Palatine Nursing Home

Inspectors wroteBased on record review and interviews during a survey, the facility failed to ensure residents were free from abuse for one (Resident #1) of three residents reviewed. Specifically, Certified Nurse Aide #1 aggressively redirected Resident #1 on 05/30/2026.

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, there was an unidentified unpleasant odor of varying levels throughout survey. This is evidenced by:During an observation on 01/22/2026 at 10:55 AM, an odor (pungent, sewer) was noted in the hallway leading to the [NAME] Unit from the Administrator's office to the Nurse's station in front of several resident rooms. [...]

Inspectors wroteBased on record review and interviews conducted during a recertification and abbreviated survey (Case #s777608, 777666, and 777668), the facility did not ensure that alleged violations involving abuse, were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to officials (including to the State Agency). Additionally, the facility did not ensure a report of the results of all investigations were submitted to the State Agency, within five (5) working days of the incident, in accordance with State law for four (4) (Residents # 58, 76, 78. and 80) of five (5) residents reviewed for abuse. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for four (4) (Resident #s 36, 49, 56 and #62) of 14 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 32.0%.This is evidenced by:The facility's Policy and Procedure titled, Medication Error Policy reviewed 1/2026 documented the facility shall maintain systems to ensure medications are administered accurately, safely, and in accordance with physician orders, professional standards of practice. Medication Error: Any preventable event that may cause or lead to inappropriate medication use or resident harm, including: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #49) of 22 residents reviewed. Specifically, Resident #49 was observed self-administering insulin without an interdisciplinary team assessment, care plan or physician order. In addition, Licensed Practical Nurse #2 provided wrong instructions when Resident #49 looked to them for directions. [...]

Inspectors wroteBased on record review and interviews conducted during a recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for two (2) (Resident's #66 and 67) of 22 residents reviewed. Specifically, Resident 66's continuous tube feed pump was stopped for more than 20 minutes, and Licensed Practical Nurse #2 did not receive instruction from the Medical Provider when Resident #67 gagged or had difficulty swallowing their medications and crushed resident's medication. This is evidenced by: The facility policy titled Medical Practitioner Notification of Change in Condition reviewed/updated on 1/2026, documented the facility would ensure quality of care for all residents by notifying the Primary Care Practitioner or the on- call Practitioner with changes in resident condition to prevent a delay in treatment. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents were free of any significant medication errors for two (2) (Resident #s 36 and 62) of 14 residents reviewed. Specifically, (a.) on 1/20/2026 at 08:00 AM, Resident #36's order to administer Lidocaine 4% patch was omitted. (b.) On 1/21/2026, Resident #62 had an order to receive six (6) medications at 07:00 AM; Licensed Practical Nurse #3 documented they administered the medications at 08:07 AM but was observed administering the medications at 09:20 AM.This is evidenced by:The facility's Policy and Procedure titled Medication Error Policy reviewed 1/2026 documented the facility shall maintain systems to ensure medications are administered accurately, safely, and in accordance with physician orders, professional standards of practice. Medication Error: [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices. The records were not accurately documented or completed for two (2) residents (Resident #7 and Resident #12) of 22 reviewed. Specifically, Resident #7's and Resident #12's Medication Administration Records and Treatment Administration Records were missing documentation indicating that medications and treatments were administered and completed as ordered. This is evidenced by: [...]

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the self-closing device on the walk-in freezer was not functioning properly as intended. This is evidenced by:During observations conducted on 1/14/2026 at 11:00 AM, as part of the inspection of the walk-in freezer, the self-closing mechanism on the main entry door was found to be inoperable and was not pulling the door closed to ensure a tight seal. During an interview on 1/15/2026 at 12:00pm, Environmental Director #1 stated that they would address the issue immediately as they were not aware of it not functioning properly. 10 New York Codes, Rules, and Regulations 415.5(e)(1)(2)

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the personal privacy and confidentiality of personal and medical records for 1 (East Unit) of 2 units reviewed for privacy and confidentiality. Specifically, the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records were maintained on 5/31/2023, 6/2/2023, and 6/6/2023, when facility staff left computer screens unattended on the East Nursing Unit Nursing Station. This is evidenced by: East Nursing Unit: The Policy and Procedure (P&P) titled Confidentiality/Health Insurance Portability and Accountability Act (HIPAA), dated 02/2023, documented health care providers may not use or disclose Protected Health Information (PHI), except as permitted by privacy regulations. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey dated 05/30/23 through 06/06/23, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen. Specifically, one (1) of 2 food temperature thermometers were found to be not in calibration when tested in a standard ice-bath method, and the correct test kit to measure the concentration of chemical sanitizer used to manually sanitize food contact surfaces (sanitizer) has color graduations that do not exceed 400 parts per million (ppm) and cannot test sanitizer concentrations exceeding the manufacturer specifications (the label on the bottle of sanitizer states the sanitizer is to be diluted to between 200 ppm and 400 ppm when sanitizing food contact surfaces). This is evidenced as follows: [...]

Inspectors wroteBased on record review, and interviews during the recertification survey, the facility did not ensure residents requiring specialized rehabilitative services were provided with services for 1 (Resident #44) of 1 residents reviewed for rehabilitation. Specifically, for Resident #44, the facility did not ensure a therapy referral entered on 05/24/2023 was addressed by the therapy department in accordance with facility policy. This is evidenced by: Resident #44 Resident #44 was admitted to the facility with diagnoses of cerebral infarction, osteoarthritis, and dementia. The Minimum Data Set (MDS - an assessment tool) dated 04/11/2023, documented the resident was able to make themselves understood, able to understand others, and was severely cognitively impaired. [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey and an abbreviated survey (Case #NY00268487), the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for five (5) (Resident #'s 3, #14, #86, #87, and #285) of nineteen (19) residents reviewed. [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility failed to 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 infection. Specifically, for 1 (West Unit) of 2 Units, which was on contact and droplet precautions, the facility did not ensure staff consistently wore gowns and gloves prior to direct contact with residents; for 2 (West and East Units) of 2 units, the facility did not ensure staff performed hand hygiene after assisting a resident to ambulate, after administering injectable medications, or after checking a blood glucose level, before touching clean multi-resident areas; [...]

Inspectors wroteBased on observations, interviews and record review during a recertification survey, the facility did not ensure that based on the comprehensive assessment, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #14) of 2 residents reviewed for pressure sores. Specifically, for Resident #14, who was at risk for developing pressure sores, the facility did not ensure interventions were developed and provided to prevent the development of pressure sores. This is evidenced by: [...]

Inspectors wroteBased on observation, interviews and record reviews during a recertification survey, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (Resident #3) of 4 residents reviewed for accidents. Specifically, for Resident #3, who was at high risk for choking, the facility did not ensure the resident was not kept in their room with the door closed. This is evidenced by: Resident #3: The resident was admitted to the facility with diagnoses of dysphasia, dementia, and Wernicke's encephalopathy. The Minimum Data Set (MDS- an assessment tool) dated 9/30/2020, documented the resident had moderately impaired cognitive skills for daily decision making. The following observations were made: -05/03/2021 at 10:00 AM and 11:35 AM, the resident was in his/her room with the room door closed. [...]