Premier Genesee Center for Nrsg and Rehabilitation

Inspectors wroteBased on observation, record review and interviews during survey, the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents/hazards for one (Resident #1) of three residents reviewed for accidents. Specifically, on 05/01/2026, Resident #1 who had documented cognitive impairments, exit seeking and wandering behaviors, exited the facility undetected by staff approximately three hours after their admission to the facility. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #1's health and safety.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 4/11/25, the facility did not ensure there were services of a Registered Nurse for at least 8 consecutive hours, 7 days a week unless when waived. Specifically, the facility did not have 8 consecutive hours of Registered Nurse coverage on 11/10/24, 11/16/24, 11/30/24, 12/8/24, 12/14/24, 12/21/24, 12/25/24, 12/28/24, 1/4/25, 1/5/25, 1/11/25, 1/12/25, 1/18/25, 1/19/25, 1/25/25, and 1/26/25 as required and did not have a waiver. The finding is: The Facility Assessment, dated 4/1/25, documented the facility's bed capacity was 160 beds and the average daily census at the time of the assessment was 150-160. The Facility Assessment documented the minimum number of staff required to meet the needs of the residents in a 24-hour period. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00355148) during a Standard survey completed on 4/11/25, the facility did not ensure the residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for three (3) (Residents #38, #121 and #355) of four (4) residents reviewed. Specifically, a resident's foley catheter was not changed monthly as per the physician order (#355) and infection control practices were not maintained (#38 and #121).

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with residents' wishes for two (2) (Resident #105 and #139) of two (2) residents reviewed for advanced directives. Specifically, the facility did not ensure Residents #105, and #139 advanced directives identifier was consistent with the resident's wishes and the provider's orders. Additionally, the MOLST (Medical Orders for Life Sustaining Treatment) binder for the 5th floor was not easily accessible to staff.

Inspectors wroteBased on interview and record review conducted during a Complaint (#NY00369028) investigation completed on 2/3/25, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choice for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was permitted by staff to leave the facility at 5:30 AM and independently walk to a nearby hospital. Upon their return the facility initiated an electronic monitoring device without adequate indications for its use.

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (Complaint #NY00308552) completed during a Standard survey completed on 5/25/23, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for three (Resident #s 93, 109, and 212) of four residents reviewed for abuse. Specifically, there was a lack of an investigation for Resident #93's allegation of verbal abuse by Certified Nurse Aide (CNA #7) that was reported to Licensed Practical Nurse (LPN #9) Nursing Supervisor. Resident #109 had a bruise of unknown origin which lacked staff statements, root cause and analysis. Resident #212 had a description of bilateral chest bruising with lack of staff statements.

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 5/24/23, it was determined that the facility did not ensure that a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #84) of four residents reviewed for dignity. Specifically, a resident, who was continent of bowel, was told to have their bowel movement in their brief instead of being toileted. The finding is: A policy and procedure (P&P) titled, Dignity and Respect dated 9/8/22 documented that residents shall be treated with dignity and respect. Further review of the P&P documented that staff shall promote dignity and assist residents by promptly assisting a resident with their toileting needs. 1. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 5/24/23, it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the Administrator and State Survey Agency for two (Resident #93 and #109) of four residents reviewed for abuse. Specifically, Resident #93 was involved in an alleged staff-to-resident verbal abuse, involving Certified Nurse Aide (CNA) # 7 which was not reported to the Administrator and to the State Agency. In addition, Resident #109 was found to have a bruise of unknown origin and it was not reported to the State Agency within the required timeframe of two hours.

Inspectors wroteBased on observation, interview, and record review during the Standard survey, completed on 5/24/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary assistance to maintain grooming and personal hygiene for two (Resident #11 and #70) of five residents reviewed. Specifically, Resident #11 was not provided incontinence care as planned. In addition, Resident #70 had multiple long whiskers on their chin and upper lip, and long jagged fingernails beyond their fingertips on their right contracted hand.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 5/24/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community for one (Resident #70) of two resident reviewed for activities. Specifically, Resident #70 was not asked to participate in activities on a daily basis and was not provided with one-on-one visits/activities. The finding is: [...]

Inspectors wroteBased on interview and record review during the Standard survey completed 5/24/23, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs, when used without adequate monitoring for one (Resident #83) of five residents reviewed for unnecessary medications. Specifically, the resident received metoprolol (medication used to treat high blood pressure) twice daily without their heart rate being monitored per the physician's order. The finding is: The policy titled Medication Management-Utilizing and Prescribing dated 2/2023 documented medications shall be administered in a safe manner as prescribed by the physician. 1. Resident #83 had diagnoses including dementia, supraventricular tachycardia (heart condition with abnormally fast heart rate), and epilepsy (neurological disorder). [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 5/24/23, the facility did not 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 for one (Resident #70) of two residents reviewed for infection control practices during incontinence care. Specifically, staff did not perform adequate hand hygiene while providing fecal incontinence care and staff emptied the dirty washbasin water directly into the sink of a shared bathroom.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed 5/24/23, the facility did not ensure MDS (Minimum Data Set- a resident assessment tool) data was electronically transmitted to the CMS (Centers for Medicare & Medicaid Services) System within 14 days after the resident's assessment was completed for 8 (#15, 60, 71,101, 102, 117, 122, 138) of 8 residents reviewed for Resident Assessments.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 11/3/21, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees A, B, C, D) of nine employees reviewed who were hired in the last four months and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed 11/3/21, the facility did not ensure that the residents' environment remains as free from accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents. Four (Units 1,3,4,5) of four resident care units had issues with water temperatures exceeding 120 degrees Fahrenheit (°F) in resident rooms and care areas. In addition, one (Resident #117) of two residents reviewed for accidents had an issue involving a resident smoking without supervision and lacked completion of timely smoking assessment.

Inspectors wroteBased on observation, interview and record review conducted during the Standard Survey and Complaint (NY00284800) completed on 11/3/2021, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, four (Unit 3, 4, 5, and Rehabilitation) of four resident care units did not have adequate staff based on the facility's established minimum number of staff for each unit and each shift. In addition, the Facility Assessment did not address Certified Nursing Assistants (CNAs). The finding is: Review of the Facility Assessment Tool 2021 dated 6/22/21 documented the average daily census 150 - 155 and the facility resources needed to provide competent support and care for the resident population every day and during emergencies include a staffing plan of: [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (Complaint #NY00280885) during the Standard survey completed on 11/3/21, the facility did not ensure that a resident has a right to choose health care and providers of health care services consistent with his or her assessments and plan of care, including arranging transportation to outside medical appointments for one (Resident #131) of two residents reviewed for choices. Specifically, the resident missed two neurological appointments on 7/2/21 including an imaging scan and provider follow up. The finding is: The facility policy and procedure titled Consultations dated 7/2017 documented the facility would obtain additional assessment from an outside source for a resident to assist in care and treatment. [...]

Inspectors wroteBased on interview and record review during a Complaint investigation (Complaint #NY00281939) during the Standard survey completed on 11/3/21, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to appropriate officials (including the State Survey Agency) for two (Resident #36, 62) of four residents reviewed for alleged abuse. Specifically, an alleged incident of sexual abuse was not reported timely to the New York State Department of Health (NYS DOH) within the two-hour timeframe as required.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 11/3/21, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain personal hygiene for two (Residents #76 and 135) of five residents reviewed for ADLs. Specifically, the lack of timely toileting/changing of an incontinent resident (Resident #76) and lack of proper hand hygiene and glove changes during incontinence care (Residents #76 and 135).

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey on 11/3/21, the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #76) of two residents reviewed for nutrition. Specifically, the resident's significant weight loss was not identified by a Registered Dietician (RD) and there were no nutritional interventions initiated to address the significant weight loss. The finding is: [...]