist lifts on all units and handwashing sinks will be conducted in the kitchen/Beauty shop. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Responsible Party: Director of Facilities
Unsealed Openings in Elevator Shaft
Penalty
Summary
During a Life Safety Code Survey conducted from February 11 to February 19, 2025, a deficiency was identified on the first floor of a long-term care facility. The facility failed to properly maintain vertical openings, specifically within a fire-rated enclosure of an elevator shaft. Observations made on February 11, 2025, at 10:48 AM revealed unsealed openings in the elevator shaft located in the first-floor elevator equipment room. These included two approximately 1/2-inch by three-inch openings around electrical raceways and two approximately 1/2-inch by three-inch semi-circular openings around hydraulic lines. These openings extended through the concrete block wall into the elevator shaft. The facility has two elevators serving the first, second, and third floors. During an interview, a Maintenance Staff Member mentioned that some upgrades to the elevators had been completed a couple of months prior to the survey.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. Facility conducted an immediate inspection on all vertical openings in the elevator shaft on 02/12/2025. All unsealed openings were sealed immediately by facilities staff using fire rated materials on 02/12/2025. 2. Maintenance performed a facility wide audit of all openings to identify any additional unsealed openings. All openings were sealed by facilities staff. 3. Education will be provided to all pertinent staff regarding the importance of sealing any needed openings/penetrations in fire walls. 4. A monthly audit of fire wall penetrations will be conducted monthly for three months. A copy of the audits will be presented to QAPI committee who will then decide the needed frequency of the audits thereafter. Responsible Party: Director of Facilities
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented to address the medical, physical, mental, and psychosocial needs of three residents. Resident #27, who was receiving oxygen therapy as per physician orders, did not have the use of oxygen or appropriate interventions included in their care plan. Despite observations of the resident receiving oxygen, the care plan lacked goals and interventions related to oxygen use. Resident #81, diagnosed with cerebral vascular accident and right-sided hemiplegia, had a physician order for a right-hand splint to be used during waking hours. However, multiple observations revealed the splint was not in use, and the resident reported not having it for months. The care plan included the use of the splint but did not document any refusal of care or reasons for its absence. Interviews with staff indicated a lack of awareness and documentation regarding the splint's status and maintenance. Resident #108, admitted with multiple diagnoses including anemia and depression, had a care plan that identified several problem areas but lacked specific interventions for each. The care plan did not include interventions for anemia, pain management, antidepressant use, skin integrity, bladder incontinence, visual impairment, falls, or anticoagulant therapy. The Registered Nurse Manager acknowledged the incomplete care plan, indicating a failure to provide comprehensive guidance for the resident's care needs.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 1. Conducted an immediate review of the care plans for all affected residents. Updated the care plans to reflect individualized needs, preferences, interventions, and goals. Communicated changes with interdisciplinary team members and residents to ensure alignment. 2. Reviewed documentation to ensure care plans are current, accurate, and person-centered. Resident #27, #81, and #108 care plans were updated on 02/20/2025 to reflect intervention. All residents' care plans were audited on 03/10/2025. 3. Conduct mandatory training for all nurse managers, clinical coordinators, and interdisciplinary team members on proper care plan development and reinforce training on resident-centered planning, assessment accuracy, and regulatory requirements. Reviewed Interdisciplinary Care Plan. Implemented a standardized checklist for care plan completeness and accuracy. 4. Monthly care plan audit will be completed, and the results of audits will be presented to QAPI for three months. The committee will determine the frequency of the audit thereafter. Responsible party: Director of Nursing
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with grooming and personal hygiene for a resident who was dependent on staff for such care. The resident, who had a history of cerebral vascular accident with right-sided hemiplegia, malnutrition, and failure to thrive, was observed with long fingernails filled with brown debris over an extended period. Despite the facility's policy requiring nail care on shower days, the resident's nails were not attended to, leading to discomfort and frustration as expressed by the resident during interviews. Observations on multiple occasions revealed the resident eating with unclean nails, which were not trimmed or cleaned as per the care plan. Interviews with staff, including a Registered Nurse Manager and the Director of Nursing, confirmed that nail care should have been performed on the resident's designated shower day or as needed. However, this care was not provided, and there was no documentation of any resident refusals or care planning adjustments, indicating a lapse in adhering to the facility's policies and care plan requirements.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. Immediately assessed and provided nail care to the resident affected. Checked for any sign of infection, overgrowth, or discomfort. 2. Identified residents who require routine or specialized nail care. Referred any residents with advanced nail care concerns to a podiatrist for further treatment. 3. Train nursing staff on proper nail care procedures, policy, hygiene importance, and documentation. Integrated nail care checks with all weekly showers. 4. Weekly nail care audits will be conducted on all units. These results will be presented to the QA committee for review. The committee will determine the frequency of the audit thereafter. Responsible: Director of Nursing
Medication Administration Errors and Non-Compliance with Physician Orders
Penalty
Summary
During a recertification survey conducted from February 11 to February 19, 2025, it was found that the facility failed to maintain a medication error rate of five percent or less, resulting in a rate of 12.5 percent. This was due to the improper administration of medications to two residents. Specifically, enteric-coated, extended-release, and sustained-action medications labeled 'Do Not Crush' were crushed and administered. Additionally, cardiovascular medications were given without checking the required vital signs, such as blood pressure and heart rate, as per physician orders. One resident, diagnosed with atrial fibrillation, hypertension, and chronic kidney disease, was prescribed diltiazem and metoprolol, both with specific hold parameters for heart rate and blood pressure. However, these medications were crushed and administered without obtaining the necessary vital signs. The LPN involved acknowledged missing the hold parameters and admitted to the error of crushing the medications. The electronic medical record showed no documentation of vital signs being checked before medication administration. Another resident, with diagnoses including gastro-esophageal reflux disease and Alzheimer's disease, was prescribed pantoprazole, an enteric-coated medication. This medication was also crushed and administered despite the 'Do Not Crush' label. Interviews with facility staff, including a Physician Assistant and the Director of Nursing, confirmed that medications labeled 'Do Not Crush' should not be crushed, and vital signs should be checked and documented before administering medications with hold parameters.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. The Licensed practical nurse immediately acknowledged the error and gave the residents uncrushed prescribed medication. 2. Assessments were done for all other residents on the Nurse's assignment, and no other residents were affected. 3. Nurse educator will provide all licensed practical nurses mandatory medication administration, documentation, and error prevention training starting 3/10/2025. 4. Two to three weekly medication audits will be conducted for all nurses. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audits thereafter. Responsible Party: Director of Nursing
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a recertification survey. Specifically, a Licensed Practical Nurse (LPN) administered two cardiovascular medications, diltiazem and metoprolol, to a resident without obtaining the required vital signs, such as heart rate and blood pressure, as per physician orders. The resident, who had diagnoses including atrial fibrillation, hypertension, and chronic kidney disease, was severely cognitively impaired. The physician's orders specified that the medications should be withheld if the heart rate was less than 60 beats per minute or systolic blood pressure was less than 100, and the LPN failed to check these parameters before administration. Additionally, the LPN crushed the metoprolol extended-release tablet despite a pharmacy label indicating 'do not crush.' This action was acknowledged as an error by the LPN during an interview. The facility's policy on medication administration required nurses to question unclear or potentially erroneous medication orders and to check and document vital signs for medications with specific parameters. The failure to adhere to these protocols resulted in the administration of medication without proper assessment, as confirmed by the absence of documented vital signs in the resident's electronic medical record.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. Assessed resident #110 for any adverse reactions; none were noted. 2. The nurse manager was notified of the errors, and the Licensed Practical Nurse was immediately re-trained on proper medication administration. The facility has initiated identifying the resident's ability to take medication as a banner in the EMR. 3. The nurse educator initiated immediate and ongoing education on medication administration, documentation, and error prevention strategies for all Licensed Practical Nurses. Conduct medication pass observation for all Licensed Practical Nurses to ensure proper techniques and adherence to policies and procedures, starting 03/10/2025. 4. Implement two to three random weekly medication pass audits. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audits thereafter. Responsible Party: Director of Nursing
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to ensure proper implementation of its Infection Control Program, specifically in the use of Personal Protective Equipment (PPE) during wound care for a resident on Enhanced Barrier Precautions. The resident, who had a history of a cerebral vascular accident with aphasia, falls, and weakness, was moderately impaired cognitively and had an unstageable pressure ulcer. The physician's orders required daily wound care, which included cleaning and dressing the wound. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care on the resident without wearing a gown, despite the Enhanced Barrier Precaution sign at the room entrance instructing staff to wear both gloves and a gown for high-contact activities. Interviews with staff, including the LPN, a Registered Nurse Manager, and the Director of Nursing, confirmed that the resident was on Enhanced Barrier Precautions due to a COVID-19 outbreak on the unit. The staff acknowledged that gowns should have been worn during wound care to prevent the spread of infection. The facility's policy required signage and appropriate PPE for rooms with transmission-based precautions, but this was not adhered to during the observed incident, leading to a deficiency in infection control practices.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 Directed Plan of Correction 1. The facility hired the services of a consultant to in-service infection Preventionist and staff educator on 03/10/2025. The consultant developed and implemented an acceptable plan of correction. 2. The facility QA Committee met on 03/06/2025 to examine the deficiencies cited. A. The QA committee's assessment of the causative factors contributing to the deficiencies was that agency staff was not adequately trained on using PPE for Enhanced Barrier Precaution. B. Facility infection Preventionists educated Licensed practical nurses on proper PPE use regarding resident #21. The infection prevention will round the facility daily on each shift to ensure staff and contracted services adhere to appropriate PPE use. C. Two Weekly PPE audits will be conducted on all units. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Directed Inservice All nursing staff will be in service from 3/10/2025 through 04/14/2025 on proper PPE use for all residents during wound care. B. The infection preventionist or designee will conduct a walkthrough of the building. Observation of nursing staff on the proper use of PPE. C. Ad hoc education will be provided to persons not correctly implementing infection prevention and control procedures. Responsible Party: Director of Nursing
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to properly maintain medical gases in compliance with the 2012 edition of NFPA 99, Standard for Health Care Facilities. During a Life Safety Code Survey, it was observed that oxygen cylinders were stored in an outdoor area unprotected from inclement weather. Specifically, a large wheeled green metal rack holding 77 full E-size oxygen cylinders was found with snow accumulation and melting snow on some of the tanks. This rack was only covered on the top and open on all four sides. Additionally, an uncovered wheeled cart holding 10 full E-size oxygen cylinders was located next to the larger rack. The Director of Facilities acknowledged the issue and suggested that the tanks could be moved to a lean-to area or an enclosure. The NFPA 99 requires that storage locations for medical gases be outdoors in an enclosure or within an enclosed interior space, protected against weather extremes, and secured against unauthorized entry.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. Facility ordered and will install an enclosure that meets NFPA 99 standards. Facility immediately ensured all gas cylinders are stored upright and were properly secured with chains and straps to prevent tipping. “No smoking” and “Flammable gas” signs have also been placed in visible locations around the storage area. Also, the facility clearly labeled full and empty cylinders to ensure separation. 2. A facility-wide review was conducted to ensure all O2 cylinders throughout the facility were stored properly. The facility also implements a weekly inspection checklist for gas storage compliance and documentation. 3. All pertinent facility staff will be educated on the proper use, transport, and storage of full and empty O2 cylinders. 4. The facility will conduct a monthly audit of O2-cylinder storage for three months. These results will be presented to the QA committee for review. The committee will determine the needed frequency of the audit thereafter. Responsible Party: Director of Facilities
Emergency Preparedness Contact Information Not Updated
Penalty
Summary
The facility failed to comply with emergency preparedness requirements as identified during an Emergency Preparedness Plan review and Life Safety Code Survey. The deficiency was noted in the facility's failure to update emergency contact information in the New York State Health Commerce System. Specifically, the 24/7 Facility Contact information was last updated in August 2021, the Director of Nursing's information was last updated in June 2023, the Emergency Medical Supplies Receiving Office was last updated in March 2020, and the Office of the Administrator was last updated in August 2021. Additionally, the contact information for the Director of Nursing was outdated, listing an email address for a former employee. During an interview, the Administrator acknowledged that the Director of Nursing's information was not current and stated that they would update it.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. Facility emergency contacts list was updated 02/13/2025 on the Health Commerce System. 2. All other facility contact lists were reviewed to ensure they were up to date as well to reflect our current staff. 3. The Contact list will be updated annually by Administrator. All pertinent staff will be educated on the need to ensure this list is always current and up to date. 4. A copy of emergency contact list will be presented to QAPI committee monthly for three months to ensure accuracy. Then the QA committee will determine the needed audit frequency thereafter. Responsible Party: Administrator
What surveyors are citing around you — mapped
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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 Pittsford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Penfield Place | 3.1 mi | ★★★★★ | 0 | 0 |
| The Friendly Home | 3.1 mi | ★★★★★ | 11 | 0 |
| Crest Manor Living And Rehabilitation Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Fairport Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Aaron Manor Rehabilitation And Nursing Center | 3.4 mi | ★★★★★ | 0 | 0 |
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