Upstate University Hosp at Community General T C U

In the surveyor’s words

From the most serious findings on record at Upstate University Hosp at Community General T C U, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Mar 13, 2024

  Based on record review and interview during the recertification survey conducted 3/11/2024-3/13/2024 the facility did not ensure they established and maintained 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 infections for 11 of 11 residents (Residents #1, 106, 107, 108, 109, 110, 111, 112, 113, 114, and 115) reviewed. Specifically, the facility did not have an infection prevention control program including standards, policies and procedure that were current, specific to the resident population, and reviewed at least annually. […]

• No harm, potential for more than minimal, isolatedF812Dec 29, 2021

  Based on observation and interview during the recertification survey conducted [DATE]-[DATE], the facility failed to ensure food was stored and served in accordance with professional standards for food service safety for 1 of 2 kitchen areas (main kitchen). Specifically, the facility failed to remove expired food items and maintain clean surfaces in the main kitchen. Findings include: The facility policy Food and Supply Storage revised ,d+[DATE] documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. […]

• No harm, potential for minimal, widespreadF835Jul 25, 2025

  Entrance conference worksheet documents required for survey were not received timely.Based on record review and interviews during the recertification survey conducted 7/23/2025-7/25/2025, the facility did not make available clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for all 15 residents of the facility. Specifically, upon survey entrance, resident-identifiable information including form CMS-802 Matrix for Providers, and an alphabetical listing of all residents was not provided to the Department of Health in a timely manner. Additional information needed from the facility within one hour and four hours of entrance was not provided in a timely manner. […]

• No harm, potential for minimal, widespreadF835Mar 13, 2024

  Based on interview and record review during the recertification survey conducted 3/11/2024-3/13/2024 the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 11 of 11 residents residing on the unit. Specifically, administration did not ensure the facility appropriately outlined the roles of the required administrative staff and that they had developed specific policies and procedures for resident care that were reviewed annually. […]