Inspection Reports for
Campbell Hall Rehabilitation Center Inc
23 Kiernan Rd, Campbell Hall, NY, 10916
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
26 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
410% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Dec 10, 2025
Visit Reason
Recertification and abbreviated surveys conducted from 12/03/2025 to 12/10/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, resident abuse prevention, activities of daily living assistance, pressure ulcer care, accident prevention, nutrition, staffing adequacy, medication management, and food safety. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (10)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with strong urine odors, soiled floors, garbage in dining areas, and cluttered resident rooms.
F 0600: The facility did not protect residents from physical abuse; Resident #7 hit Resident #110 causing injury and threats, with inadequate interventions following the incident.
F 0677: The facility failed to provide adequate care for activities of daily living; Residents #6, #76, and #105 missed scheduled showers and had hygiene issues.
F 0686: Resident #106 with pressure ulcers did not receive timely wound care; wound assessments were delayed over 20 days resulting in actual harm.
F 0689: The facility failed to provide adequate supervision to prevent accidents; Resident #7 fell down a stairwell in a wheelchair causing fractures and injury.
F 0692: The facility did not ensure adequate nutrition for Residents #1 and #3; Resident #1 had significant weight loss and poor meal monitoring, Resident #3 had weight loss and delayed dietary supplementation.
F 0725: Staffing levels were below desired levels on multiple shifts, resulting in unmet resident care needs including missed showers and delayed assistance.
F 0755: The facility failed to maintain accurate and complete narcotic drug counts; 37 missing nurse signatures on narcotic count logs over 104 days were identified.
F 0760: Resident #98 missed five doses of Lamictal due to medication unavailability and lack of physician notification, resulting in a breakthrough seizure.
F 0812: Food safety violations included unlabeled, undated, and expired food items in kitchen and unit pantries, risking foodborne illness.
Report Facts
Missing narcotic count signatures: 37
Missed medication doses: 5
Weight loss percentage: 12
Weight loss percentage: 9.8
Staffing shifts below desired levels: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #12 | Signed medication administration record but did not administer Lamictal on 09/03/2025. | |
| Registered Nurse Supervisor #1 | Conducted wound assessment on Resident #106 and spoke with pharmacist about medication delay. | |
| Certified Nurse Aide #28 | Assigned to Resident #7 and involved in incident response when resident fell down stairwell. | |
| Director of Nursing | Reviewed wound care delays and narcotic count discrepancies; provided staff education. |
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Aug 5, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements related to resident care, abuse prevention, pressure ulcer care, accident prevention, and pest control.
Findings
The facility was found deficient in protecting residents from abuse, timely reporting of alleged abuse, suspension of staff during investigations, pressure ulcer care, accident prevention, and maintaining an effective pest control program. Multiple residents experienced violations including mental abuse via unauthorized video recording, failure to report alleged abuse, inadequate suspension of involved staff, inconsistent wound care, lack of accident investigation, and presence of mice in resident rooms.
Deficiencies (6)
F 0600: The facility failed to protect Resident #111 from mental abuse when a Certified Nurse Aide live streamed video of the resident undressed during care, causing humiliation. The staff member was terminated.
F 0609: The facility did not timely report an alleged rape for Resident #112 to the state health department, as the allegation was retracted but not reported within two hours.
F 0610: The facility failed to suspend Certified Nurse Aide #11 during an abuse investigation involving Resident #71, allowing the staff member to return to work before completion of the investigation.
F 0686: The facility did not ensure proper pressure ulcer care for Residents #34 and #114, including failure to offload heels as ordered and omissions in wound treatment documentation.
F 0689: The facility failed to provide adequate supervision and a hazard-free environment to prevent accidents for Resident #112, lacking documentation of an incident report for a fall on 1/5/25.
F 0925: The facility did not maintain an effective pest control program, resulting in mice infestations in Resident #10 and #66's rooms without documented inspections or remediation.
Report Facts
Residents reviewed for abuse: 4
Residents reviewed for accidents: 7
Residents reviewed for pressure ulcers: 4
Omissions in wound care treatment: 20
Omissions in air mattress checks: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #22 | Named in mental abuse finding for live streaming Resident #111. | |
| Registered Nurse #14 | Registered Nurse | Interviewed regarding phone and video policies and abuse prevention. |
| Registered Nurse Supervisor #17 | Registered Nurse Supervisor | Documented and responded to Resident #112's fall and alleged rape. |
| Certified Nurse Aide #11 | Involved in abuse incident with Resident #71 and not suspended during investigation. | |
| Licensed Practical Nurse #10 | Involved in abuse incident with Resident #71. | |
| Director of Nursing | Director of Nursing | Interviewed regarding suspension policies and wound care oversight. |
| Director of Human Resources / Staffing Coordinator | Director of Human Resources / Staffing Coordinator | Interviewed regarding suspension and disciplinary actions for Certified Nurse Aide #11. |
| Certified Nurse Aide #15 | Interviewed about offloading Resident #34's heels. | |
| Registered Nurse #5 | Registered Nurse | Interviewed about wound care and pest control awareness. |
| Nurse Practitioner #2 | Nurse Practitioner | Documented Resident #112's fall assessment. |
| Social Worker #19 | Social Worker | Interviewed about pest control complaints from Resident #10. |
| Maintenance Worker #20 | Maintenance Worker | Interviewed about pest control procedures and resident room inspections. |
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Aug 5, 2025
Visit Reason
The survey was a recertification and abbreviated annual inspection to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including environmental safety, grievance handling, abuse prevention and reporting, resident assessments, care planning, pressure ulcer care, accident prevention, catheter care, nutrition and hydration, respiratory care, staffing adequacy, medication storage, dental care, infection control, equipment maintenance, pest control, and nurse aide training.
Deficiencies (19)
10NYCRR 415.5(h)(2): The facility did not ensure a safe, clean, comfortable environment; air conditioner casings were loose or detached and walls had unfinished plaster or holes in multiple resident rooms.
10NYCRR 415.5(c)(6): Resident grievances for missing property were not acted on promptly or investigated properly for two residents.
10NYCRR 415.4(b)(2): Resident #111 was subjected to mental abuse when a staff member live streamed video of them without consent.
10NYCRR 415.4(b)(3): Staff involved in an abuse incident were not suspended during the entire investigation, allowing potential further risk.
10NYCRR 415.11(b): Resident assessments were inaccurate; dental issues and tobacco use were not properly documented for two residents.
10NYCRR 415.11(e): Preadmission screening for Resident #6 was incomplete and contained errors.
10NYCRR 415.11(c)(1): Care plans were incomplete or missing for anxiety, depression, and nutrition for three residents.
10NYCRR 415.11(c)(2): Care plans were not updated to reflect changes in resident status including discharge planning, pressure ulcer orders, and fall-related neuro-checks.
10NYCRR 415.12(c)(1): Pressure ulcer care was inconsistent and physician orders to offload heels were not incorporated into care plans or followed.
10NYCRR 415.12(h)(2): Resident #112's fall was not properly documented with an incident/accident report or investigation.
10NYCRR 415.12(d)(1): Resident #19's indwelling catheter care was inadequate; catheter tubing was improperly positioned and catheter care documentation had multiple omissions.
10NYCRR 415.12(i)(1): Resident #6 lacked a nutritional assessment upon admission and Resident #34 had significant weight loss without an active nutrition care plan or new interventions.
10NYCRR 415.14(a)(1)(2): The facility lacked a licensed dietician from 6/28/2025 to 8/4/2025 to oversee dietary needs.
10NYCRR 415.14(c)(1-3): Residents did not consistently receive meals as ordered; one resident received a magic cup not ordered or documented on meal ticket.
10NYCRR 415.15(a): The Medical Director or designee did not participate in Quality Assurance & Performance Improvement meetings for six consecutive sessions.
10NYCRR 415.19: Infection control practices were deficient; staff failed to don gowns when providing care to residents on enhanced barrier precautions.
10NYCRR 415.5(e)(1)(2): Resident #71's electrical bed was inoperable for over a year and had not been repaired despite resident complaints.
10NYCRR 415.29(j)(5): The facility did not maintain an effective pest control program; residents reported mice in rooms and no documented inspections or remediation were evident.
10NYCRR 415.26: Certified nurse aides did not receive the required 12 hours of annual in-service training including dementia care.
Report Facts
Days understaffed for certified nurse aides: 34
Days understaffed for licensed practical nurses or registered nurses: 15
Weight loss percentage: 12.49
Medication capsules counted: 31
Certified nurse aide in-service hours: 3
Certified nurse aide in-service hours: 1.17
Certified nurse aide in-service hours: 1
Certified nurse aide in-service hours: 2.75
Omissions in catheter care documentation: 35
Omissions in air mattress checks: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #15 | Observed providing care without gown to Resident #34 on enhanced barrier precautions. | |
| Registered Nurse #14 | Observed providing wound care without gown to Resident #66 on enhanced barrier precautions. | |
| Certified Nurse Aide #22 | Involved in live streaming video of Resident #111 without consent. | |
| Certified Nurse Aide #11 | Not suspended during abuse investigation involving Resident #71. | |
| Registered Nurse Supervisor #17 | Responded to Resident #112 fall and alleged rape; reported incident but no accident report found. | |
| Director of Nursing | Provided multiple statements regarding deficiencies and corrective actions. | |
| Director of Social Work | Discussed grievance investigations and discharge planning. | |
| Staff Educator Resident Nurse | Provided in-service training for certified nurse aides. | |
| Administrator | Provided statements on staffing, dental care, and quality assurance meetings. | |
| Director of Human Resources/Staffing Coordinator | Discussed staffing challenges and recruitment efforts. | |
| Food Service Director | Discussed meal ticket and tray inconsistencies. | |
| Maintenance Assistant #20 | Repaired Resident #71's bed motor. | |
| Resident Transport/Appointment Coordinator | Discussed dental appointment scheduling for Resident #101. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Apr 29, 2025
Visit Reason
Complaint Survey with 6 standard health citations related to accuracy of assessments, care plans, abuse prevention, investigation of violations, nurse aide training, and dementia treatment. All deficiencies corrected by May 28, 2025.
Findings
Complaint Survey with 6 standard health citations related to accuracy of assessments, care plans, abuse prevention, investigation of violations, nurse aide training, and dementia treatment. All deficiencies corrected by May 28, 2025.
Deficiencies (6)
Accuracy of assessments
Develop/implement comprehensive care plan
Free from abuse and neglect
Investigate/prevent/correct alleged violation
Required in-service training for nurse aides
Treatment/service for dementia
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Apr 29, 2025
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with regulations related to resident abuse prevention, accurate resident assessments, care planning, dementia care, and nurse aide training.
Findings
The facility failed to protect a resident from abuse by staff, did not thoroughly investigate alleged abuse incidents, inaccurately documented resident behaviors in assessments, lacked comprehensive care plans for residents with behavioral issues, and failed to provide required dementia and abuse prevention training to nurse aides.
Deficiencies (6)
F 0600: The facility did not ensure Resident #1 was free from abuse; a Certified Nurse Aide hit the resident during care and lacked abuse training.
F 0610: The facility failed to thoroughly investigate alleged abuse; missing camera review, law enforcement report, and timely notification to medical staff.
F 0641: The Minimum Data Set assessment inaccurately documented no behaviors for Resident #1 despite documented aggressive behaviors.
F 0656: The facility did not develop or implement comprehensive care plans addressing behavioral needs for Residents #1 and #2.
F 0744: Residents #1 and #2 with dementia did not receive individualized care plans addressing their verbal and physical aggression.
F 0947: Certified Nurse Aide #1 did not receive required dementia management and abuse prevention training; facility lacked a staff educator.
Report Facts
Residents reviewed for abuse: 3
Dates of documented aggressive behaviors for Resident #1: 11
Dates of documented aggressive behaviors for Resident #2: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in abuse incident and lack of abuse/dementia training | |
| Certified Nurse Aide #2 | Witnessed abuse incident involving Certified Nurse Aide #1 and Resident #1 | |
| Director of Nursing | Director of Nursing | Provided statements on abuse incident, investigation, care planning, and staff training |
| Physician #1 | Physician | Notified late of abuse incident and expected timely notification |
| Medical Director | Medical Director | Notified late of abuse incident and expected timely notification and involvement |
| Human Resources Director | Human Resources Director | Unable to provide Certified Nurse Aide #1 training records |
| Administrator | Administrator | Provided statements on investigation process, staff educator vacancy, and referrals |
| Minimum Data Set Coordinator | MDS Coordinator | Acknowledged errors in behavior documentation and plans to revise assessments |
| Director of Social Services | Director of Social Services | Provided information on Resident #2's behaviors and care plan challenges |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 22, 2024
Visit Reason
The inspection was a recertification, abbreviated, and extended survey conducted from 12/15/2024 to 12/22/2024 to assess compliance with regulatory requirements including resident safety, medication management, infection control, and facility operations.
Findings
The facility failed to ensure residents' rights to self-determination regarding smoking, did not provide adequate supervision to prevent smoking-related accidents including a fire, lacked proper medication regimen review follow-up, had deficiencies in infection control practices including lack of a water management plan and incomplete staff vaccination records, and failed to maintain effective governance and quality assurance oversight related to smoking and safety.
Deficiencies (6)
F0561: The facility did not ensure residents had a right to make choices regarding smoking, failing to offer a designated smoking area or cessation programs for known smokers.
F0689: The facility failed to provide adequate supervision to prevent smoking-related accidents for 6 residents, resulting in a fire caused by a resident's cigarette butt and lack of safety assessments or supervision.
F0756: The facility did not ensure licensed pharmacist recommendations from monthly drug regimen reviews were reviewed and acted upon timely by physicians for 3 residents.
F0835: The facility failed to provide effective operational oversight, including inadequate supervision to prevent smoking accidents, failure to conduct required fire drills, incomplete emergency preparedness training, inadequate staffing, and failure to offer COVID-19 vaccinations to staff.
F0837: The facility did not ensure a clear line of communication and reporting between the Administrator and governing body, failing to address smoking-related safety issues and quality assurance performance improvement.
F0880: The facility did not implement an effective infection prevention and control program, lacking a current water management plan for Legionella, accurate infection tracking, and complete staff vaccination documentation.
Report Facts
Residents identified as smokers: 6
Facility staff: 109
Cigarette butts observed: 12
Staff reviewed for vaccination records: 10
Shifts with inadequate nursing staffing: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #41 | Known smoker involved in fire incident on 11/1/2024 and observed smoking unsupervised | |
| Administrator | Acknowledged smoking issues and lack of quality assurance reporting | |
| Director of Nursing | Infection Preventionist | Responsible for infection control program and acknowledged deficiencies in vaccination tracking and infection surveillance |
| Medical Director | Unaware of smoking incidents and fire, no smoking-related agenda items at quality assurance meetings | |
| Owner | Aware of smoking issues but did not bring to quality assurance committee | |
| Certified Nurse Aide #6 | Reported residents smoked on patio and cigarettes were held by Administrator | |
| Certified Nurse Aide #5 | Advised to watch Resident #41 closely due to smoking | |
| Licensed Practical Nurse #8 | Acknowledged residents smoked but were not tracked | |
| Director of Human Resources | Observed fire and extinguished it, aware of smoking on patio | |
| Social Worker | Assisted in fire extinguishing and reported smelling smoke |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Dec 22, 2024
Visit Reason
The survey was conducted as a Recertification, Abbreviated, and Extended Survey from 12/15/24 to 12/22/24 to assess compliance with regulatory requirements for nursing home operations, resident care, and safety.
Complaint Details
Complaint investigation NY00359302 triggered the recertification, abbreviated, and extended surveys from 12/15/24 to 12/22/24. The complaint involved concerns about smoking safety, fire safety, infection control, staffing, and resident care.
Findings
The facility was found non-compliant in multiple areas including failure to ensure resident rights regarding smoking, inadequate building maintenance, failure to notify residents of bed hold policies, incomplete PASARR screening, deficient comprehensive care plans, inadequate supervision of smokers leading to a fire, insufficient nursing staffing, improper catheter care, significant unaddressed weight loss in a resident, improper respiratory care, expired medications storage, lack of infection control measures including missing Legionella testing and incomplete staff vaccination records, and failure to provide COVID-19 vaccination education and documentation for staff.
Deficiencies (16)
F 0561: The facility failed to ensure residents had the right to make choices regarding smoking and did not offer a designated smoking area or cessation program for known smokers.
F 0584: The facility did not maintain the building in good repair, including dusty fans, stained ceiling tiles, nonfunctional fans in nurse stations, and doors that did not close properly.
F 0625: The facility failed to notify residents or their representatives in writing about the bed hold policy for hospital transfers for 2 residents.
F 0645: The facility did not complete a Preadmission Screening and Resident Review (PASARR) for 1 resident as required.
F 0656: The facility failed to develop and implement comprehensive care plans addressing all resident needs for 4 residents, including missing plans for dementia, pressure ulcer risk, smoking, and respiratory care.
F 0689: The facility failed to provide adequate supervision to prevent accidents related to smoking for 6 residents, resulting in a fire caused by a resident's cigarette on the patio.
F 0690: The facility did not develop a care plan or obtain appropriate physician orders for a resident's suprapubic catheter care.
F 0692: The facility did not ensure acceptable nutritional status for a resident with significant weight loss and failed to communicate this to the physician for assessment.
F 0695: The facility provided oxygen therapy without a physician order for 1 resident and administered oxygen at a higher rate than ordered for another resident.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs for 17 of 90 shifts reviewed.
F 0761: The facility stored expired antibiotics and intravenous fluids in the medication storage room.
F 0835: The facility failed to provide operative oversight ensuring effective systems for resident safety, including supervision of smokers, fire safety procedures, emergency preparedness, COVID-19 vaccination, and adequate staffing.
F 0837: The facility failed to establish a governing body process for reporting and communication regarding facility management and operation, including failure to address smoking safety issues in Quality Assurance meetings.
F 0880: The facility did not implement an infection prevention and control program including lack of Legionella testing, incomplete infection tracking, and incomplete staff vaccination documentation.
F 0883: The facility failed to ensure residents were offered pneumococcal immunizations and education regarding benefits and side effects.
F 0887: The facility did not ensure staff were screened, offered, and educated about COVID-19 vaccination, and lacked documentation of vaccination status or declinations for multiple staff members.
Report Facts
Weight loss percentage: 28.12
Staffing shortfalls: 17
Expired medication date: 2024
Number of smokers identified: 6
Number of staff missing COVID vaccine documentation: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding unawareness of resident #93 weight loss and lack of communication. |
| Director of Nursing | Director of Nursing and Infection Preventionist | Interviewed regarding infection control program, COVID-19 vaccine tracking, and smoking supervision. |
| Administrator | Facility Administrator | Interviewed regarding smoking policy, supervision, and Quality Assurance reporting. |
| Owner | Facility Owner | Interviewed regarding awareness of smoking issues and Quality Assurance reporting. |
| Director of Human Resources | Director of Human Resources | Interviewed regarding fire incident and smoking supervision. |
| Maintenance Director | Maintenance Director | Interviewed regarding smoking on patio and fireproofing of gazebo. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jul 22, 2024
Visit Reason
Complaint Survey with 7 standard health citations including administration, behavioral health services, facility assessment, accident hazards, investigation of violations, nurse aide training, and staff competency. One Level 3 severity for accident hazards. All deficiencies corrected by September 30, 2024.
Findings
Complaint Survey with 7 standard health citations including administration, behavioral health services, facility assessment, accident hazards, investigation of violations, nurse aide training, and staff competency. One Level 3 severity for accident hazards. All deficiencies corrected by September 30, 2024.
Deficiencies (7)
Administration
Behavioral health services
Facility assessment
Free of accident hazards/supervision/devices
Investigate/prevent/correct alleged violation
Nurse aide peform review-12 hr/yr in-service
Sufficient/competent staff-behav health needs
Inspection Report
Abbreviated Survey
Capacity: 134
Deficiencies: 7
Date: Jul 22, 2024
Visit Reason
The survey was conducted as an abbreviated and partial extended survey to investigate allegations of abuse, accident hazards, behavioral health care, staff performance evaluations, and facility administration issues.
Findings
The facility failed to thoroughly investigate and timely report abuse allegations, ensure adequate supervision to prevent accidents, provide necessary behavioral health care and staff training, complete performance evaluations, and maintain an updated facility assessment. Resident #1 suffered actual harm due to staff actions during an attempted elopement. Behavioral care plans lacked goals and interventions for unsafe behaviors. The facility experienced an electronic medical record outage without an emergency plan.
Deficiencies (7)
F 0610: The facility did not ensure all abuse allegations were thoroughly investigated and reported timely for 4 of 5 residents reviewed. Investigations lacked root cause analysis and some incident reports were missing.
F 0689: The facility failed to provide adequate supervision to prevent accidents for Resident #1, who fell after a staff member pushed a door against them, causing actual harm including a bloody nose and bruises.
F 0730: The facility did not complete performance reviews for certified nurse assistants annually; last evaluations were in 2018 and 2019.
F 0740: The facility did not ensure residents received necessary behavioral health care; care plans lacked goals and interventions for wandering, elopement risk, and aggressive behaviors for Residents #1 and #2.
F 0741: The facility failed to provide staff education on behavioral health needs between 1/1/2024 and 7/2024; no behavioral health policy was available during the survey.
F 0835: The facility was not administered to use resources effectively; the facility assessment was not updated from 7/31/2021 to 7/18/2024, an electronic medical record outage occurred without an emergency plan, and abuse investigation reports were not timely submitted to the state.
F 0838: The facility did not conduct and document a facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies; the assessment was not readily available and not reviewed or updated for nearly three years.
Report Facts
Facility total bed capacity: 134
Incident date: 2024
Incident date: 2024
Incident date: 2024
Incident date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Involved in incident pushing door against Resident #1 causing fall | |
| Director of Nursing | Responsible for investigations and reporting; interviewed multiple times | |
| Registered Nurse Supervisor #1 | Assessed Resident #1 after fall; involved in incident reporting | |
| Administrator | Facility administrator interviewed regarding reporting and facility assessment | |
| Physician Assistant #1 | Provided medical evaluation of Resident #1 after fall | |
| Staff Educator | Interviewed regarding behavioral health training and care plan updates |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Apr 18, 2024
Visit Reason
Complaint Survey with 2 standard health citations related to accuracy of assessments and care plan timing and revision. Both Level 2 severity and corrected by May 24, 2024.
Findings
Complaint Survey with 2 standard health citations related to accuracy of assessments and care plan timing and revision. Both Level 2 severity and corrected by May 24, 2024.
Deficiencies (2)
Accuracy of assessments
Care plan timing and revision
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Apr 18, 2024
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with regulatory requirements related to resident assessments and care planning.
Findings
The facility failed to ensure that the Minimum Data Set assessments accurately reflected residents' conditions and that comprehensive care plans were reviewed and updated quarterly and as needed. Specifically, Resident #1's assessments and care plans were incomplete or outdated, with documented refusals of care and untreated conditions not properly recorded.
Deficiencies (2)
F 0641: Ensure each resident receives an accurate assessment. The facility did not ensure the Minimum Data Set accurately reflected Resident #1's rejection of care, pressure ulcer status, and complaints of mild pain.
F 0657: Develop the complete care plan within 7 days of the comprehensive assessment; and prepare, review, and revise it by a team of health professionals. The facility did not ensure comprehensive care plans were reviewed and updated quarterly and as needed for Resident #1.
Report Facts
Residents reviewed: 3
Minimum Data Set score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator | Responsible for updating Minimum Data Sets and acknowledged inaccuracies in Resident #1's assessment | |
| Social Service Director | Responsible for resident assessment and care plan updates; provided information on Resident #1's refusals | |
| Director of Nursing | Provided information on care plan update responsibilities and staffing issues | |
| Licensed Practical Nurse Unit Manager | Described care plan update process and system alerts | |
| Registered Nurse Unit Manager | Described care plan update frequency and dashboard alerts |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
Covid-19 Survey with 1 standard health citation related to reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with 1 standard health citation related to reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with 1 standard health citation for reporting to national health safety network. Level 2 severity, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
Complaint Survey with 1 standard health citation related to free of accident hazards/supervision/devices. Level 2 severity, isolated scope, corrected by March 20, 2024.
Findings
Complaint Survey with 1 standard health citation related to free of accident hazards/supervision/devices. Level 2 severity, isolated scope, corrected by March 20, 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety regulations, specifically focusing on accident hazards and supervision to prevent accidents.
Findings
The facility failed to ensure adequate supervision and a safe environment free from accident hazards for one resident who was able to disarm a door alarm and fell down stairs in a wheelchair. The resident was not previously identified as an elopement risk and was not assigned a wander guard prior to the incident.
Deficiencies (1)
F 0689: The facility did not ensure adequate supervision and accident hazard prevention for Resident #6 who disarmed a 15 second hold on the exit door and fell down stairs in a wheelchair on 5/13/2023. The resident was found supine with the wheelchair on top and was transported to the hospital.
Report Facts
Residents Affected: 1
Residents Reviewed for Accidents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Licensed Practical Nurse | Signed the Accident/Incident report dated 5/13/2023 and worked the shift when the incident occurred. |
| Staff #8 | Certified Nurse Aide | Provided interview details about the incident and worked the shift on 5/13/2023 with Resident #6. |
| Staff #10 | Director of Nursing | Provided information about facility procedures for elopement risk and wander guard assignment. |
| Staff #25 | Assistant Director of Nursing | Participated in follow-up interview regarding supervision and elopement risk procedures. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 23, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care, specifically regarding treatment and care of residents, including wound care management.
Findings
The facility failed to ensure that Resident #1 with a deteriorating pressure ulcer received weekly assessments by a qualified professional between 9/29/22 and 11/23/22. There was no evidence that the physician was notified of the wound's deterioration or that new interventions were applied to stabilize the pressure ulcer during this period.
Deficiencies (1)
F 0684: The facility did not ensure Resident #1 with a deteriorating pressure ulcer was assessed weekly by a qualified professional between 9/29/22 and 11/23/22. There was no evidence that the physician was notified of the wound's deterioration or that treatment interventions were updated.
Report Facts
Wound size: 5.5
Wound size: 6.4
BIMS score: 9
Braden score: 17
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 10, 2023
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with care standards, specifically focusing on the provision of assistance with activities of daily living for residents unable to perform them independently.
Findings
The facility failed to ensure that a resident unable to carry out activities of daily living received necessary personal hygiene care. Resident #2 was observed lying in a heavily saturated adult brief for several hours without being changed, despite care plans and staffing policies requiring timely assistance.
Deficiencies (1)
F 0677: The facility did not provide timely care and assistance for activities of daily living to Resident #2, who was found in a heavily saturated brief after several hours without a change. Staff failed to follow care plans and staffing standards requiring regular hygiene support.
Report Facts
Residents reviewed for ADLs: 10
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA #1) | Assigned to Resident #2 and observed not changing the resident during the shift | |
| Unit Manager (UM) | Interviewed regarding staff responsibilities and resident care | |
| Licensed Practical Nurse (LPN #2) | Interviewed about nurse oversight and awareness of resident care | |
| Nurse Practitioner (NP) | Interviewed about risks of prolonged exposure to wet briefs and infection |
Inspection Report
Deficiencies: 0
Date: Mar 20, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Campbell Hall Rehabilitation Center Inc, related to a regulatory survey completed on 03/20/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Apr 29, 2022
Visit Reason
The inspection was a recertification survey conducted from 4/18/2022 to 4/29/2022 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, delays in resident transfers using Hoyer lifts, inadequate notification of Medicare coverage termination, incomplete investigations of abuse and accidents, failure to apply physician-ordered heel booties, improper food storage and thawing practices, lapses in infection control hand hygiene, and failure to maintain COVID-19 vaccination records for staff.
Deficiencies (8)
F 0550: The facility did not ensure residents received lunch meal trays in a timely manner, resulting in some residents not being served simultaneously with their tablemates.
F 0558: The facility did not ensure timely transfer of Resident #90 out of bed using a Hoyer lift as per resident preference and physician orders.
F 0582: The facility failed to provide appropriate liability and appeal notices to Medicare beneficiaries at the termination of their Medicare Part A benefits for Residents #21 and #82.
F 0610: The facility did not conduct thorough investigations for alleged abuse of Resident #275 and for a fall-related injury of Resident #112, lacking complete documentation and signatures.
F 0684: The facility failed to apply heel booties as ordered for Resident #109 and did not provide ongoing monitoring and timely medical intervention following a fall for Resident #112.
F 0812: The facility did not ensure food was stored and prepared to prevent contamination, with undated rice, pastrami, turkey, and improperly thawed shrimp observed in the kitchen.
F 0880: The facility failed to maintain an infection prevention and control program, as two CNAs were observed not performing hand hygiene during resident lunch assistance.
F 0888: The facility did not maintain COVID-19 vaccination medical records for a newly hired staff member who worked in resident care areas prior to providing proof of vaccination.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Staff affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in delay of transfer with Hoyer lift and fall incident investigation |
| CNA #12 | Certified Nursing Assistant | Named in delay of transfer with Hoyer lift |
| Director of Nursing | Director of Nursing | Interviewed regarding dining tray delivery and investigation processes |
| Social Worker #1 | Social Worker | Named in failure to provide Medicare liability notices |
| LPN #3 | Licensed Practical Nurse | Named in incomplete accident investigation for Resident #112 |
| Administrator | Administrator | Interviewed about discrepancies in incident investigations |
| CNA #10 | Certified Nursing Assistant | Named in infection control hand hygiene deficiency and heel booties removal |
| LPN #4 | Licensed Practical Nurse | Named in COVID-19 vaccination policy and oversight |
| Maintenance Supervisor | Maintenance Supervisor | Named in hiring and vaccination status of housekeeper |
| Human Resources Director | Human Resources Director | Named in staff vaccination record keeping process |
| Facility Consultant | Facility Consultant | Named in staff vaccination tracking system |
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