Charles T Sitrin Health Care Center Inc

In the surveyor’s words

From the most serious findings on record at Charles T Sitrin Health Care Center Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 29, 2026

  Based on record review and interviews, the facility failed to ensure a resident received adequate supervision and failed to identify and reduce hazards and risks for one of one resident (Resident #1) reviewed. Specifically, Resident #1 was admitted to the Neurodegenerative Unit with a history of suicidal ideations and hearing voices they referred to as demons. On [DATE], Resident #1 was found unresponsive in their room with a cord wrapped around their neck; cardiopulmonary resuscitation was initiated; Emergency Medical Services arrived and transported the resident to the hospital where they were pronounced deceased . […]

• Immediate jeopardy, isolatedF600Feb 12, 2025

  Based on record review and interviews during the abbreviated survey (NY00368525) the facility failed to ensure residents were free from abuse for one (1) of seven (7) residents reviewed (Resident #1). Specifically, Resident #1 was physically removed, against the resident's will, from the dining room by Licensed Practical Nurse #4, who then continued to have an altercation in the hallway, which resulted in the resident falling several times. The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 173 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. […]

• Immediate jeopardy, isolatedF609Feb 12, 2025

  Based on record review and interviews during the abbreviated survey (NY00368525) the facility failed to ensure an incident of staff abuse toward a resident was reported to the State Agency, law enforcement, and the Administrator for one (1) of seven (7) residents reviewed (Resident #1). Specifically, facility staff witnessed or were present when Licensed Practical Nurse #4 abused Resident #1 and the incident was not reported to facility Administration, law enforcement, and the New York State Department of Health for seven (7) days. Additionally, Licensed Practical Nurse #4 continued to have access to residents following the witnessed abuse. […]

• Immediate jeopardy, isolatedF689Jan 31, 2023

  Based on observation, interview, and record review during the recertification and abbreviated surveys (NY00289926) the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents reviewed (Resident #103). Specifically, on/around July 2, 2022, a cognitively impaired resident (Resident #103) with exit-seeking behaviors was able to leave their facility house undetected. Staff were not immediately aware the resident was missing. The resident was located by resident service aide (RSA) #3 who was entering an adjacent house and they notified staff in the Aspen house a resident was found outside. […]

• No harm, potential for more than minimal, patternF804Nov 19, 2024

  35045 46276 Based on observations and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays tested (Rehabilitation Unit lunch) and beverages for the [NAME] house breakfast. Specifically, scrambled eggs, home-fried potatoes, toast, applesauce, mixed fruit, corn, milk, orange juice and cranberry juice were not served at palatable temperatures. Findings include: The facility policy, Meal Service, revised 1/2022, documented food was served in a manner to encourage consumption. Food was seasoned and not overcooked to conserve nutrients and flavor. […]