Schuyler Hospital Inc and Long Term Care Unit

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving abuse were reported to the New York State Department of Health within the required timeframe for two of five residents reviewed (Resident #15 and Resident #111). Specifically, on 06/07/2026, Resident #108 alleged Resident #15 placed both hands around Resident #111's neck. Facility staff became aware of the allegation on 06/07/2026 when Certified Nursing Assistant #2 and Certified Nursing Assistant #6 notified Licensed Practical Nurse #1 and Licensed Practical Nurse #2 and Resident #111 was assessed. The allegation was not reported to facility administration until 06/09/2026 and was not reported to the New York State Department of Health until 06/09/2026 at 4:25 PM.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving abuse were thoroughly investigated and residents were protected from further potential abuse while the investigation was in progress for two of five residents reviewed (Resident #15 and Resident #111). Specifically, on 06/07/2026, facility staff became aware of an allegation Resident #15 placed both hands around Resident #111's neck. Although Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were notified immediately following the alleged incident on 06/07/2026, the facility did not begin a documented investigation until Registered Nurse Manager #1 became aware of the allegation on 06/09/2026 at approximately 3:30 PM. [...]

Inspectors wroteBased on record review and interview conducted during the Recertification Survey, it was determined that for two of seven newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry abuse screening was not completed for newly hired employees prior to starting work.

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, for five (Resident #15, #23, #48, #59 & #64) of five residents reviewed the facility did not ensure that the influenza and/or pneumococcal immunizations were offered and provided if appropriate or that education was provided to the residents or the resident representative if appropriate. Specifically, there was no documented evidence that Resident #64 (who was eligible) or their representative had been offered, provided, declined, and/or educated on the pneumococcal immunization or had received it prior to admission. For Residents #15, #23, #48 and #59, there was no documented evidence that the residents had been offered, received, had declined and/or been educated on the influenza immunization for this year's flu season. The evidence includes but is not limited to the following: [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey for two (Residents #5 and #59) of four residents reviewed, the facility did not ensure the residents were treated with respect and dignity and care for the resident in a manner and environment that promotes enhancement of their quality of life. Specifically, staff did not provide the resident privacy during the medication administration of injections. This is evidenced by the following: 1. Resident #59 was admitted to the facility with diagnoses that included diabetes, obesity, and lymphedema (tissue swelling in the arms or legs). The Minimum Data Set Resident assessment dated [DATE] revealed Resident #59 was moderately impaired cognitively and received daily insulin injections. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey for one (Resident #27) of two residents reviewed for positioning and mobility, the facility did not ensure that the resident's person-centered care plan was implemented to ensure the resident's goals and outcomes were met. Specifically, Resident #27 was not provided a hand roll to their left-hand contracture (permanent tightening of the muscles, tendons and skin causing a decrease in range of motion and often painful) on multiple observations per physician orders, therapy recommendations and the resident's care plan. This is evidenced by the following: Resident #27 had diagnoses including Alzheimer's disease, anxiety, and contractures. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey, for one (Resident #5) of one resident reviewed for insulin administration, the facility did not ensure that the services and care provided met professional standards of quality. Specifically, several nurses did not clarify a contradictory physician order regarding insulin injections, when to give and when not to give as it relates to Resident #5's meal intakes. This is evidenced by the following: The facility policy, Medication Administration - General Guidelines, dated January 2018, included that medications were to be administered in accordance with the written orders of the attending physician. Additionally, if a medication order was not clear, or questionable in any way, the nurse should contact the provider for clarification. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey, for one (Resident #50) of five residents reviewed, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living received the necessary services to maintain good oral hygiene. Specifically, Resident #50 who is dependent on staff for assistance with oral hygiene was observed on several occasions with poor oral hygiene. Additionally, interviews with staff revealed that oral hygiene had not been completed despite documentation that it had been. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey, the facility did not ensure the nurse staffing information was posted daily and included the required information. Specifically, the nurse staffing information did not consistently include the total number and actual hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, the current resident census (the number of residents currently residing in the facility) and was not posted on a daily basis at the beginning of each shift to include any staffing changes as per the regulations. This is evidenced by the following: During an observation on 3/24/24 at 1:24 PM, the facility's nurse staffing information posted was dated 3/23/24 and did not include the current resident census. There was no information posted throughout the day for 3/24/24. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 12/17/21, it was determined that for one (Resident #21) of two residents reviewed, the facility did not provide the necessary services to maintain personal hygiene. The issue involved lack of nail care. This is evidenced by the following: Resident #21 had diagnoses including Parkinson's disease, dementia without behavioral disturbance, and anxiety disorder. The Minimum Data Set Assessment, dated 10/14/21, documented that the resident had moderately impaired cognition and required extensive assistance for personal hygiene. Review of the Comprehensive Care Plan dated 10/21/21, and the current Certified Nursing Assistant (CNA) [NAME] (used by the CNA to drive daily care) revealed that Resident #21 required extensive assistance of staff for personal hygiene. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #111) of four residents reviewed for accidents, the facility did not thoroughly investigate an injury to rule out abuse, neglect, or mistreatment. Specifically, the facility did not thoroughly or timely investigate an incident involving injury following a transfer. This is evidenced by the following: Resident #111 was admitted to the facility on [DATE] and has diagnoses including a stroke, left sided hemiplegia (paralysis), and depression. The Minimum Data Set Assessment, dated 5/1/19, revealed the resident was cognitively intact, required extensive assist of two staff members for transfers, and had no behaviors. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for activities of daily living, the facility did not provide the necessary care and services to maintain personal hygiene. Specifically, Resident #15 did not receive the necessary assistance or support to maintain good oral hygiene. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] and has diagnoses including dementia with behavioral disturbance, Gastro-Intestinal Reflux Disease (GERD), and dysphagia (difficulty swallowing). The Minimum Data Set Assessment, dated 2/20/19, revealed the resident had moderately impaired cognition, required extensive assistance of one staff member for personal hygiene, and rejected care on one to three days during the look back period. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #6 and #89) of four residents reviewed for pressure ulcers, the facility did not identify and provide care and services to address residents' skin care/wound care needs in accordance with professional standards of practice based on the comprehensive assessment, person centered care plan, and resident's choice. Specifically, wound care was not thoroughly identified, assessed, and/or treated according to physician orders and/or wound clinic recommendations. This is evidenced by the following: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses including colon cancer with liver metastasis, a knee fracture status post-surgical repair, surgical removal of hardware on 4/24/19, and multiple Stage III pressure ulcers. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #95) of two residents reviewed for nutrition, the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrated that it was not possible. The issue involved lack of timely interventions following a significant weight loss. This is evidenced by the following: Resident #95 was admitted to the facility on [DATE] and has diagnoses including heart failure, depression, failure to thrive, and pneumonia. The Minimum Data Set Assessment, dated 4/22/19, revealed that the resident was cognitively intact, required extensive assist of staff for eating, and had no swallowing issues. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #48) of eight residents reviewed for unnecessary medications, the facility did not ensure that all identified irregularities noted by the pharmacist had been reviewed by the physician and/or a response was documented in the medical record. In addition, the facility did not have a policy for the Medication Regimen Review that included the necessary minimum information regarding timeframes for the different steps in the process and medical responsibilities. This was evidenced by the following: Review of the policies, Psychotropic Medication, dated January 2019, and Management of Residents on Psychotropic Medications, dated March 2014, revealed that documentation regarding pharmacy recommendations is placed in the resident's medical record. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of eight residents reviewed for unnecessary medications, the facility did not ensure orders for as needed psychotropic medications were limited to 14 days. Specifically, Resident #91's as needed order for an anti-anxiety medication was not limited to 14 days. This is evidenced by the following: Resident #91 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease with hemodialysis, diabetes, and anxiety disorder. The Minimum Data Set (MDS) Assessment, dated 4/18/19, revealed the resident was cognitively intact and had received an antidepressant medication. The MDS Assessment, dated 4/25/19, revealed an anti-anxiety (psychotropic) medication had been administered one time. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not provide food and drink that is palatable, attractive, or at a safe and appetizing temperature. Specifically, the issues involved food that was unpalatable and at suboptimal temperatures. This is evidenced by the following: Observations of the lunch meal on Unit 1 conducted on 5/13/19 included the following: a. At 12:23 p.m., staff applied margarine to peas and pearl onions (main vegetable) and rice, and the margarine did not melt. b. At 12:28 p.m., Licensed Practical Nurse (LPN) #1 said the margarine was not melting but she thought it was the product. c. At 12:31 p.m., Resident #33 said she has not been eating because of the meals served. She said the food was bland and had no flavor. d. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one walk-in freezer in the main kitchen, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. The issues included a visible build-up of ice on and around the evaporator fan unit and the insulated pipe servicing it, pieces of ice were in direct contact with food inside of open boxes, and ice was observed frozen on the top and sides of food packaging (boxes) and the wire shelving unit directly below the evaporator. This is evidenced by the following: On 5/13/19 at 9:33 a.m. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #66) of one resident reviewed for hospitalization, the facility did not ensure that the resident's representative and the Office of the State Long Term Care Ombudsman were notified in writing of the resident's transfer/discharge to the hospital. This is evidenced by the following: Resident #66 was admitted to the facility on [DATE] and had diagnoses that included diabetes, peripheral vascular disease, and arthritis. The Minimum Data Set Assessment, dated 3/29/19, revealed the resident was unable to complete the Brief Interview for Cognitive Status, and that the resident was independent in making decisions regarding tasks of daily life. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #66) of one resident reviewed for hospitalization, the facility did not ensure a written notification, which specifies the duration of the bedhold policy, was provided to the resident and/or the resident's representative at the time of transfer to the hospital. This is evidenced by the following: Resident #66 was admitted to the facility on [DATE] and had diagnoses that included diabetes, peripheral vascular disease, and arthritis. Review of the nursing progress notes revealed the resident was admitted to the hospital on [DATE] and returned to the facility on 4/8/19. Further review of the medical record revealed there was no documented evidence that the resident and/or resident's representative had been notified in writing of the facility's bedhold policy. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for 13 (Residents #3, #6, #8, #21, #34, #48, #71, #81, #91, #92, #95, #97, and #114) of 15 residents reviewed for Baseline Care Plans, the facility did not develop a Baseline Care Plan within 48 hours of admission that included the minimum required information and/or the resident and/or representative were not provided with a written summary of the plan. This is evidenced by, but not limited to, the following: The facility policy, Baseline Care Plan (BCP), dated as initiated November 2017 and revised March 2019, includes that the facility will complete a BCP within 48 hours of admission, including but not limited, to physician orders, dietary orders, therapy services, social services, and resident goals of care. [...]