Inspection Reports for
Affinity Skilled Living and Rehabilitation Center
305 Locust Avenue, Oakdale, NY, 11769
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 11, 2024
Visit Reason
The inspection was initiated as a Recertification Survey and Abbreviated Survey (Complaint #NY 00346145) to ensure the facility provided treatment and care in accordance with professional standards and the comprehensive person-centered care plan.
Complaint Details
The complaint investigation (Complaint #NY 00346145) was initiated on 9/4/2024 and completed on 9/11/2024. The complaint involved concerns about treatment and care deficiencies related to wound care and tube feeding management. The complaint was substantiated based on findings.
Findings
The facility failed to ensure appropriate treatment and care for residents, including lack of physician orders and treatment administration for wounds and a gastronomy tube. Specific deficiencies were identified for three residents related to wound care and tube feeding management.
Deficiencies (3)
Resident #544 had an abdominal surgical incision with no physician's orders for wound treatment, and no documented evidence of treatment administration as recommended by the hospital and wound care consultant.
Resident #10 was observed with a gauze dressing on the left second toe without a physician's order or documented treatment, and nursing staff failed to notify appropriate personnel for assessment.
Resident #193 had a gastronomy tube no longer in use with no physician's order to flush or monitor the tube, and nursing staff did not flush the tube or obtain an order.
Report Facts
Wound measurement: 15
Staples count: 18
Wound measurement: 1
Wound measurement: 1.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Documented Resident #10's complaints and notified physician; failed to notify unit manager or wound care nurse |
| Licensed Practical Nurse #5 | Unit Manager | Interviewed regarding wound care treatment for Resident #10 and lack of notification |
| Physician #1 | Physician | Interviewed about lack of awareness and documentation regarding Resident #10's toe wound and Resident #193's gastronomy tube |
| Registered Nurse #3 | Wound Care Nurse and Nursing Supervisor | Interviewed about wound care treatment responsibilities and oversight |
| Director of Nursing Services | Director of Nursing Services | Interviewed about nursing responsibilities for obtaining physician orders and wound care treatment |
| Licensed Practical Nurse #4 | Unit Nurse Manager | Interviewed about physician orders for flushing Resident #193's gastronomy tube |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about not flushing Resident #193's gastronomy tube due to lack of order |
| Chief Dietician | Chief Dietician | Interviewed about responsibility for placing physician orders to flush gastronomy tube |
| Licensed Practical Nurse #17 | Nurse Manager | Interviewed about wound care treatment documentation for Resident #544 |
| Nurse Practitioner #1 | Nurse Practitioner | Provided wound care consultation and recommended treatment for Resident #544 |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Sep 11, 2024
Visit Reason
The survey was a Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024 to assess compliance with regulatory requirements for a skilled nursing facility.
Findings
The facility was found deficient in multiple areas including timely completion and transmission of Minimum Data Set assessments, appropriate treatment and care according to physician orders, pressure ulcer care, environmental safety, intravenous fluid administration, medication labeling, nutrition accommodations, and infection prevention and control practices.
Deficiencies (9)
F0636: The facility did not ensure comprehensive assessments of residents were conducted within 14 calendar days after admission and at least every 12 months, identified for Resident #18.
F0640: The facility did not ensure Minimum Data Set assessments were transmitted electronically to CMS within 14 days of assessment completion for seven residents.
F0684: The facility failed to provide appropriate treatment and care according to orders for residents including wound care, dressing changes, and monitoring of gastronomy tubes.
F0686: The facility did not ensure pressure ulcer care was consistent with professional standards; specifically, the air mattress weight setting was not accurate for Resident #2.
F0689: The facility did not ensure the resident environment was free from accident hazards; an aerosol Lysol spray was found in Resident #208's room despite being prohibited.
F0694: The facility did not ensure intravenous fluids were administered according to physician orders; Resident #58 received Dextrose IV at 50 cc/hour instead of the ordered 70 cc/hour.
F0761: The facility did not ensure drugs and biologicals were labeled properly; insulin pens for Residents #21 and #97 lacked dates indicating when first opened.
F0806: The facility did not ensure residents received food accommodating allergies; Resident #27 was served sugar-free puddings and syrup containing artificial sweeteners despite a no artificial sweeteners order.
F0880: The facility failed to implement an effective infection prevention and control program; staff did not consistently use appropriate personal protective equipment or perform hand hygiene for residents on contact precautions.
Report Facts
Days late for MDS transmission: 6
Days late for MDS transmission: 3
Days late for MDS transmission: 1
Days late for MDS transmission: 2
Days late for MDS transmission: 5
Days late for MDS transmission: 1
Days late for MDS transmission: 6
Air mattress weight setting: 265
Resident weight: 156
IV infusion rate observed: 50
IV infusion rate ordered: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Named in wound care and skin integrity deficiency related to Resident #10's left second toe. |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in infection control deficiency for improper glove use and hand hygiene with Resident #214. |
| Physical Therapist #1 | Physical Therapist | Named in infection control deficiency for failure to use PPE and hand hygiene with Resident #214. |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Named in IV fluid administration deficiency for Resident #58. |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Named in medication labeling deficiency for insulin pens. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in infection control deficiency for failure to use PPE and hand hygiene with Resident #546. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 13, 2023
Visit Reason
The inspection was a Recertification Survey and Abbreviated Survey conducted to assess compliance with regulatory requirements for nursing home care.
Complaint Details
The survey included a complaint investigation (Complaint # NY00287059) related to inadequate supervision resulting in a resident fall with injury.
Findings
The facility was found deficient in multiple areas including failure to report narcotic diversion, incomplete and outdated care plans, inadequate resident positioning and support, failure to provide adequate supervision to prevent accidents, improper respiratory care, discrepancies in controlled substance records, and failure to follow infection prevention and control protocols.
Deficiencies (8)
F0609: The facility failed to timely report suspected narcotic diversion involving Licensed Practical Nurse #6 to the New York State Department of Health.
F0656: The facility did not implement a comprehensive person-centered care plan including physician's orders for heel booties for Resident #30, who was observed not wearing them.
F0657: The facility failed to update residents' comprehensive care plans within 7 days of assessment, including discontinuation of Lymphedema pump for Resident #42.
F0684: Resident #65, ventilator dependent, was improperly positioned in a Geri recliner without head support, risking ventilator airflow obstruction.
F0689: The facility failed to ensure adequate supervision to prevent accidents, resulting in Resident #310 falling and sustaining a hip fracture after being left unsupervised in a high visibility area.
F0695: Resident #42 was observed with an empty oxygen tank and shortness of breath despite physician orders for continuous oxygen therapy.
F0755: The facility failed to maintain accurate records and reconcile controlled substances; a discrepancy was found in Morphine Sulfate medication for Resident #410.
F0880: Registered Nurse #3 failed to follow proper hand hygiene and infection control procedures during wound care treatment for Resident #113.
Report Facts
Deficiencies cited: 8
Oxygen saturation level: 83
Morphine Sulfate discrepancy: 1.25
Fall risk score: 19
BIMS scores: Multiple residents had BIMS scores documented (e.g., Resident #30 score 12, Resident #42 score 15, Resident #310 score 7).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | LPN | Terminated for narcotic diversion; involved in unreported narcotic diversion incident. |
| Certified Nursing Assistant #4 | CNA | Assigned to Resident #30; reported resident refusal to wear heel booties. |
| Licensed Practical Nurse #2 | LPN | Responsible for updating care plans; failed to update Resident #30 and #42 care plans. |
| Registered Nurse #3 | RN | Performed wound care on Resident #113 without proper hand hygiene. |
| Licensed Practical Nurse #5 | LPN | Observed discrepancy in Morphine Sulfate medication for Resident #410. |
| Licensed Practical Nurse #7 | LPN | Medication and treatment nurse for Resident #42; acknowledged empty oxygen tank. |
| Certified Nursing Assistant #5 | CNA | Failed to monitor high visibility area leading to Resident #310 fall. |
| Director of Nursing Services | DNS | Interviewed multiple times regarding deficiencies including narcotic diversion reporting, care plan updates, supervision failures, oxygen monitoring, and infection control. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Feb 7, 2020
Visit Reason
The visit was a Recertification Survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including delayed investigation of alleged abuse, late transmission of Minimum Data Set assessments, incomplete care plans for urinary tract infections and pressure ulcers, inadequate discharge planning, failure to maintain residents' ambulatory abilities, lack of supervision for residents on aspiration precautions, insufficient nursing staff to meet resident needs, and failure to provide scheduled showers.
Deficiencies (8)
F 0610: The facility failed to timely investigate an alleged injury of unknown origin for Resident #257, with the investigation completed seven days after the bruise was identified.
F 0640: The facility did not transmit Minimum Data Set (MDS) assessments within 14 days after completion for 9 of 10 residents reviewed.
F 0656: The facility failed to develop and implement complete care plans with measurable objectives and timeframes for one resident with a UTI and two residents with pressure ulcers.
F 0660: The facility did not develop and implement an effective discharge planning process for Resident #58, who desired discharge to another long-term care facility but lacked assistance obtaining necessary military discharge papers.
F 0676: The facility failed to ensure Resident #197 received the necessary Floor Ambulation Program as per the care plan to maintain ambulatory abilities.
F 0689: Resident #110, on aspiration precautions, was observed eating meals in bed without staff supervision as required by facility policy.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs, as evidenced by resident council complaints, staff interviews, and documentation of frequent call outs and short staffing.
F 0725: Resident #87 did not receive scheduled showers for five consecutive days due to staffing shortages and lack of time for CNAs to provide care.
Report Facts
Residents reviewed for MDS transmission: 10
Residents with late MDS transmission: 9
Residents interviewed for Resident Council: 10
Staff interviewed for Sufficient and Competent Staffing: 5
Residents reviewed for Activities of Daily Living: 5
CNA call outs on 9/29/19 7AM-3PM shift: 11
CNA call outs on 9/29/19 3PM-11PM shift: 11
CNA call outs on 12/8/19 7AM-3PM shift: 10
CNA call outs on 12/8/19 3PM-11PM shift: 10
Residents census on 3 South unit on 2/1/20: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported staffing shortages and inability to complete all treatments |
| LPN #2 | Licensed Practical Nurse | Confirmed staffing shortages and agreed with LPN #1 |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding staffing issues and deficiencies |
| Administrator | Facility Administrator | Interviewed regarding staffing and facility issues |
| Staffing Coordinator | Staffing Coordinator | Reported staffing directives to staff down CNAs and inability to fill call outs |
| Registered Nurse (RN) MDS Coordinator | RN MDS Coordinator | Interviewed about late MDS transmissions |
| Registered Nurse (RN) Charge Nurse | RN Charge Nurse | Interviewed about incomplete care plans and supervision failures |
| Wound Care Nurse | Wound Care Nurse | Interviewed about pressure ulcer care plan deficiencies |
| Licensed Practical Nurse (LPN) | LPN | Interviewed about failure to supervise resident on aspiration precautions |
| Certified Nursing Assistant (CNA) #1 | CNA | Interviewed about failure to supervise resident on aspiration precautions |
| Certified Nursing Assistant (CNA) #2 | CNA | Interviewed about failure to supervise resident on aspiration precautions |
Inspection Report
Capacity: 60
Deficiencies: 2
Date: Inspection Report
Visit Reason
Inspection history and enforcement summary for Affinity Skilled Living and Rehabilitation Center
Findings
No citations or deficiencies reported from inspections between October 1, 2021 and September 30, 2025. Enforcement actions include stipulations and fines for multiple deficiencies and quality of care issues in 2020 and 2023.
Deficiencies (2)
Multiple Deficiencies
Quality of Care
Report Facts
Total inspections: 0
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