Inspection Reports for Briarcliff Manor Center For Rehabilitation & Nursing
NY, 10510
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
18.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
257% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Jun 20, 2025
Visit Reason
Complaint Survey with 2 health citations including abuse and neglect and reporting of alleged violations; one corrected by August 12, 2025.
Findings
Complaint Survey with 2 health citations including abuse and neglect and reporting of alleged violations; one corrected by August 12, 2025.
Deficiencies (2)
| Description | Severity |
|---|---|
| Free from abuse and neglect | Level 3 |
| Reporting of alleged violations | Level 2 |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 20, 2025
Visit Reason
The abbreviated survey was conducted to investigate and assess the facility's compliance with abuse prevention regulations following an allegation that a resident was physically abused by a Certified Nurse Aide.
Findings
The facility failed to ensure a resident remained free from physical abuse. Resident #1 reported being hit in the groin by Certified Nurse Aide #3 on 6/11/2025, resulting in psychosocial harm. The facility investigation confirmed the abuse occurred, leading to the suspension and termination of the Certified Nurse Aide involved.
Complaint Details
The complaint was substantiated. Resident #1 reported being hit in the groin by Certified Nurse Aide #3 on 6/11/2025. The facility investigation, including witness statements and photo lineup identification, confirmed the abuse. Certified Nurse Aide #3 was suspended and subsequently terminated. The police were notified and involved in the investigation.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect a resident from physical abuse by a Certified Nurse Aide. | Level of Harm - Actual harm |
Report Facts
Residents sampled: 4
Residents affected: 1
Date of abuse incident: Jun 11, 2025
Date survey completed: Jun 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Certified Nurse Aide | Alleged and confirmed perpetrator of physical abuse against Resident #1 |
| Director of Social Work | Director of Social Work | Followed up with Resident #1 regarding abuse complaint and corroborated allegations |
| Administrator | Administrator | Responsible for reporting the abuse allegation to the New York State Department of Health and terminating Certified Nurse Aide #3 |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse allegation and confirmed facility's determination of abuse |
| Medical Director | Medical Director | Assessed Resident #1 post-incident and supported facility's actions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 23
Mar 12, 2025
Visit Reason
Complaint Survey with 12 health and 11 life safety citations covering multiple quality of care and life safety deficiencies, all corrected by May 7 or May 12, 2025.
Findings
Complaint Survey with 12 health and 11 life safety citations covering multiple quality of care and life safety deficiencies, all corrected by May 7 or May 12, 2025.
Deficiencies (23)
| Description | Severity |
|---|---|
| ADL care provided for dependent residents | Level 2 |
| Care plan timing and revision | Level 2 |
| Free of accident hazards/supervision/devices | Level 2 |
| Influenza and pneumococcal immunizations | Level 2 |
| Nurse aide peform review-12 hr/yr in-service | Level 2 |
| Quality of care | Level 2 |
| Reporting of alleged violations | Level 2 |
| Request/refuse/dscntnue trmnt;formlte adv dir | Level 2 |
| Resident rights/exercise of rights | Level 2 |
| Respiratory/tracheostomy care and suctioning | Level 2 |
| Safe/clean/comfortable/homelike environment | Level 2 |
| Sufficient nursing staff | Level 2 |
| Cooking facilities | Level 2 |
| Electrical equipment - power cords and extens | Level 2 |
| Electrical systems - essential electric syste | Level 2 |
| Fire alarm system - testing and maintenance | Level 2 |
| Fire drills | Level 2 |
| Illumination of means of egress | Level 2 |
| Maintenance, inspection & testing - doors | Level 2 |
| Physical environment | Level 0 |
| Sprinkler system - installation | Level 2 |
| Sprinkler system - maintenance and testing | Level 2 |
| Standards of construction for new existing nh | Level 0 |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 12, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey from March 5, 2025 to March 12, 2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to broken window clips, radiator covers, stained window shades, and faulty air conditioning units allowing cold air entry. Additionally, the facility failed to timely review and update a resident's care plan after falls, and did not ensure adequate supervision for a resident requiring two-person assistance, resulting in a fall and injury.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Broken window clips, broken radiator cover, stained window shade, and black scuff marks in resident rooms; faulty window unit and air conditioner allowing cold air entry. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #164's care plan was not reviewed or updated timely after a medical assessment and a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #165 did not receive required two-person assistance, resulting in a fall and laceration/abrasion injuries. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Fall Risk Assessment score: 21
Minutes of therapy: 120
Dates of falls: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding environmental deficiencies and maintenance issues. | |
| Director of Nursing | Interviewed regarding failure to update Resident #164's care plan after falls. | |
| Licensed Practical Nurse #1 | Interviewed about care plan interventions and review process. | |
| Certified Nurse Aide #8 | Witnessed Resident #165's fall and reported lack of two-person assistance. | |
| Physical Therapist #9 | Interviewed about Resident #165's care needs and therapy progress. |
Inspection Report
Annual Inspection
Deficiencies: 10
Mar 12, 2025
Visit Reason
The inspection was a recertification survey conducted from 03/05/2025 to 03/12/2025 to assess compliance with regulatory requirements for Briarcliff Manor Center for Rehab and Nursing Care.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified care, accuracy of advance directives, environmental safety issues, timely reporting of injuries of unknown origin, provision of personal hygiene care, appropriate respiratory care, staffing shortages, and inadequate nurse aide training. Several residents were observed with unmet care needs and documentation deficiencies were noted.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident #24 was observed multiple times with food/crumbs on their chin and gown after meals, indicating failure to ensure dignified care. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #82's Medical Orders for Life Sustaining Treatment were changed from Do Not Resuscitate to Full Code but physician orders and facility identifiers were not updated accordingly. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure a clean, comfortable, and homelike environment; broken window clips, radiator covers, stained window shades, and faulty air conditioning units were observed. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to timely report an injury of unknown origin to the state agency for Resident #10 who was observed with bruising on the face. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #52 and #57 who required assistance with activities of daily living were observed with long, ungroomed fingernails. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #10 was not assessed by a registered nurse after being hit in the face with a bed control; no documentation of assessment was found. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #34 was observed receiving oxygen at a rate lower than the physician's order and no oxygen use signage was posted on the room door. | Level of Harm - Minimal harm or potential for actual harm |
| Staffing levels were below minimum requirements on multiple dates in February and March 2025, with fewer Certified Nurse Aides than required on several shifts. | Level of Harm - Minimal harm or potential for actual harm |
| Five randomly selected Certified Nurse Aides received only 10 of the required 12 hours of annual in-service training, missing mandatory topics such as abuse and resident rights. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #1 and #24 were not offered pneumococcal vaccinations nor provided education regarding the benefits and side effects, with no documentation of offer or declination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiency dates with staffing below minimum: 13
Certified Nurse Aides with insufficient in-service hours: 5
Required annual in-service hours: 12
Actual in-service hours received: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Stated Resident #24 was independent when eating and cleaned resident's face, hands, and clothing as needed after meals. | |
| Director of Nursing | Provided statements regarding expectations for meal cleanup, advance directive procedures, and staffing issues. | |
| Certified Nurse Aide #7 | Provided care to Resident #10 when bed control accidentally hit resident's face. | |
| Licensed Practical Nurse #1 | Described procedures for identifying residents with advance directives and handling hospital transfers. | |
| Social Work Director | Explained process for updating advance directives and acknowledged failure to update Resident #82's orders. | |
| Licensed Practical Nurse #5 | Reported being informed about Resident #10's face injury but did not report or document it. | |
| Licensed Practical Nurse #6 | Observed Resident #10 after injury but did not document or report bruising. | |
| Certified Nurse Aide #10 | Described responsibilities for nail care and activities of daily living. | |
| Registered Nurse Unit Manager #11 | Stated expectations for nail care and supervision of Certified Nurse Aides. | |
| Director of Human Resources and Staffing | Discussed staffing shortages, turnover, and efforts to fill vacancies. | |
| Administrator | Acknowledged Certified Nurse Aides did not meet annual in-service training requirements. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jan 17, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to investigate whether the facility honored residents' rights to receive written notice before room or roommate changes.
Findings
The facility failed to ensure that Resident #1 received written notice prior to multiple room changes, violating the resident's right to be informed. Interviews with the resident, social worker, and Director of Nursing confirmed that written notification was not provided and that residents were not given a choice regarding room moves.
Complaint Details
The visit was complaint-related, investigating allegations that Resident #1 was moved multiple times without written notice or consent. Resident #1 denied receiving any written documentation or prior notification. The complaint was substantiated based on record review and interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide written notice to Resident #1 before room changes, violating the resident's right to receive written notification prior to transfer. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Room changes for Resident #1: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Social Worker | Interviewed regarding notification process for room changes; stated no written notice was provided and was not employed at time of incident |
| Director of Nursing | Director of Nursing | Interviewed regarding room change procedures and documentation expectations |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Jan 17, 2025
Visit Reason
Complaint Survey with one health citation for room/roommate change notification, corrected by March 10, 2025.
Findings
Complaint Survey with one health citation for room/roommate change notification, corrected by March 10, 2025.
Deficiencies (1)
| Description | Severity |
|---|---|
| Choose/be notified of room/roommate change | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Apr 19, 2024
Visit Reason
Complaint Survey with one health citation for free of accident hazards, corrected by June 14, 2024.
Findings
Complaint Survey with one health citation for free of accident hazards, corrected by June 14, 2024.
Deficiencies (1)
| Description | Severity |
|---|---|
| Free of accident hazards/supervision/devices | Level 2 |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 5, 2024
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety standards, specifically focusing on accident hazards and supervision to prevent accidents.
Findings
The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. A certified nursing assistant transferred Resident #1 without the required assistance, resulting in the resident falling to the floor without injury.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the environment remained free of accident hazards and provide adequate supervision to prevent accidents, resulting in a resident fall during transfer without injury. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accidents: 3
Residents affected: 1
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 2, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to investigate allegations of abuse and neglect involving residents, as well as to assess compliance with nursing care, staffing, and medical record-keeping requirements.
Findings
The facility failed to thoroughly investigate allegations of abuse for two residents, did not report or complete investigations timely, failed to provide ordered intravenous fluids to a resident, was understaffed on multiple shifts, and did not maintain accurate medical records regarding a resident's wound care.
Complaint Details
The investigation was complaint-driven based on allegations of sexual abuse and staff-to-resident abuse involving Residents #273 and #267. The facility failed to conduct thorough investigations, obtain statements from all witnesses, suspend accused staff, and submit required reports to the Department of Health. Resident #273 was sent to the hospital for evaluation following an allegation of sexual abuse by a family member, but the facility did not report the hospital transfer or complete the investigation properly. Resident #267 reported being pushed by a staff member but the facility did not provide documentation of investigation or submit the 5-day investigative conclusion.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate allegations of abuse for 2 residents and failure to report and submit investigation conclusions to the Department of Health. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #272 was not administered intravenous fluids as ordered, with no documented attempts to start IV line until 3 days after order. | Level of Harm - Minimal harm or potential for actual harm |
| Insufficient nursing staff provided to meet resident needs on multiple shifts, with residents and staff reporting delays in call bell response and inadequate care. | Level of Harm - Minimal harm or potential for actual harm |
| Medical records for Resident #269 were incomplete and inaccurate, with nursing documentation indicating 'skin intact' despite wound consults documenting an open surgical wound. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Staffing understaffed days: 14
Staffing understaffed days: 15
Staffing understaffed days: 10
IV fluid infusion rate: 75
Wound measurements: 13
Wound measurements: 6
Wound measurements: 4.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #32 | Director of Social Work | Responded to incident involving Resident #273 and family member, documented investigation details |
| Staff #3 | Licensed Practical Nurse Unit Manager | Received family member call regarding Certified Nurse Aide, documented nursing progress notes for Resident #273 |
| Staff #33 | Certified Nurse Aide | Provided care to Resident #273 during incident, interviewed about event |
| Administrator | Reported incident to Department of Health, participated in investigation and interviews | |
| Regional Nurse #1 | Involved in investigation of Resident #267 abuse allegation | |
| Regional Nurse #2 | Provided Summary of Investigation for Resident #267 | |
| Staff #9 | Licensed Practical Nurse | Documented IV fluid administration attempts for Resident #272 |
| Staff #13 | Licensed Practical Nurse | Responsible for IV fluid administration on 9/22/2023 and documented wound care notes for Resident #269 |
| Nurse Practitioner #2 | Ordered IV fluids for Resident #272 and requested evaluation | |
| Medical Director | Interviewed regarding expectations for IV fluid administration notifications | |
| Staff #26 | Certified Nurse Aide | Reported staffing shortages during interviews |
| Staff #25 | Certified Nurse Aide | Reported inadequate staffing and workload challenges |
| Staff #27 | Nurse | Clarified documentation meaning regarding wound care |
| Consultant #1 | Wound Doctor | Provided wound assessment and measurements for Resident #269 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Feb 2, 2024
Visit Reason
Complaint Survey with 12 health and 4 life safety citations including criminal history checks, infection control, nutrition, nursing staff sufficiency, and electrical systems; all corrected by March 2024.
Findings
Complaint Survey with 12 health and 4 life safety citations including criminal history checks, infection control, nutrition, nursing staff sufficiency, and electrical systems; all corrected by March 2024.
Deficiencies (16)
| Description | Severity |
|---|---|
| Criminal history record check process | Level 2 |
| Department criminal history review | Level 2 |
| Dispose garbage and refuse properly | Level 2 |
| Food procurement,store/prepare/serve-sanitary | Level 2 |
| Free of accident hazards/supervision/devices | Level 2 |
| Infection prevention & control | Level 2 |
| Investigate/prevent/correct alleged violation | Level 2 |
| Medicaid/medicare coverage/liability notice | Level 2 |
| Nutrition/hydration status maintenance | Level 2 |
| Resident records - identifiable information | Level 2 |
| Resident rights/exercise of rights | Level 2 |
| Sufficient nursing staff | Level 2 |
| Electrical systems - essential electric syste | Level 2 |
| Exit signage | Level 2 |
| Maintenance, inspection & testing - doors | Level 2 |
| Physical environment | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 10
Feb 2, 2024
Visit Reason
The inspection was a recertification survey conducted from 1/28/24 to 2/2/24 to assess compliance with regulatory requirements including resident care, infection control, staffing, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate notification of Medicare non-coverage, incomplete abuse investigations, environmental hazards, insufficient nursing staff, improper food storage and handling, incomplete medical record documentation, and lapses in infection prevention and control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident #78's urinary catheter drainage bag was not concealed to maintain dignity. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate liability and appeal notices to Medicare beneficiaries at termination of Medicare coverage for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not thoroughly investigate all allegations of abuse for 2 residents, including failure to suspend accused staff and obtain statements. | Level of Harm - Minimal harm or potential for actual harm |
| Cable wire in Resident #365's room was unsecured and posed a fall hazard. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #272 was not administered intravenous fluids as ordered, with no documented attempts to start IV line for several days. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure sufficient nursing staff to meet resident needs on all shifts, with multiple reports of delayed call bell response and inadequate care. | Level of Harm - Minimal harm or potential for actual harm |
| Food service deficiencies including peeling metal shelves, unlabeled and undated food items, uncovered food, staff not wearing beard covering, improper food temperature recording, and unclean dishware. | Level of Harm - Minimal harm or potential for actual harm |
| Garbage was observed on the ground surrounding the compactor and the area was not maintained in a sanitary condition to prevent pest harborage. | Level of Harm - Minimal harm or potential for actual harm |
| Nursing staff documented 'skin intact' for Resident #269 on multiple occasions despite wound consults documenting an open surgical wound. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain timely physician orders for transmission based precautions for five residents with positive COVID test results. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 10
Understaffed shifts: 14
Understaffed shifts: 15
Understaffed shifts: 10
Wound measurements: 13
Wound measurements: 6
Wound measurements: 4.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Certified Nurse Aide | Named in dignity bag deficiency for Resident #78 |
| Staff #2 | Licensed Practical Nurse | Interviewed regarding catheter dignity bag responsibility |
| Director of Nursing | Interviewed regarding catheter dignity bag and abuse investigation | |
| Staff #32 | Social Worker | Interviewed regarding Notice of Non-Medicare Coverage and abuse investigation |
| Staff #3 | Licensed Practical Nurse Unit Manager | Involved in abuse investigation and resident transfer |
| Staff #33 | Certified Nurse Aide | Involved in abuse incident with Resident #273 |
| Regional Nurse #1 | Involved in investigation of abuse allegation for Resident #267 | |
| Regional Nurse #2 | Provided summary of investigation for Resident #267 | |
| Staff #15 | Registered Unit Nurse Manager | Interviewed regarding unsecured cable wire hazard |
| Staff #20 | Maintenance Director | Interviewed regarding cable wire hazard and garbage compactor area |
| Staff #22 | Food Service Director | Interviewed regarding food safety and storage deficiencies |
| Staff #18 | Cook | Observed not wearing beard covering while preparing food |
| Staff #13 | Licensed Practical Nurse | Documented wound note and interviewed regarding wound care |
| Consultant #1 | Wound Doctor | Interviewed regarding wound status for Resident #269 |
| Staff #24 | Licensed Practical Nurse | Interviewed regarding COVID transmission based precaution orders |
| Staff #30 | Licensed Practical Nurse | Interviewed regarding COVID transmission based precaution orders |
Inspection Report
Capacity: 60
Deficiencies: 1
Dec 11, 2023
Visit Reason
Covid-19 Survey with one health citation for reporting to national health safety network; widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one health citation for reporting to national health safety network; widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Oct 17, 2023
Visit Reason
Covid-19 Survey with one health citation for reporting to national health safety network; widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one health citation for reporting to national health safety network; widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Sep 29, 2023
Visit Reason
Complaint Survey with two health citations including pharmacy services and significant medication errors (Level 4, immediate jeopardy), corrected by November 13, 2023.
Findings
Complaint Survey with two health citations including pharmacy services and significant medication errors (Level 4, immediate jeopardy), corrected by November 13, 2023.
Deficiencies (2)
| Description | Severity |
|---|---|
| Pharmacy srvcs/procedures/pharmacist/records | Level 2 |
| Residents are free of significant med errors | Level 4 |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Sep 29, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate pharmaceutical services and medication administration compliance, specifically focusing on anti-seizure medication administration for two residents.
Findings
The facility failed to provide pharmaceutical services ensuring accurate medication administration for Resident #1 and Resident #2, resulting in multiple missed doses of prescribed anti-seizure medications. Resident #1 suffered a seizure and was hospitalized due to omitted doses of Vimpat. Documentation and communication failures were noted, including lack of notification to medical providers and inadequate medication stock management.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, and administering of drugs for 2 of 5 residents, resulting in missed doses of Vimpat and Keppra. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents were free from significant medication errors, with 12 doses of Vimpat and 7 doses of Keppra not administered, resulting in Immediate Jeopardy and actual harm to Resident #1. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Missed doses of Vimpat: 12
Missed doses of Keppra: 7
Medication supply delivery date: Sep 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Assigned to administer medications to Resident #1; reported medication shortages and attempted to notify NP and physician. |
| Nurse Practitioner (NP) | Nurse Practitioner | Notified that nurses should have reported medication shortages; was not notified about Vimpat unavailability. |
| Physician #1 | Physician | Responsible for signing medication orders; unaware of missed medication doses; expected nurses to notify about medication issues. |
| Pharmacy Supervisor (PS) | Pharmacy Supervisor | Reported Medicaid billing issue delayed medication refill; did not notify facility of refill rejection. |
| DNS | Director of Nursing Services | Notified of resident transfer but not medication shortage; responsible for supervising medication administration reports. |
| RNS #1 | Registered Nurse Supervisor | Not notified of medication shortage; did not run medication administration reports on relevant dates. |
| LPN #2 | Licensed Practical Nurse | Notified LPNS #1 of missing medication and borrowed medication from another resident for Resident #1. |
| LPNS #1 | Licensed Practical Nurse Supervisor | Instructed borrowing medication from another resident; did not run administration reports regularly. |
| LPN #4 | Licensed Practical Nurse | Notified LPNS #2 of missing medication; submitted refill requests; did not follow up on medication delivery. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
May 30, 2023
Visit Reason
Complaint Survey with two health citations for accident hazards and quality of care, corrected by July 26, 2023.
Findings
Complaint Survey with two health citations for accident hazards and quality of care, corrected by July 26, 2023.
Deficiencies (2)
| Description | Severity |
|---|---|
| Free of accident hazards/supervision/devices | Level 2 |
| Quality of care | Level 2 |
Inspection Report
Abbreviated Survey
Deficiencies: 2
May 30, 2023
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with professional standards of care, specifically reviewing treatment and care for residents, including weight loss management and accident prevention.
Findings
The facility failed to ensure proper documentation of supplement intake and daily weights for a resident at risk of malnutrition, and did not provide adequate supervision to prevent a resident's fall resulting in injury. Interviews revealed staff confusion and inconsistent implementation of care plans and supervision protocols.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to document supplement intake amount and daily weights as ordered for Resident #1 at risk for malnutrition. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate supervision leading to Resident #1 falling out of bed and sustaining a subarachnoid hemorrhage. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without documented Nepro intake amount: 27
Days without documented Nepro intake amount: 29
Days without documented daily weights: 27
Days without documented Nepro intake amount: 27
Days without documented daily weights: 22
Days without documented Nepro intake amount and daily weights: 18
Fall risk assessment scores: 14
Fall risk assessment scores: 11
Fall risk assessment scores: 15
Fall risk assessment scores: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Stated responsibility for documenting medication administration and lack of knowledge on documenting Nepro intake amount. |
| Director of Nursing | Director of Nursing | Described nurses' responsibilities for documentation and reporting medication/treatment issues. |
| Registered Dietician | Registered Dietician | Stated documentation of supplement intake is helpful for assessing effectiveness. |
| CNA #3 | Certified Nursing Assistant | Assigned 1:1 supervision on day of resident's fall; described circumstances of fall. |
| LPN #2 | Licensed Practical Nurse | Witnessed resident fall and initiated neuro-checks; described supervision practices. |
| LPN Supervisor | LPN Supervisor | Directed CNA #3 to provide 1:1 supervision and communicated with physician after fall. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Dec 27, 2022
Visit Reason
Complaint Survey with two health citations for comprehensive care plan and accident hazards, corrected by February 24, 2023.
Findings
Complaint Survey with two health citations for comprehensive care plan and accident hazards, corrected by February 24, 2023.
Deficiencies (2)
| Description | Severity |
|---|---|
| Develop/implement comprehensive care plan | Level 2 |
| Free of accident hazards/supervision/devices | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 6
Nov 10, 2020
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, inadequate call bell accessibility for residents, incomplete and improperly followed care plans for pressure ulcers and medications, poor oral hygiene care, failure to offload pressure ulcers as ordered, and lapses in infection prevention and control practices such as improper catheter bag placement, laundry handling, and hand hygiene.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Staff were observed feeding residents while standing instead of seated, compromising dignified dining experience. | Level of Harm - Potential for minimal harm |
| Call bell system was not accessible or within reach for several residents. | Level of Harm - Potential for minimal harm |
| Facility failed to develop and implement complete care plans with measurable goals for pressure ulcers, medications, and ADLs for several residents. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #58 was observed with substantial residue on her tongue indicating inadequate oral hygiene care. | Level of Harm - Minimal harm or potential for actual harm |
| Pressure ulcer care was inadequate; residents #74 and #92 did not have heel booties or heel float devices applied as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Infection prevention and control deficiencies included foley catheter bag and tubing resting on the floor, improper laundry handling and transport, and failure of staff to perform hand hygiene after contact with potentially contaminated surfaces. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 6
Residents affected: 1
Residents affected: 2
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in feeding assistance and oral hygiene findings |
| CNA #1 | Certified Nursing Assistant | Named in feeding assistance and catheter bag placement findings |
| LPN #2 | Licensed Practical Nurse | Named in call bell accessibility and pressure ulcer care findings |
| CNA #2 | Certified Nursing Assistant | Named in call bell accessibility and oral hygiene findings |
| CNA #3 | Certified Nursing Assistant | Named in pressure ulcer care and oral hygiene findings |
| RN #1 | Registered Nurse | Named in pressure ulcer care and catheter bag placement findings |
| Corporate Nurse | Named in pressure ulcer care findings related to documentation | |
| Laundry Staff #1 | Named in infection control findings related to laundry handling | |
| Supervisor of Central Supply/Housekeeping | Named in infection control findings related to laundry handling |
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