Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Apr 12, 2024
Visit Reason
Complaint Survey with 8 health citations and 1 life safety code citation, several deficiencies corrected by June 2024.
Findings
Complaint Survey with 8 health citations and 1 life safety code citation, several deficiencies corrected by June 2024.
Deficiencies (9)
| Description |
|---|
| Baseline care plan |
| Develop/implement comprehensive care plan |
| Entering into binding arbitration agreements |
| Free of accident hazards/supervision/devices |
| Reporting of alleged violations |
| Right to survey results/advocate agency info |
| Routine/emergency dental srvcs in nfs |
| Treatment/svcs to prevent/heal pressure ulcer |
| Means of egress - general |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Apr 12, 2024
Visit Reason
The inspection was conducted as a Recertification and Abbreviated survey from 4/7/2024 to 4/12/2024 to assess compliance with regulations related to abuse reporting and accident prevention.
Findings
The facility failed to timely report two alleged abuse incidents involving Resident #80 and Resident #119 to the New York State Department of Health. Resident #80 sustained a fall and fracture due to inadequate supervision and failure to provide required 2-person assistance, resulting in actual harm. Resident #119 had an unwitnessed fall with fractures that were also not reported. The facility policies on abuse reporting and fall prevention were not properly followed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse involving Resident #80 and Resident #119 to the New York State Department of Health. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate supervision and failure to provide required 2-person assistance to Resident #80, resulting in a fall and left distal femoral neck fracture. | Level of Harm - Actual harm |
Report Facts
Residents sampled: 38
Residents reviewed for accidents: 3
Bed mobility assistance instances: 30
Certified Nursing Assistant suspension duration (weeks): 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in fall incident causing Resident #80's fracture and suspension |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding abuse reporting policies and investigation |
| Acting Assistant Director of Nursing | Acting Assistant Director of Nursing | Interviewed about supervision and task list procedures for CNAs |
| Rehabilitation Director | Rehabilitation Director | Interviewed about Resident #80's care needs prior to fall |
| Medical Doctor #1 | Medical Doctor | Interviewed regarding Resident #80's fall and medical status |
| Registered Nurse #1 | Registered Nurse | Notified of Resident #80's fall during care |
Inspection Report
Annual Inspection
Deficiencies: 8
Apr 12, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 4/6/2024 to 4/12/2024 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, failure to timely report suspected abuse, incomplete baseline care plans, lack of comprehensive care plans for antipsychotic medication use, inadequate pressure ulcer prevention, insufficient supervision leading to resident falls, failure to provide dental services, and improper binding arbitration agreement terms.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility did not ensure the results of the most recent facility survey were posted in a place readily accessible to residents, family members, and legal representatives. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health immediately or within 2 hours after the allegation was made for 2 residents with fractures from falls. | Level of Harm - Minimal harm or potential for actual harm |
| Baseline care plan was not developed within 48 hours of admission and a copy was not provided to the resident. | Level of Harm - Minimal harm or potential for actual harm |
| Comprehensive care plan was not developed and implemented for a resident's use of antipsychotic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Resident was observed without ordered bilateral heel float boots to prevent pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Resident received inadequate supervision resulting in a fall and fracture due to failure to provide 2-person assistance as required. | Level of Harm - Actual harm |
| Facility did not ensure dental services were provided from an outside resource to meet the needs of a resident when a tooth extraction was recommended. | Level of Harm - Minimal harm or potential for actual harm |
| Binding Arbitration Agreement did not grant the resident or representative the right to rescind the agreement within 30 calendar days of signing it. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 38
Residents affected: 12
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Suspension duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in fall incident causing resident fracture due to failure to provide 2-person assistance | |
| Registered Nurse #1 | Involved in fall incident report and interviews regarding care supervision | |
| Director of Nursing | Director of Nursing | Interviewed regarding reporting abuse, care plans, and supervision |
| Registered Nurse #2 | Responsible for developing comprehensive care plans, interviewed about antipsychotic medication care plan | |
| Registered Nurse #3 | Interviewed about dental consult and follow-up | |
| Certified Nursing Assistant #2 | Interviewed regarding pressure ulcer care for Resident #27 | |
| Licensed Practical Nurse #1 | Interviewed regarding pressure ulcer care and family communication | |
| Director of Social Service | Director of Social Service | Interviewed about Binding Arbitration Agreement rescind rights |
| Administrator | Administrator | Interviewed about Binding Arbitration Agreement rescind rights |
| Medical Doctor #1 | Medical Doctor | Interviewed about Resident #80 fall and fracture |
| Medical Doctor #3 | Medical Doctor | Interviewed about Resident #203 dental pain and consult |
| Rehabilitation Director | Rehabilitation Director | Interviewed about Resident #80 care needs |
Inspection Report
Capacity: 60
Deficiencies: 1
Feb 12, 2024
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Feb 6, 2024
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Dec 11, 2023
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Jun 12, 2023
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Apr 17, 2023
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Aug 2, 2022
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Mar 30, 2022
Visit Reason
Complaint Survey with 5 life safety code citations related to building construction, egress doors, electrical systems, staff/patient tracking, and sprinkler system, all corrected by mid-2022.
Findings
Complaint Survey with 5 life safety code citations related to building construction, egress doors, electrical systems, staff/patient tracking, and sprinkler system, all corrected by mid-2022.
Deficiencies (5)
| Description |
|---|
| Building construction type and height |
| Egress doors |
| Electrical systems - essential electric syste |
| Procedures for tracking of staff and patients |
| Sprinkler system - installation |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 30, 2022
Visit Reason
The inspection was conducted as an annual survey of Concourse Rehabilitation and Nursing Center Inc to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were unknown.
Inspection Report
Capacity: 60
Deficiencies: 1
Nov 22, 2021
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Nov 15, 2021
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, widespread scope, not corrected.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Annual Inspection
Deficiencies: 5
Aug 5, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without proper assessment or care planning, failure to timely submit Minimum Data Set (MDS) assessments, lack of care plan development for a resident using a lap tray, failure to ensure physician review and follow-up after resident readmission, and inadequate infection control practices related to oxygen tubing management.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Potential for minimal harm: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from physical restraints without proper assessment and monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely submit Minimum Data Set (MDS) assessments within required timeframes. | Level of Harm - Potential for minimal harm |
| Failure to develop and implement a complete care plan for a resident using a lap tray. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the resident's physician reviewed and followed up on the resident's care after readmission, including lack of referral to physical therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain infection control practices related to oxygen tubing being left on the floor. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Physical Restraints: 39
Residents reviewed for Resident Assessment Facility Task: 57
Residents reviewed for Unnecessary Medications and Dementia Care: 39
Residents affected by physical restraint deficiency: 1
Residents affected by MDS submission deficiency: 57
Residents affected by care plan deficiency: 1
Residents affected by physician review deficiency: 1
Residents affected by infection control deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Spoke Spanish to resident and interpreted during physical restraint observation |
| RNM #2 | Registered Nurse Manager | Present during physical restraint observation and interviewed about restraint protocol |
| OTRD | Occupational Therapy and Rehab Director | Interviewed regarding assessment and use of lap tray restraint |
| CNA #2 | Certified Nursing Assistant | Interviewed about resident's confusion and lap tray use |
| RN #1 | Registered Nurse Supervisor | Interviewed about care planning responsibilities and lap tray use |
| RN #3 | Registered Nurse, MDS Coordinator | Interviewed about MDS submission process |
| Facility Administrator | Administrator | Interviewed about MDS submission responsibility and process |
| NP #9 | Nurse Practitioner | Assessed resident #58 upon readmission but did not refer to PT/OT |
| Physical Therapist #6 | Physical Therapist | Interviewed about resident #58 therapy orders and re-evaluation |
| RN #4 | Registered Nurse | Interviewed about resident #58 therapy and nursing responsibilities |
| Rehab Clinical Supervisor #2 | Rehab Clinical Supervisor | Interviewed about rehab staffing and resident #58 discharge |
| Physical Therapist #7 | Physical Therapist | Interviewed about resident #58 therapy status and discharge |
| Medical Director #5 | Medical Director | Interviewed about resident #58 care and facility coordination |
| CNA #1 | Certified Nursing Assistant | Interviewed about oxygen tubing infection control for resident #120 |
| Director of Nursing | Director of Nursing (DNS) | Interviewed about infection control policies and oxygen tubing care |
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