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 Lilac Manor Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Ceiling Tiles in Resident Rooms Were Stained, Cracked, and Bowing: The facility failed to maintain two resident rooms in a sanitary, orderly, and comfortable condition. Observations found multiple ceiling tiles with brown stains, and in one resident’s room several tiles were bowing with one cracked around a sprinkler. The resident had HTN, depression, anxiety disorder, and moderate cognitive impairment, and stated they had complained to Maintenance about the ceiling looking nasty when admitted. The DORM stated the tiles needed to be replaced, and the Administrator said they were not aware of the issue.
Pest Control Program Not Effective: Mouse droppings and pest harborage were observed on multiple resident-use floors, including beneath heaters in dining rooms and in resident rooms. A resident stated they had seen a mouse in their room, and staff reported seeing mice and mouse droppings in the facility. The DON and Administrator acknowledged the mouse problem and said the current pest control frequency was monthly rather than weekly.
A resident with severe cognitive impairment and a history of blood clots was prescribed Lovenox injections, which were refused multiple times and subsequently discontinued by a provider. The facility did not notify the resident's representative of the refusals or the discontinuation, despite policy requirements. The representative later reported being unaware of the medication status when the resident was hospitalized for an acute ischemic stroke.
The facility failed to provide a safe and sanitary environment, with hot water temperatures consistently below required levels, inadequate housekeeping, and maintenance services leading to unsanitary conditions. Residents reported not receiving showers due to cold water, and the facility was understaffed in maintenance, exacerbating these issues.
The facility failed to investigate allegations of abuse and injuries for several residents. A resident reported abuse by CNAs, but no investigation was documented. Another resident with a laryngeal fracture was not investigated for potential trauma. Two residents involved in a resident-to-resident incident also lacked a documented investigation. Missing investigations were noted, possibly due to leadership changes.
A facility failed to ensure residents were free from significant medication errors, affecting four residents. One resident received multiple doses of oxycodone beyond the prescribed amount, while another experienced inconsistent dosing due to a shortage of medication. A third resident did not receive a full course of antibiotics, and a fourth missed multiple prescribed medications. The errors were not properly documented or communicated to medical providers.
The facility failed to ensure safe medication storage and proper labeling, with medications found in an unlocked room, undated insulin bottles, and unclean medication carts containing loose pills. Interviews revealed unclear responsibilities for maintaining cleanliness and organization.
The facility failed to manage resources effectively, leading to unsanitary conditions, inadequate investigation of abuse allegations, and insufficient care for residents' daily living activities. Essential equipment was not maintained, and behavioral health services were inconsistent, with medication errors also noted.
The facility did not maintain essential equipment, including exhaust vents, oxygen concentrators, and hoyer lifts, leading to significant odors and inadequate oxygen delivery to a resident. Maintenance staffing issues contributed to unresolved equipment failures, affecting hot water boilers and laundry machines.
The facility failed to ensure an organized system for honoring residents' wishes regarding CPR and DNR orders, resulting in discrepancies in code status documentation for several residents. A resident with heart failure had conflicting DNR documentation, while another resident's care plan and MOLST form did not match. Additionally, a cognitively impaired resident's code status was not regularly reviewed, leading to inconsistencies in documentation.
The facility failed to protect residents' belongings, with reports of missing items and money from several residents. Despite policies requiring prompt investigation, the facility lacked documentation of any investigations or resolutions. Specific cases involved residents with missing clothing, personal items, and money, with staff interviews revealing communication and follow-up issues.
The facility failed to provide timely written notifications of transfers to residents, their representatives, and the Ombudsman for three residents with urgent medical needs. Despite having a policy in place, there was no documentation of such notices being provided. Interviews revealed confusion among staff about notification responsibilities, and the facility could not provide evidence of notifying the Ombudsman, citing access issues to previous records.
Three residents in an LTC facility did not receive necessary assistance for personal hygiene and grooming. A resident with dementia reported infrequent showers and desired hair washing, but records showed no documentation of showers or refusals. Another resident with Alzheimer's remained unshaven with long nails despite scheduled weekly showers, and a third resident expressed a need for a haircut, which was unmet due to the absence of a facility stylist.
A resident with cerumen impaction did not receive ear flushing as ordered by a physician, leading to continued hearing difficulties. Facility staff were unaware of the order and lacked the necessary equipment to perform the procedure. Interviews revealed a lack of communication and understanding among staff regarding the resident's care needs.
Two residents with limited range of motion did not consistently receive the prescribed hand splints to prevent further decline. Despite care plans and staff education, observations showed the splints were not applied as required, leading to increased pain and potential decline in function. Staff interviews revealed forgetfulness and lack of adherence to care plans, contributing to the deficiency.
A resident with respiratory failure and other conditions did not receive proper respiratory care due to the absence of a physician order and a care plan for oxygen therapy. The resident's oxygen concentrator was not functioning properly, leading to low oxygen saturation levels. Facility staff confirmed the lack of necessary documentation and maintenance for the equipment.
A resident with multiple chronic pain conditions did not receive appropriate pain management as per their care plan. The facility failed to administer prescribed medications consistently, and the care plan lacked person-centered goals and non-pharmacological interventions. Medication records showed discrepancies, and the resident reported increased pain and hallucinations due to missed doses.
A resident with schizoaffective disorder and other mental health conditions did not receive necessary behavioral health services, including timely medication changes and consistent psychiatric care. The care plan was not individualized, and the resident's power wheelchair remained unrepaired, affecting their mobility and well-being. Missed telepsychiatry appointments and poor communication between providers contributed to the deficiency.
The facility failed to comply with the 2015 International Fire Code by not having carbon monoxide detectors in the first-floor laundry room and kitchen, where natural gas-powered appliances are present. Staff interviews revealed a lack of awareness about detector placement, and records showed monthly signoffs but did not include these areas.
The facility did not ensure that the New York State Department of Health survey results were readily accessible to residents, family members, and legal representatives. Residents were unaware of the survey results' location, and the sign indicating their availability was not visible at wheelchair level. The facility was unable to provide the previous three years' survey results, and the Administrator acknowledged the oversight.
The facility did not provide Medicare Noncoverage notices to two residents, failing to inform them of their appeal rights after the termination of Medicare benefits. One resident continued in LTC without coverage, and another was discharged without receiving the required notice. The responsibility for issuing these notices was with the Social Worker or other designated staff, but no evidence was found to confirm the notices were given.
The facility failed to complete baseline care plans within 48 hours of admission for several residents, including those with serious medical conditions. Additionally, summaries of these care plans were not provided to the residents or their representatives. Staff interviews revealed confusion about responsibilities, and facility leadership was unaware of these deficiencies.
The facility did not consistently post accurate nurse staffing information, including the number and hours worked by staff and the daily resident census. Observations showed outdated postings, and interviews revealed staff were unaware of the requirements for updating and posting this information, particularly on weekends.
Ceiling Tiles in Resident Rooms Were Stained, Cracked, and Bowing
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in two resident rooms, including Rooms 215 and 524. The facility’s Maintenance Service policy dated April 2025 stated that the Maintenance Department was responsible for maintaining the building in compliance with applicable laws, regulations, and guidelines and for keeping the building in good repair. During observations, Room 524 had six ceiling tiles with brown stains, and Room 215 had multiple ceiling tiles with stains, cracks, and bowing. The Director of Maintenance stated that the ceiling tiles in Room 524 needed to be replaced. Resident #4, who occupied Room 215, had diagnoses including hypertension, depression, and anxiety disorder, and the MDS dated 03/07/2026 showed moderate cognitive impairment. On 05/14/2026, Room 215 was observed to have six ceiling tiles with brown stains; three of the stained tiles were bowing and one tile had visible cracks around a ceiling sprinkler. Resident #4 stated they had complained to Maintenance when admitted because the ceiling tiles looked nasty, and Maintenance said they would look into it. The Director of Maintenance stated the tiles were bowing, did not know how long they had been like that, and needed to be replaced. The Administrator stated they were not aware of ceiling tiles that needed to be replaced, and that ceiling tiles had been ordered to have in stock for the facility.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program on the Second, Third, and Fifth resident-use floors. During observations, mouse droppings and pest harborage conditions were found in multiple areas, including beneath heaters in the Fifth Floor dining room, where holes were also seen in the wall on both sides of one heater and near another heater. Mouse droppings and wall openings were also observed in the Second Floor dining room and in a resident room on the Second Floor, with additional droppings seen in a resident room on the Fifth Floor. Resident #1, who was cognitively intact and had diagnoses including dysphagia, diabetes, and immunodeficiency due to drugs, stated they had seen a mouse in their room the night before the observation. Staff interviews confirmed awareness of mice in the facility, including a housekeeper who reported cleaning mouse droppings and seeing a mouse in the basement, a CNA who stated they had seen mice near traps, and the Director of Environmental Services and Administrator who acknowledged the facility had a mouse problem and was changing pest control vendors because the current monthly service was not frequent enough. The Director of Maintenance also identified an opening in the wall near the droppings under the heater in the resident room and stated it needed to be fixed.
Failure to Notify Resident Representative of Significant Medication Change
Penalty
Summary
The facility failed to immediately notify a resident's representative when there was a significant change in the resident's treatment plan. Specifically, a resident with diagnoses including acute embolism, thrombosis of the right femoral vein, vascular dementia, and a history of cerebral infarction was prescribed Lovenox injections for deep vein thrombosis. The resident, who had severely impaired cognition, refused the Lovenox on several occasions, leading to the medication being discontinued by a provider. Despite facility policy requiring notification of the resident's representative in such cases, there was no documented evidence that the representative was informed of either the refusals or the discontinuation of the medication. Further review of the resident's records showed that after the medication was discontinued, the resident experienced a medical event and was transported to the hospital, where they were diagnosed with an acute ischemic stroke. During the hospital admission, the resident's representative reported being unsure if the resident had been receiving the Lovenox injections at the facility. Interviews confirmed that the provider should have notified the representative about the medication change, but this did not occur.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by numerous deficiencies observed during the survey. The hot water temperature in various locations throughout the facility was consistently below the required 90 degrees Fahrenheit, with some areas reporting temperatures as low as 73.8 degrees Fahrenheit. This issue was compounded by low water pressure, making it difficult for residents to receive proper hygiene care. Interviews with residents and staff revealed that many residents had not received showers for extended periods due to the lack of hot water, and some were forced to take bed baths with cold water. Additionally, the facility's housekeeping and maintenance services were inadequate, leading to unsanitary and unsafe conditions. Observations included dirty and disrepaired floors, walls, and ceilings, non-functional ventilation systems resulting in foul odors, and plumbing fixtures that were either not maintained or not working properly. There were also reports of standing water in various areas, exposed electrical wiring, and damaged light fixtures, all of which contributed to an unsafe environment for residents and staff. The facility's staffing issues further exacerbated these problems, as the maintenance department was understaffed, with only the regional maintenance director available to address the numerous deficiencies. This lack of adequate maintenance personnel likely contributed to the ongoing issues with water temperature, pressure, and overall facility upkeep. Interviews with staff and residents highlighted the persistent nature of these problems, with some issues reportedly ongoing for several months.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to provide evidence of thorough investigations into allegations of abuse and injuries of unknown origin for six residents. Resident #22 reported physical aggression by two Certified Nursing Assistants, but the facility could not provide documentation of a completed investigation. Although one of the CNAs was terminated, the Director of Nursing acknowledged the lack of a documented investigation. Resident #371, who had a history of falls and was cognitively intact, was found to have a laryngeal fracture after being sent to the hospital for neck swelling and difficulty swallowing. The hospital physician noted that trauma could not be excluded as a cause, yet the facility did not initiate an investigation into the injury of unknown origin. The Director of Nursing admitted that an investigation should have been conducted but was not. Residents #68 and #100, both with severe cognitive impairments, were involved in a resident-to-resident incident where Resident #100 sustained a head injury. The facility failed to provide evidence of a thorough investigation into this incident or subsequent similar incidents. The Corporate Infection Preventionist noted that investigations were missing, possibly due to changes in facility leadership.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting four out of ten residents reviewed for medication administration. Resident #42, who had diagnoses including heart failure and diabetes, was prescribed oxycodone 5 milligrams daily for pain management. However, the facility's records showed that multiple doses of oxycodone were removed and possibly administered on several days, exceeding the prescribed amount. This discrepancy was noted by a Nurse Practitioner, and the error was reported to the Medical Director and consulting pharmacist. The involved LPN claimed to have followed a previous order, not the current one. Resident #52, diagnosed with ankylosing spondylitis and complex regional pain syndrome, was prescribed 7.5 milligrams of oxycodone three times daily. However, the facility's records indicated inconsistencies in the administration of the medication, with instances of both under-medication and over-medication. The resident reported that the facility ran out of the 2.5 milligram tablets, leading to incorrect dosing. The LPN involved did not document any waste of medication, and there was no evidence of suspension or investigation into the errors. Resident #100, with severe cognitive impairment, was prescribed a three-day course of ceftriaxone for pneumonia. The first dose was not administered as scheduled, and there was no documentation of the medical team being notified of the missing dose. The Corporate Infection Prevention Nurse confirmed that the antibiotic should have been available from the facility's emergency supply. Additionally, Resident #37, with moderate cognitive impairment, did not receive multiple prescribed medications on specific days, with no documentation of administration or notification to the medical provider. The facility's Director of Nursing acknowledged that a blank box on the Medication Administration Record indicated that nothing was done.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications and proper labeling in accordance with professional standards. During the Recertification Survey, it was observed that medications were stored in an unlocked clean utility room on the 3rd floor, which contained cleaning supplies and an open cabinet with over-the-counter medications and topical creams. Additionally, the 3rd Floor medication room had several bottles of insulin that were open and undated, and the 4th Floor medication refrigerator contained opened and expired insulin pens. Furthermore, the medication carts on both the 3rd and 4th floors were found to be unclean and disorganized. The 3rd Floor medication cart contained unlabeled inhalers, multiple loose unidentified pills, spilled red liquid, and dust and debris. Similarly, the 4th Floor medication cart had approximately 40 loose unidentified pills. Interviews with nursing staff revealed a lack of clarity regarding responsibility for organizing and cleaning these areas, with the Director of Nursing stating that medication cart and room audits should be conducted weekly, and all medications should be kept behind locked doors or cabinets.
Resource Mismanagement and Care Deficiencies
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in several deficiencies impacting resident care and safety. The facility did not maintain a sanitary, orderly, and comfortable environment, as evidenced by dirty and disrepaired floors, walls, and ceilings, non-functional ventilation systems, and malfunctioning plumbing and electrical fixtures. Additionally, essential equipment such as laundry machines, hot water boilers, and patient care lifts were not maintained in safe operating condition, leading to further discomfort and potential safety hazards for residents. The facility also failed to thoroughly investigate allegations of resident abuse and injuries with unknown origins. For six residents reviewed, there was no evidence of comprehensive investigations into these allegations. This lapse was attributed to changes in facility leadership, as noted by the Corporate Infection Preventionist. Furthermore, the facility did not ensure that residents requiring assistance with activities of daily living received necessary services, such as nail care, shaving, bathing, and hair grooming, compromising their personal hygiene and dignity. Behavioral health services were inadequately provided, as one resident did not receive consistent psychiatric services or medication changes as recommended. The facility's telepsychiatry services were disrupted due to a lack of clinical staff to accompany residents during appointments and communication issues with providers. Additionally, medication administration errors were identified, with residents receiving incorrect doses or omissions of significant medications. These deficiencies highlight the facility's failure to maintain a safe and supportive environment for its residents.
Facility Fails to Maintain Essential Equipment
Penalty
Summary
The facility failed to maintain essential mechanical, electrical, and resident care equipment in safe operating condition across all five resident-use floors and the basement. Observations revealed that multiple exhaust vents were not functioning, leading to significant odors throughout the facility. The main fire alarm panel displayed trouble signals related to exhaust fans. An oxygen concentrator was not working effectively for a resident, resulting in low oxygen saturation levels until a mask was attached to an oxygen cylinder. Additionally, two hoyer lifts were marked as broken without documentation of repair efforts. The facility's maintenance department was understaffed, with only the regional maintenance director available due to staff absences and recent terminations. Two of the three hot water boilers were operational, affecting the entire facility, including the kitchen, which reported no hot water and had to use paper for serving meals. Laundry equipment was also non-functional, with a dryer and washing machine out of service for extended periods. The regional maintenance director was unaware of the exhaust ventilation issues, and further observations confirmed non-functional exhaust motors on the roof.
Discrepancies in Advanced Directives and Code Status Documentation
Penalty
Summary
The facility failed to ensure an organized system for honoring residents' wishes regarding Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) orders, as evidenced by discrepancies in the code status of several residents. Resident #59, who was cognitively intact and had a diagnosis of heart failure, wound infection, and diabetes, had conflicting documentation regarding their DNR status. Although their Medical Orders for Life Sustaining Treatment (MOLST) form indicated a DNR preference, Nurse Practitioner #2's notes documented the resident as Full Code due to the absence of medical orders for advanced directives. Resident #22, also cognitively intact with diagnoses including heart failure and chronic obstructive pulmonary disease, had a care plan indicating a DNR preference, but their MOLST form, signed by the resident and witnessed by a Registered Nurse and a family member, documented a preference for CPR. This discrepancy was not known to the Licensed Practical Nurse Manager until the day of the interview, highlighting a lack of awareness and communication regarding the resident's advanced directives. Resident #29, who was severely cognitively impaired with diagnoses of depression, schizophrenia, and hypertension, had a MOLST form indicating a DNR preference. However, Nurse Practitioner #2's notes documented the resident as Full Code, and there was no evidence of regular review of the resident's code status by a medical provider. The Nurse Practitioner admitted that their documentation system defaulted to Full Code unless specified otherwise, contributing to the inconsistency in the resident's code status documentation.
Failure to Protect Residents' Personal Belongings
Penalty
Summary
The facility failed to protect residents from the misappropriation of their belongings, as evidenced by multiple reports of missing personal items and money from residents. During a Resident Council meeting, several residents reported missing items such as an electric razor, cell phone, and cell phone charger, with no resolutions provided by the facility. The facility's policies on personal property and lost and found require prompt investigation and documentation of missing items, but the facility was unable to provide any documentation of investigations or resolutions for the past year. Specific cases include Resident #28, who was cognitively intact and reported missing several clothing items despite labeling them, and Resident #57, who was moderately cognitively impaired and reported missing clothing, wheelchair padding, a blanket, and $60. Interviews with staff revealed a lack of communication and follow-up on missing items, with some staff unaware of the missing items and others not completing necessary paperwork. The Director of Nursing was not aware of the missing items and expected staff to report and replace them if not found, but no documentation was available to support these actions.
Failure to Provide Timely Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to residents and their representatives, as well as to the Office of the State Long-Term Care Ombudsman, for three residents who required immediate transfers due to urgent medical needs. The facility's policy, dated March 2021, mandates that such notifications be provided in writing and in a language and manner understood by the resident or their representative. However, the facility did not adhere to this policy for Residents #90, #116, and #371, as there was no documentation of written notices being provided. Resident #371, who was cognitively intact and had diagnoses including adult failure to thrive and chronic kidney disease, was transferred to the emergency department due to difficulty swallowing. Resident #90, with severe cognitive impairment and conditions such as seizure disorder and dysphagia, was transferred to the hospital to address issues with their PEG tube. Resident #116, also cognitively intact and diagnosed with chronic obstructive pulmonary disease and congestive heart failure, was transferred to the hospital by EMS. In all cases, the facility failed to document that written notices of these transfers were provided to the residents or their representatives. Interviews with facility staff revealed confusion and lack of clarity regarding the responsibility for completing and providing transfer notifications. The Director of Nursing initially stated that the Business Office was responsible for these notifications, but later indicated that the Ombudsman was notified monthly via fax. However, the facility was unable to provide documentation of such notifications, citing an inability to access the previous Social Worker's files. This lack of documentation and communication highlights a deficiency in the facility's adherence to regulatory requirements for resident transfer notifications.
Deficiencies in Personal Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living to three residents, leading to deficiencies in personal hygiene and grooming. Resident #87, diagnosed with Lewy body dementia, COPD, and major depressive disorder, was severely cognitively impaired and required extensive assistance with personal hygiene. Despite this, the resident reported having only a few showers over six months and expressed a desire for hair washing during showers instead of using a no-water cap. Observations confirmed the resident's hair appeared oily and unwashed, and there was no documentation of showers or refusals in the electronic health record. Resident #76, with Alzheimer's disease, legal blindness, and hypertension, was also severely cognitively impaired and needed staff assistance for personal hygiene and nail trimming. Despite being scheduled for weekly showers, observations over several days showed the resident remained unshaven with long nails. The Treatment Administration Record indicated only one shower was documented for May, and staff interviews revealed inconsistencies in providing and documenting care. Resident #52, who was cognitively intact but dependent on staff for grooming, expressed a desire for a haircut, which had not been provided due to the absence of a stylist in the facility. The Activities Director confirmed that the last barber had left over a month ago, and there was no system in place to track haircut requests. These deficiencies highlight the facility's failure to ensure residents received necessary services to maintain good grooming and personal hygiene.
Failure to Provide Ear Flushing for Resident with Cerumen Impaction
Penalty
Summary
The facility failed to provide proper treatment to maintain the hearing abilities of a resident, as evidenced by the lack of ear flushing per physician orders. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease, diabetes, and hypertension, was found to have significant cerumen impaction in both ears. Despite a physician's order to flush the resident's ears, there was no documentation that this procedure was ever completed, and the resident continued to experience hearing difficulties. Interviews with facility staff revealed a lack of awareness and understanding regarding the order to flush the resident's ears. The Licensed Practical Nurse Manager was unaware of the order and did not know who was responsible for performing the procedure or where the necessary equipment was located. The Director of Nursing confirmed that either a Licensed Practical Nurse or a Registered Nurse could perform the ear flushing but was unable to explain why the order was not carried out. Additionally, the Nurse Practitioner indicated that the facility lacked the necessary equipment, such as an otoscope and curettes, to perform the procedure, and that the medical team was not informed of the need to bring their own equipment.
Failure to Apply Hand Splints for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to prevent further decline. Resident #37, who has dementia, malnutrition, and contractures, was observed multiple times without the recommended hand splints, which were intended to decrease pain and minimize contractures. Despite a care plan and instructions for staff to apply the splints, observations revealed that the splints were not consistently worn, and staff interviews indicated a lack of adherence to the care plan. The resident experienced pain due to joint stiffness, and the splints were noted to reduce pain when applied. Resident #90, with diagnoses including dementia, seizures, and a stroke, also did not consistently wear the prescribed hand splint. The resident's care plan included a schedule for wearing the splint, but observations showed the splint was often not applied. Staff interviews revealed that the splint was not put on due to forgetfulness and lack of continuity in care. The resident's current pain was attributed to the lack of stretching from not wearing the splint, as noted by the occupational therapist. The deficiency was further highlighted by the occupational therapy discharge summaries, which indicated that staff were non-compliant with the splint schedule despite being educated on the procedure. The Director of Nursing acknowledged that the care plan should be followed and any resident refusal should be documented, but there was no indication that the residents refused the splints. The lack of consistent application of the splints contributed to the residents' pain and potential decline in their range of motion.
Deficiency in Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #42, who required oxygen therapy. The resident, who had diagnoses including respiratory failure, congestive heart failure, and hypertension, did not have a physician order for oxygen use, nor was there a person-centered comprehensive care plan for oxygen therapy. Observations revealed that the resident was using an oxygen concentrator that was not functioning properly, as evidenced by a low oxygen saturation level of 86 percent, which improved to 96 percent when switched to an oxygen tank. The facility's policy required verification of a physician's order, a review of the care plan, and ensuring equipment was in good working order, none of which were adhered to in this case. Interviews with facility staff, including Licensed Practical Nurse #5, Licensed Practical Nurse Manager #1, and Registered Nurse Manager #3, confirmed the absence of a physician order and a care plan for the resident's oxygen therapy. Additionally, the Corporate Infection Preventionist acknowledged the lack of preventive maintenance inspections for patient care equipment, including oxygen concentrators. The Director of Nursing was unaware of any concerns related to oxygen administration, despite a quality assurance initiative supposedly in place to ensure proper servicing of oxygen equipment.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, identified as Resident #52, during a recertification survey and complaint investigation. The resident, who had multiple diagnoses including ankylosing spondylitis, complex regional pain, and schizoaffective disorder, experienced significant pain rated at 9 out of 10, which affected their sleep, rehabilitation therapy participation, and daily activities. Despite having a comprehensive care plan, it lacked person-centered goals and non-pharmacological interventions. The resident's pain medication was not administered as ordered on several occasions, and there was no physician notification regarding these omissions. The Medication Administration Records for April, May, and June 2024 showed multiple instances where the resident did not receive their prescribed doses of Tylenol, Lyrica, and oxycodone. Additionally, there were discrepancies in the administration of oxycodone, with records indicating incorrect dosages and lack of documentation for wasted medication. Interviews with the resident revealed that they experienced increased pain and hallucinations due to missed or partial doses of medication. The resident also reported that non-pharmacological interventions, such as ice or heat therapy, were not offered, and they no longer received patches that previously helped with their pain. The facility's failure to manage the resident's pain effectively was acknowledged by the Registered Nurse Manager, who admitted the care plan was not individualized.
Deficiency in Behavioral Health Services and Care Plan Implementation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, as evidenced by the lack of medication changes, an inadequate care plan, and inconsistent psychiatric services. The resident, who has diagnoses including schizoaffective disorder, major depressive disorder with psychotic features, and anxiety disorder, did not receive the recommended medication adjustments. Specifically, the Seroquel dosage changes recommended by telepsychiatry were not implemented in a timely manner, and there was a lack of communication between the telepsychiatry providers and the facility's medical team. Additionally, the resident's comprehensive care plan was not individualized to address their specific behavioral health needs. The care plan lacked person-centered interventions and did not reflect the necessary psychiatric evaluations and follow-up services. The resident also experienced missed telepsychiatry appointments due to the facility's failure to provide the required computer access and clinical staff presence during appointments, further contributing to the inconsistency in psychiatric care. The resident's power wheelchair, damaged due to a facility incident, remained unrepaired, limiting their mobility and contributing to their distress. The facility did not provide evidence of when the wheelchair would be repaired, and the resident reported increased anxiety and depression due to the disorganization of their care. The facility's failure to ensure the resident received appropriate behavioral health services and support for their mobility needs resulted in a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being.
Non-Compliance with Carbon Monoxide Detection Requirements
Penalty
Summary
The facility was found to be non-compliant with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which mandates the use of carbon monoxide detection in buildings with fuel-burning appliances. During the Recertification Survey, it was observed that carbon monoxide detectors were absent in the first-floor laundry room and kitchen, despite the presence of three natural gas-powered dryers in the laundry room and a natural gas range in the kitchen. This deficiency was identified through observations and interviews conducted by the surveyor. Interviews with facility staff revealed a lack of awareness regarding the presence and proper placement of carbon monoxide detectors. A laundry employee was unsure if detectors were installed in the laundry room, and the Assistant Food Service Director indicated that a detector was not in its designated location in the kitchen. The facility's records for inspection and testing of carbon monoxide detectors were reviewed, showing monthly signoffs and listings of detector locations, but these did not include the areas where deficiencies were observed.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the results of the most recent New York State Department of Health inspection survey were readily accessible to residents, family members, and legal representatives. During a Resident Council Meeting, five alert and oriented residents reported being unaware of the location of the posted survey results. An observation revealed that the sign indicating the availability of the survey report was not visible at wheelchair level, and the survey results were not accessible without requesting them. Furthermore, when the previous three years' survey results were requested, the facility was unable to provide them. Interviews with the Receptionist Supervisor and the Administrator confirmed the deficiency. The Receptionist Supervisor acknowledged that the sign was not placed at a level accessible to individuals in wheelchairs and that only the 2023 recertification survey was available, with no results from the previous three years. The Administrator admitted to not realizing the sign was not at eye level and stated that the receptionist should assist in providing the results if asked. This deficiency was cited under 10NYCRR415.3(d)(1)(vi).
Failure to Provide Medicare Noncoverage Notices
Penalty
Summary
The facility failed to provide the appropriate appeal notices to Medicare beneficiaries prior to the termination of their Medicare benefits for two residents. Resident #12, who was admitted under Medicare Part A services, had their benefits terminated on 12/28/23 but continued to reside in the facility for long-term care services not covered by Medicare. There was no documented evidence that a Notice of Medicare Noncoverage letter was provided to the resident or their representative, informing them of their appeal rights following the termination of their Medicare benefits. Similarly, Resident #534, who was also admitted under Medicare Part A services, was discharged to the community on 4/30/24 without evidence of receiving a Notice of Medicare Noncoverage letter. This letter should have been provided at least two days before the end of their Medicare-covered stay to inform them of their appeal rights prior to discharge. Interviews with the Corporate Director of Resident Services and the Administrator revealed that the responsibility for issuing these notices lay with the Social Worker, or alternatively, the Minimum Data Set Resident Assessment department staff or the Business Office. However, no evidence was available to confirm that the notices were given to the residents or their representatives.
Failure to Complete and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed within 48 hours of admission for several residents, as required by their policy. Specifically, for one resident with diagnoses including End Stage Renal Disease, diabetes, and chronic kidney disease, there was no documented evidence of a baseline care plan being completed following admission. This resident had moderately impaired cognition, which underscores the importance of having a care plan in place to address immediate needs. The absence of documentation indicates a lapse in the facility's adherence to its own policy. Additionally, for three other residents with various medical conditions such as diabetes, chronic kidney disease, major depressive disorder, myelodysplastic syndrome, congestive heart failure, and anemia, the facility did not provide evidence that a summary of the baseline care plan was shared with the residents or their representatives. Interviews with staff revealed confusion about who was responsible for presenting the care plan summary, with some believing it was the responsibility of social work or nursing. The Director of Nursing and the Administrator were unaware of any issues related to baseline care plans, indicating a lack of communication and oversight within the facility.
Inconsistent Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily and included all required details, as observed during a Recertification Survey. The posted nurse staffing information consistently lacked the accurate number and total hours worked by both licensed and unlicensed nursing staff responsible for resident care. Additionally, the daily resident census was not documented, and staffing changes throughout the day were not reflected in the postings. Observations on multiple dates revealed that the facility's nurse staffing information was outdated and did not match the actual staffing schedules. Interviews with facility staff highlighted a lack of awareness and communication regarding the posting of nurse staffing information. The Staffing Coordinator admitted to not posting the information on weekends and was unaware of the requirement to update the postings to reflect current staffing per shift and include the resident census. The Director of Nursing also expressed uncertainty about who was responsible for adding the census to the staffing information and was not aware of the inconsistencies in weekend postings or the need for updates throughout the day.
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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 Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kirkhaven | 0.5 mi | ★★★★★ | 10 | 0 |
| Church Home Of The Protestant Episcopal Church | 1.7 mi | ★★★★★ | 0 | 0 |
| The Brightonian, Inc | 1.9 mi | ★★★★★ | 0 | 0 |
| St. John's Health Care Corporation | 2.1 mi | ★★★★★ | 0 | 0 |
| Blossom Health Care Center Inc. | 2.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.