Waters of Dunkirk Skilled Nursing Facility, The

In the surveyor’s words

From the most serious findings on record at Waters of Dunkirk Skilled Nursing Facility, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 30, 2026

  Based on observation, interview, and record review, the facility failed ensure residents were protected from sexual abuse when Resident B, who had moderate cognitive impairment, was found performing oral sex on Resident C, who had severe cognitive impairment and a known history of sexually inappropriate behaviors. The facility failed to assess the residents' capacity to consent to sexual activity prior to the incident and did not implement interventions in place to mitigate Resident C's sexually inappropriate behaviors. […]

• No harm, potential for more than minimal, widespreadF812Jun 1, 2026

  A. Based on observation, interview, and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions regarding food handling, lack of hair restraint use, dented can handling, and hand washing. This deficient practice had the potential to impact 44 of 44 residents who received their meals from the kitchen.B. Based on observation, interview, and record review, the facility failed to ensure food was distributed in a sanitary manner when meal trays prepared for room delivery were left uncovered during random observations.Findings include: A.1.During an initial kitchen observation, on 5/26/26 at 10:01 a.m., the following was observed: To the left of the kitchen door, numerous bowls and plates were stored face up on a small two-shelf wheeled cart. […]

• No harm, potential for more than minimal, widespreadF803Mar 21, 2025

  Based on observation, record review, and interview, the facility failed to ensure menus and the resident's preferences were followed for 3 of 5 residents reviewed for dining services. (Resident 12, 14, and 26) This deficiency had the potential to affect 31 of 31 residents who receive meals from the facility's dining services. Findings include: 1. During an observation, on 3/18/25 at 2:11 p.m., a sign on the wall by the kitchen indicated the following lunch and dinner options were available: grilled cheese sandwich, hamburger on bun, hot dog on bun, peanut butter and jelly sandwich on bread, mashed potatoes, potato chips, alternate fruit, cottage cheese (as a protein substitute), and green beans. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2025

  A. Based on observation, interview, and record review, the facility failed to ensure the high-temperature dishwasher functioned at a level to maintain proper sanitization requirements. This deficient practice had the potential to impact 31 of 31 residents who received meals from the facility kitchen. B. Based on observation and interview, the facility failed to properly store and distribute food under sanitary conditions while maintaining equipment cleanliness. This deficient practice had the potential to impact 31 of 31 residents who received meals from the facility kitchen. Findings include: During the initial kitchen tour, on 3/17/25 at 9:59 a.m., the following concerns regarding inaccurate high temperature dishwashing were observed: A. […]

• No harm, potential for more than minimal, widespreadF726Jun 15, 2023

  Based on interview and record review, the facility failed to ensure residents received medications, including insulin injections, from qualified nursing personnel and failed to ensure medications were prepared and administered within professionally accepted standards for 5 of 5 residents reviewed for medication administration (Residents B, C, E, F, and G). These deficient practices had the potential to effect 41 of 41 residents in the facility. Findings include: Review of a facility self reportable, dated 5/26/2023 indicated on 5/25/2023, during job shadowing activity, LPN 1 allowed a nursing student to pass medications to five facility residents. […]