Finger Lakes Health

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision and assistive devices were provided to prevent accidents for four (4) of eight (8) residents reviewed (Residents #65, #75, #98, and #101). Specifically, Residents #65, #75, and #101 were at risk for accidents related to inconsistent and unsafe use of full body lift slings (a fabric device used with a mechanical lift to support and transfer a resident) including use of incorrect sling sizes and reuse of disposable slings. Resident #98 experienced a fall on 11/11/2025 from a full body lift, resulting in a head injury that required staples. This resulted in actual harm for Resident #98 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care and services were provided in accordance with the resident's needs and professional standards for two (2) of eight (8) residents reviewed (Residents #96 and #131). Specifically, Resident #96 who had a diagnosis of dysphagia (difficulty swallowing that can lead to choking, coughing, or food feeling stuck in the throat), received a diet inconsistent with their swallowing needs due to failure to implement and communicate a diet recommendation and supervision needs, and experienced a choking episode requiring abdominal thrusts. Additionally, Resident #131 sustained thermal burns (a skin injury caused by contact with heat sources like hot liquids, causing tissue damage) after staff failed to follow safe food reheating practices. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure allegations and incidents were thoroughly investigated and documented, including identification of root cause and implementation of corrective actions, for two (2) of eight (8) residents reviewed (Residents #98 and #131). Specifically, the facility failed to conduct a thorough and complete investigation for Resident #98 following a fall from a full body lift resulting in a head injury, and for Resident #131 following a thermal burn (a skin injury caused by contact with heat sources like hot liquids, causing tissue damage) incident related to reheated food.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an allegation of neglect and an incident involving an injury of unknown source was reported to the State Survey Agency for one (1) of eight (8) residents reviewed (Resident #98). Specifically, Resident #98 experienced a fall from a full body lift resulting in a head injury requiring staples, and the facility did not report the incident to the State Survey Agency as required.

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey at the Geneva Living Center North, Geneva Living Center South, and Huntington Living Centers 8/28/23 to 9/1/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances.

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey at Huntington Living Center 8/28/23 to 9/1/23, it was determined that for one (Resident #12) of 37 resident's reviewed for care planning, the facility did not ensure the residents person-centered Comprehensive Care Plan (CCP) was implemented to meet the resident's medical needs as identified in the CCP and their physician orders. Specifically, Residents #12 did not have a strap securing their indwelling catheter and did not have wound care done according to their physician orders and their CCP. This was evidenced by the following: [...]

Inspectors wroteBased on observation, interviews, and record review conducted during an Recertification Survey at Huntington Living Center and Geneva Living Center North, from 8/28/23 to 9/1/23, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of five residents reviewed for unnecessary medications, and for one of one resident reviewed for edema (swelling of the tissues due to excess fluid). Specifically, the facility did not ensure that the bowel protocol was initiated as ordered by the physician for Resident #158. For Resident #36, the facility did not ensure that the resident's soap was used appropriately per manufacturer's guidelines or as ordered by the physician for a chronic skin condition. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey 8/28/23 to 9/1/23, it was determined for one (Resident #104) of one resident reviewed for range of motion (ROM) services at Huntington Living Center and for one (Resident #150) three residents reviewed for position and mobility at Geneva Living Center South, the facility did not ensure that a residents with limited ROM received appropriate treatment and equipment to prevent a further decline. Specifically, for Resident #104 the facility did not ensure the resident who had increased edema (swelling) and limited ROM to both hands was evaluated by a therapist per physician orders in a timely manner. For Resident #150, the facility did not ensure the resident had wheelchair safety equipment in place as recommended by Physical Therapy (PT) for proper and safe positioning. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey at Geneva Living Center South 8/28/23 to 9/1/23, it was determined that for one (Resident #86) of one resident reviewed for smoking, the facility did not ensure that the resident environment remained free of accident hazards as possible. Specifically, Resident #86 was observed smoking in an unsafe area several times and the facility was unable to provide evidence that the resident had been assessed for safe smoking. This is evidenced by the following: The facility policy Smoking Assessment Guidelines, review date of 3/30/23, included that smoking is not allowed on facility property. A resident who is physically and cognitively able to leave the facility property with the intent of using tobacco products will be assessed for their capability to smoke unsupervised and unattended. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey 8/28/23-9/1/23 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one (Huntington Living Center) of two main kitchens had issues with the dish machines' wash cycle that did not reach adequate temperatures for sanitizing and was being logged by facility staff as inadequate multiple times for August 2023, with no action taken by the facility. In addition, a dietary employee with not wearing a beard guard/net over their facial hair while serving on the food tray line.

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey at Huntington Living Center 8/28/23-9/1/23 the facility did not ensure for one (Resident #104) of six residents reviewed for Activities of Daily Living (ADL's), that staff members (non-nursing) working in the facility and feeding residents had successfully completed a New York State approved training program. Specifically, the facility did not ensure that a unit clerk (UC) who was observed feeding a resident had been trained through a state approved paid feeding assistant program per the regulations. This is evidenced by the following: Resident #104 had diagnoses including dementia, depression, and unspecified edema (swelling in the extremities). [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey at the Geneva North and South and Huntington Living Centers, completed on 7/22/22, it was determined that for six (Residents #112, #150, #330, #329, #163, and #336) of eight residents reviewed for Baseline Care Plans (BCP), the facility did not ensure that the BCP was reviewed with, and a written copy provided to the resident and/or the resident representative as per the regulations. This was evidenced by the following: Review of facility policy Baseline Care Plan, dated as last reviewed on 11/22/21, documented that the policy of the facility was to develop a BCP within 48 hours of admission and that a summary of the BCP would be provided to the resident and/or their representative to provide information on the initial plan for delivery of care and services. [...]

Inspectors wroteBased on observations, interviews, and record reviews, conducted during the Recertification Survey, completed on 7/22/22, it was determined that for one (Huntington Living Center) of two main kitchens, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple open, undated, and unlabeled food items and a non-food contact surface within the kitchen was not maintained in a clean and sanitary condition. This is evidenced by the following: The facility policy, 'Food Storage', reviewed/revised March 2022, included that all foods stored after opening or preparation would be securely covered, labeled, and dated. [...]

Inspectors wroteBased on observations, interviews, and record reviews, conducted during the Recertification Survey, completed on 7/18/22 to 7/22/22, it was determined that for one (Huntington Living Center) of two facility sites, the facility failed to dispose of garbage and refuse properly. Specifically, the garbage dumpster outside the facility was not equipped with a tight-fitting lid, door, or cover, which created a potential feeding and harborage area for pests. This is evidenced by the following: The facility policy, 'Environmental Sanitation', revised 2016, included that garbage cans will have a tight-fitting lid and that a pest control policy was in place and should be followed accordingly. Observations during the follow-up kitchen tour on 7/20/22 at approximately 12:15 p.m. revealed a large, rectangular, open-top, roll-off garbage dumpster outside the facility. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey at Geneva Living Center South, completed on 7/22/22, it was determined that for one (Resident #163) of one resident reviewed for dental, the facility did not ensure the accuracy of the Minimum Data Set (MDS) Assessment. Specifically, the MDS Assessment did not identify Resident #163's oral status accurately. This was evidenced by the following: The facility policy Dental Services dated December 2017, included an initial screening of each resident's oral health status will be conducted within 24 hours of admission to determine need for emergency dental care. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey at Geneva Living Center North, completed on 7/22/22, it was determined that for one (Resident #100) of one resident reviewed for dialysis, the facility did not ensure a Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's medical, physical, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, Residents #100 's CCP did not address the monitoring or care required for their AV fistula (arterial venous surgical site used as an access for dialysis treatments). This was evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey at Geneva North Living Center and Huntington Living Center, completed on 7/22/22, it was determined that two of eight residents reviewed did not receive the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #131's was not provided assistance with nail care and Resident #143 did not receive nail care or skin care to the palm of a severely contracted hand. This is evidenced by the following: The facility policy, Nail Care, dated December 2020, included that care givers are responsible for cleaning fingernails and toenails weekly on the resident's scheduled shower day and as needed. Fingernails and toenails will be evaluated by the nurse on a weekly basis to determine if intervention is required. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey at Huntington Living Center, completed on 7/22/22, it was determined that for one (Resident #91) of one resident reviewed for Activities, the facility did not provide a program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of the resident. Specifically, the resident was care planned for room-to-room cart activities and lounge activities, but there was only one day of documented activities during a two-month period. This was evidenced by the following: Resident #91 had diagnoses including dementia, depression, and a history of repeated falls. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey at Huntington Living Center completed on 7/22/22, it was determined that for two (Residents #116 and #120) of six residents reviewed for accidents and one (Skilled Nursing Unit or SNU) of three units reviewed for acceptable water temperatures, the facility did not ensure that the environment remained as free of accident hazards as possible, and that each resident received adequate supervision to prevent accidents. Specifically, water temperatures in the SNU were found to exceed 120 degrees (°) Fahrenheit (F), Resident #116's, who had a history of frequent falls, environment was not as free of accident hazards as possible, and Resident #120, with a history of obtaining medications from outside the facility, was observed with unsecured medications brought in from home at the resident's bedside. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey at Huntington Living Center, completed on 7/22/22, it was determined for one of two residents reviewed, the facility did not ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, Resident #12's oxygen concentrator filter was dirty, and their nebulizer mask and tubing was dated as last changed three months prior. This is evidenced by the following: The facility policy Oxygen Therapy and Pulse Oximetry, dated August 1999, included oxygen tubing is to be changed every seven days or when visibly soiled or malfunctioning. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey at Huntington Living Center, it was determined that for one (Resident #221) of one resident reviewed for personal property, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft. Specifically, the resident reported that they had a quilted blanket made for them by a relative that was missing, and the facility did not take reasonable steps to find the blanket. This is evidenced by the following: Resident #221 had diagnoses including a stroke, depression, and anxiety. The admission Minimum Data Set (MDS) Assessment, dated 7/31/19, revealed that the resident was cognitively intact and that it was very important to them to take care of their personal belongings. The MDS Assessment, dated 1/9/20, included the resident was cognitively intact. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey and complaint investigations (#NY00246278 and #NY00248525) at Huntington Living Center, it was determined that for two (Residents #78 and #101) of four residents reviewed for abuse, the facility did not ensure that alleged incidents, including injuries of unknown origin were thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, the facility did not complete thorough investigations into injuries of unknown origin for Residents #78 and #101, and Resident #101's complaint of roughness by staff. This is evidenced by the following: 1. Resident #101 had diagnoses that included dementia without behaviors, glaucoma, and macular degeneration. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey at Finger Lakes Health, it was determined for two of 39 residents reviewed for Minimum Data Set (MDS) Assessment accuracy, the facility did not ensure that MDS Assessments accurately reflected the residents' status. Specifically, the facility did not attempt a Brief Interview for Mental Status (BIMS) for Residents #163 and #424, and there was a lack of an attempt of a mood interview for Resident #424. This is evidenced by the following: Resident #163 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing), and a gastrostomy tube feeding. The MDS Assessment, dated 1/26/20, was coded as not assessed for the BIMS interview. Section B7 (making self-understood) was coded as zero (the resident was able to make their self-understood). [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey at Huntington Living Center, it was determined that for two of three residents reviewed for vision and hearing, the facility did not ensure each resident received treatment and/or devices to maintain vision. Specifically, Resident #42 did not have an eye exam or broken glasses replaced in a timely manner and medical was not notified of the resident refusals of eye drops, and Resident #52 did not have lost glasses replaced in a timely manner. This is evidenced by the following: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses including glaucoma, diabetes, and a history of cataracts. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey at Finger Lakes Health, it was determined that for one of one resident reviewed for smoking, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, Resident #141 was smoking in a non-designated smoking area and was storing their own lighter. This is evidenced by the following: Resident #141 has diagnoses including paraplegia following a motor vehicle accident, schizophrenia, and tobacco use. The Minimum Data Set Assessment, dated 12/19/19, revealed the resident was cognitively intact and was independent in locomotion on and off the unit. The current Comprehensive Care plan included that the resident was a former smoker. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three of three residents reviewed for blood glucose testing and one of one resident reviewed for wound infections, the facility staff did not follow appropriate infection control techniques or hand hygiene. Specifically, at the Huntington facility, the blood glucose monitoring device was not cleaned after use for Residents #23, #59, and #179, and at the Finger Lakes facility appropriate hand hygiene was not used during wound care for Resident #421. This is evidenced by the following: 1. [...]