Finger Lakes Center for Living

Inspectors wroteBased on observations and interviews (iQIES intake #26844070), the facility failed to follow proper sanitation practices to prevent the outbreak of food borne illness in one of one main kitchen. Specifically, the dish machine sanitizer concentration was not monitored, and dishware was not sanitized.

Inspectors wroteBased on record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for legionella (a bacteria causing Legionnaires' disease-a respiratory disease) testing. Specifically, the facility's water management plan and Environmental Assessment of Water Systems in Healthcare Settings was not reviewed/updated since 2022 and legionella testing was not completed since 2024.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure medication error rates were not greater than 5% for two of three residents (Residents #20 and #61) reviewed. Specifically, Residents #20 and #61 received discontinued medications resulting in a medication error rate of 9.38%.

Inspectors wroteBased on record review and interviews during a survey (iQIES #2733288), the facility failed to implement immediate measures to protect residents from abuse for two (2) of four (4) residents (Residents #1 and #2) reviewed. Specifically, there was witnessed verbal and physical abuse by Certified Nurse Aide #7 toward Resident #1. Certified Nurse Aide #7 continued to have access to residents, resulting in an incident of verbal abuse with Resident #2. There was no documented evidence that a registered nurse completed assessments on Resident #1 or Resident #2 on [DATE] after the incidents of witnessed abuse. Specifically:-On [DATE] at approximately 4:00 PM, Certified Nurse Aide #9 witnessed Certified Nurse Aide #7 handling Resident #1 roughly, spraying them with perfume when they were combative with care, and making a verbally abusive statement. [...]

Inspectors wroteBased on record review and interviews during a survey, the facility failed to timely report witnessed verbal and physical abuse for two (2) of four (4) residents (Residents #1 and #2) reviewed, resulting in the alleged perpetrator having continued access to residents. Specifically, on 02/01/2026 at approximately 4:00 PM, Certified Nurse Aide #9 witnessed Certified Nurse Aide #7 handling Resident #1 roughly, spraying them with perfume when they were combative with care, and making a verbally abusive statement. Certified Nurse Aide #9 reported the incident to Registered Nurse Supervisor #12, who did not assess Resident #1. Certified Nurse Aide #7 continued to have access to residents, and after supper, they made a verbally abusive statement to Resident #2, which was witnessed by Certified Nurse Aide #10. [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey (IQIES #2626859), the facility failed to ensure residents were free from significant medications errors for one (1) of five (5) residents (Resident #1) reviewed for admission orders. Specifically, Resident #1's hospital discharge medications included an anticoagulant (blood thinner). The medication was not ordered upon admission, and the resident did not receive an anticoagulant from 09/02/2025 - 09/18/2025. Resident #1 was subsequently sent to the hospital and diagnosed with a deep vein thrombosis (a blood clot in a vein). This resulted in actual harm to Resident #1 and the likelihood of serious injury, serious harm, serious impairment, or death that was Immediate Jeopardy and Substandard Quality of Care to resident's health and safety for all residents with potential admission/readmission orders.

Inspectors wroteBased on record review and interviews during the abbreviated survey (#2626859) the facility did not ensure a significant medication error was reported to the State Agency as required for one (1) of five (5) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge medications included an anticoagulant (blood thinner), the medication was not ordered upon admission to the facility, and the resident did not receive an anticoagulant from 9/2/2025 - 9/18/2025. Resident #1 was subsequently sent to the hospital and diagnosed with deep vein thrombosis (a blood clot in a vein). The facility did not report the incident to the New York State Department of Health in the required time frame.

Inspectors wroteBased on observations, record review and interviews during the abbreviated survey (NY00383652), the facility did not ensure one (1) of three (3) residents (Resident #1) reviewed received their needed respiratory care. Specifically, Resident #1 had a medical order for oxygen at bedtime, and on 6/13/2025 their oxygen tubing with the nasal cannula was not applied as ordered by Licensed Practical Nurse #3. This resulted in a decrease in Resident #1's oxygen saturation, and they were subsequently transferred to the emergency department to be evaluated for their respiratory distress.

Inspectors wroteBased on observations, record review, and interviews during the abbreviated survey (NY00381595), the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 4 of 4 residents (Residents #1-4) reviewed. Specifically, the facility investigation was not thorough and did not identify concerns related to: -Resident #1's roommate (Resident #2) alleged on 5/19/2025 Certified Nurse Aides #1 and 2 yelled at Resident #1 while providing care. There was no documentation Resident #1 was assessed by a qualified professional, Certified Nurse Aides #1 and 2 continued to work at the facility after the allegation was made, and there was no documentation the Administrator was notified of the allegation. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 9/3/2024-9/6/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen had multiple unclean areas, expired food, and unwrapped and undated food.

Inspectors wroteBased on observation and interview during the recertification survey conducted 9/3/2024-9/6/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication rooms (Interlaken). Specifically, the Interlaken medication room refrigerator temperatures were not consistently documented.

Inspectors wroteBased on observation, interview, and record review during recertification survey conducted 9/3/2024-9/6/2024, the facility did not provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional needs, taking into consideration the preferences of each resident for 2 of 3 residents (Resident #29 and #50) reviewed. Specifically, Residents #29 and #50 were missing food items or had the wrong items on their meal trays.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 9/3/2024-9/6/2024, the facility did not ensure the Director of Nursing served as a unit manager only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, Acting Director of Nursing #2 served as the Unit Manager for the Stillwater Unit in addition to their full time Director of Nursing role.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 10/11/22-10/14/22, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 3 medication carts (the stepdown unit medication cart) reviewed. Specifically, all prescribed controlled drugs on the stepdown unit were stored in an untethered medication cart and not in a permanently affixed compartment as required.