Inspection Reports for
Acadia Center for Nursing and Rehabilitation
1146 Woodcrest Avenue, Riverhead, NY, 11901
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 18, 2024
Visit Reason
The inspection was a recertification survey conducted from 2024-09-11 to 2024-09-18 to assess compliance with medication storage and food safety regulations at the nursing facility.
Findings
The facility failed to ensure proper medication storage, with loose and unidentified medications, non-medication items in medication carts, and unsanitary conditions in medication storage areas. Additionally, food safety violations were found including expired and unlabeled food items in refrigerators, freezers, and dry storage areas.
Deficiencies (2)
F 0761: The facility did not ensure medications were properly stored in medication carts, with loose unidentifiable medications and non-medication items such as hearing aids and nail clippers found in carts. The medication storage room refrigerator had a dried pink substance spilled on the shelf.
F 0812: The facility did not ensure food was stored in accordance with professional standards, with expired and opened containers of food in the refrigerator, unlabeled frozen food in the freezer, and unlabeled dry goods in the basement storage area.
Report Facts
Unidentified loose medications: 18
Unidentified loose medications: 24
Expired containers of cottage cheese: 3
Unlabeled frozen broccoli bags: 6
Unlabeled bags of shredded cheese: 8
Unlabeled bags of cake mix: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | Interviewed regarding medication cart storage violations | |
| Licensed Practical Nurse 4 | Interviewed regarding unidentified loose pills in medication cart | |
| Licensed Practical Nurse 5 | Interviewed regarding medication cart and storage room violations | |
| Director of Nursing Services | Interviewed regarding medication storage and cleanliness expectations | |
| Food Service Director | Interviewed regarding food storage violations and policies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Sep 18, 2024
Visit Reason
Complaint survey with 2 standard health and 2 life safety code citations, all corrected by November 2024 or earlier.
Findings
Complaint survey with 2 standard health and 2 life safety code citations, all corrected by November 2024 or earlier.
Deficiencies (4)
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Egress doors
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Feb 7, 2023
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home resident assessments, care, medication management, infection control, and other standards.
Findings
The facility was found deficient in completing timely admission, annual, and quarterly Minimum Data Set (MDS) assessments for multiple residents. Deficiencies were also found in respiratory care for a resident requiring continuous oxygen, pain management for a resident with inadequate pain control, medication administration errors related to Midodrine, and infection prevention practices for a resident with RSV.
Deficiencies (6)
F0636: The facility did not complete admission and annual MDS assessments within required timeframes for 13 of 19 residents reviewed, with 103 MDS assessments overdue facility-wide as of 2/2/2023.
F0638: The facility failed to complete quarterly MDS assessments at least every 92 days for 19 residents reviewed, with 28 quarterly MDS assessments overdue.
F0695: Resident #224 was not provided continuous oxygen as ordered; oxygen tubing was observed off the resident on two occasions, and staff failed to ensure oxygen therapy was consistently administered.
F0697: Resident #64's pain was inadequately managed; pain complaints were not promptly communicated to the physician, and pain assessments before and after medication administration were inconsistent.
F0760: Resident #271 received Midodrine medication despite physician orders to hold it if systolic blood pressure exceeded 110 mmHg; medication was administered incorrectly due to input errors and lack of nurse verification.
F0880: Infection prevention was inadequate when LPN #1 administered medications to Resident #272 with RSV; appropriate PPE including face shield or goggles was not worn and N95 mask was not changed after exiting the room.
Report Facts
Overdue MDS assessments: 103
Residents reviewed for MDS assessments: 19
Residents with deficient admission or annual MDS: 13
Overdue Quarterly MDS assessments: 28
Pain medication administrations without proper monitoring: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Named in respiratory care deficiency for Resident #224 oxygen therapy |
| LPN #2 | Licensed Practical Nurse | Named in pain management deficiency for Resident #64 |
| LPN #6 | Licensed Practical Nurse | Named in medication error deficiency for Midodrine administration |
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency for PPE use during medication administration for Resident #272 |
| Director of Nursing Services | DNS | Interviewed regarding MDS assessment delays, medication errors, and infection control |
| Physician Assistant #2 | Physician Assistant | Interviewed regarding oxygen therapy and Midodrine medication orders |
| RN #1 | Assistant Director of Nursing Services and Infection Preventionist | Interviewed regarding infection control practices for RSV |
| RN #2 | Inservice Coordinator | Interviewed regarding pain management and infection control practices |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Feb 7, 2023
Visit Reason
Complaint survey with 7 standard health and 10 life safety code citations, all corrected by April 2023 or earlier.
Findings
Complaint survey with 7 standard health and 10 life safety code citations, all corrected by April 2023 or earlier.
Deficiencies (17)
Comprehensive assessments & timing
Infection prevention & control
Pain management
Qrtly assessment at least every 3 months
Requirements before submitting a request for
Residents are free of significant med errors
Respiratory/tracheostomy care and suctioning
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Fundamentals - building system categories
Hazardous areas - enclosure
Illumination of means of egress
Organization and administration
Physical environment
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke compar
Subsistence needs for staff and patients
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 24, 2020
Visit Reason
The inspection was a Recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to develop person-centered Comprehensive Care Plans (CCPs) for residents using bed and chair alarms, and did not ensure appropriate treatment and care according to orders and resident needs, including skin condition assessments and documentation.
Deficiencies (2)
F 0656: The facility did not develop a Comprehensive Care Plan for the use of a bed alarm for Resident #134 and a chair alarm for Resident #77, despite physician orders and documented use.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences for Residents #13 and #99, including lack of skin condition assessments, failure to notify physicians, and improper handling of Silvadene cream.
Report Facts
Residents affected: 2
Residents affected: 2
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