Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 16, 2024
Visit Reason
The visit was an abbreviated survey to assess whether the nursing facility meets professional standards of quality in providing services to residents.
Findings
The facility failed to ensure proper reporting and assessment of a resident fall, resulting in neglect. Registered Nurse #1 did not report or properly document a fall of Resident #1, who sustained an acute nondisplaced right femur intertrochanteric fracture.
Deficiencies (1)
F 0658: The facility failed to ensure that services met professional standards of quality. Registered Nurse #1 did not report or document the fall of Resident #1, who sustained a right femur fracture. The facility investigation found evidence of neglect.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Named in neglect finding for failure to report and assess Resident #1's fall | |
| Licensed Practical Nurse #1 | Documented Resident #1's hip pain and bruising and notified Nursing Supervisor #2 and Nurse Practitioner #1 | |
| Nursing Supervisor #2 | Assessed Resident #1 and notified Nurse Practitioner #1 | |
| Nurse Practitioner #1 | Evaluated Resident #1 and ordered x-ray | |
| Certified Nursing Assistant #1 | Observed Resident #1 on floor and assisted in transferring back to bed | |
| Director of Nursing | Conducted investigation and confirmed neglect finding |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with reporting requirements related to allegations of abuse within the facility.
Findings
The facility failed to report a resident-to-resident altercation involving suspected abuse to the New York State Department of Health within the required 2-hour timeframe. The incident was reported the following day after staff interviews and investigation.
Deficiencies (1)
F 0609: The facility did not report allegations of abuse involving a resident-to-resident altercation to the New York State Department of Health within 2 hours of occurrence as required by regulation 10 NYCRR 415.4(b).
Report Facts
Residents sampled: 38
Residents involved in altercation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the reporting of the abuse incident | |
| Administrator | Interviewed regarding the reporting of the abuse incident |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, ensuring appropriate treatment for limited range of motion, providing dialysis services with proper physician orders, and maintaining food safety standards by preventing expired food from being served.
Deficiencies (4)
F 0656: The facility did not develop a comprehensive care plan with measurable goals and interventions to address Resident #36's urinary (Foley) catheter care needs.
F 0688: Resident #243 did not receive appropriate care to maintain range of motion as bilateral hand rolls were not applied according to Physician's Order.
F 0698: Resident #645 requiring hemodialysis did not have a Physician's Order for dialysis treatment three times weekly as required.
F 0812: The facility failed to ensure food was prepared and served in accordance with professional standards, as expired food was found in kitchen refrigerators.
Report Facts
Residents sampled: 38
Residents reviewed for urinary catheter: 2
Residents reviewed for limited range of motion: 3
Residents affected by expired food: Many
Expired food items: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #5 | Registered Nurse | Interviewed regarding development of Resident #36's care plan |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan responsibilities and Resident #36 and #243 care |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed about Resident #243's need for bilateral hand rolls |
| Registered Nurse #6 | Registered Nurse | Interviewed about Resident #645's hemodialysis treatment |
| Medical Director #1 | Medical Director | Interviewed about Resident #645's dialysis orders |
| Dietary Aide #1 | Dietary Aide | Interviewed about food delivery and expired food checks |
| Food Service Manager | Food Service Manager | Interviewed about refrigerator checks for expired food |
| Food Service Director | Food Service Director | Interviewed about kitchen walk-throughs and expired food oversight |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 8, 2021
Visit Reason
The inspection was conducted as a recertification and complaint survey to investigate an alleged violation involving resident-to-resident abuse and to assess compliance with infection control and food storage standards.
Complaint Details
The complaint investigation found that the facility failed to report an alleged resident-to-resident abuse incident within the required 2-hour timeframe. The investigation was completed and signed by the Assistant Director of Nursing. The facility reported the incident to the NYSDOH on 8/17/2021, after the delay.
Findings
The facility failed to timely report an alleged resident-to-resident abuse incident to the New York State Department of Health within the required timeframe. Additionally, the facility did not ensure proper food storage practices and failed to maintain infection control protocols, specifically sanitizing shared blood pressure cuffs between residents.
Deficiencies (3)
F 0609: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The facility did not report an alleged resident-to-resident abuse incident within 2 hours as required.
F 0812: Procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards. Undated and expired food items were observed in the kitchen and storage room.
F 0880: Provide and implement an infection prevention and control program. A Certified Nursing Assistant was observed using a blood pressure cuff on multiple residents without sanitizing the device or performing hand hygiene between uses.
Report Facts
Residents affected: 2
Residents affected: 5
Food items undated: 9
Food items undated: 4
Food items undated: 2
Food items undated: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Observed not sanitizing blood pressure cuff between residents |
| Assistant Director of Nursing | ADNS | Signed the investigation report of the abuse incident |
| Director of Nursing | DON | Interviewed regarding abuse reporting requirements |
| Dietary Aide #1 | Dietary Aide | Interviewed about food item dating and rotation |
| Chef | Chef | Interviewed about food storage and labeling practices |
| Food Service Director | FSD | Interviewed about food dating and storage procedures |
| Licensed Practical Nurse #2 | LPN | Interviewed about shared equipment cleaning procedures |
| Infection Preventionist | IP | Interviewed about infection control observations and audits |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: May 14, 2019
Visit Reason
The survey was a recertification annual inspection to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and care, personal funds management, advance directives education, timely submission and accuracy of Minimum Data Set (MDS) assessments, comprehensive care planning, smoking policy enforcement and safety, medication management including inappropriate use of psychotropic medication, food handling and sanitation, and proper garbage disposal.
Deficiencies (11)
F 0550: The facility failed to ensure a resident was treated with dignity, evidenced by food debris and wet stains on clothing during multiple observations.
F 0568: The facility did not ensure residents consistently received quarterly statements for their personal funds accounts, with one resident not receiving any since admission.
F 0578: The facility failed to inform a cognitively intact resident about advance directives, and staff had not discussed or provided written information as required.
F 0640: The facility did not submit completed MDS assessments electronically within required timeframes for 18 of 19 residents reviewed.
F 0641: A resident's MDS assessment did not accurately document active dialysis treatment due to a data entry error.
F 0656: Comprehensive care plans were incomplete and lacked measurable goals and interventions for multiple residents' medical and psychosocial needs.
F 0657: Care plans were not reviewed and revised by an interdisciplinary team to reflect changes in residents' conditions, including smoking behavior and edema.
F 0689: The facility failed to ensure a resident who smokes was assessed timely for supervision needs, smoking materials were improperly stored, and the resident smoked unsafely with burn holes on clothing.
F 0758: A resident was prescribed Quetiapine without appropriate clinical indication or documented evaluation, and the medication was continued despite lack of clear diagnosis and family concerns.
F 0812: Food service workers failed to wear gloves when handling raw and cooked food, did not wear hairnets during meal service, and cross-contaminated food by touching garbage lids and food without proper hygiene.
F 0814: Garbage receptacles in the kitchen and dining areas were uncovered, increasing risk of contamination and odors.
Report Facts
Residents reviewed for Resident Assessment facility task: 19
Residents sampled: 38
Residents reviewed for unnecessary medication care area: 5
Number of lighters observed: 8
Number of cigarettes observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | RN MDS Director | Interviewed about MDS submission delays and process |
| MD #2 | Physician | Interviewed regarding psychotropic medication use for Resident #256 |
| LPN #1 | Licensed Practical Nurse | Interviewed about smoking policy and resident supervision |
| RN #1 | Registered Nurse | Interviewed about Resident #256 care and medication |
| Director of SW | Director of Social Work | Interviewed about smoking policy and resident education |
| Food Service Director | FSD | Interviewed about food handling and sanitation practices |
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