5 Reports
Inspection Report — Apr 12, 2024
Complaint Investigation State
Date: Apr 12, 2024
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2024 with citation and enforcement history.
Complaint Details
The state logged 50 complaints about this facility; 2 led to on-site inspections resulting in 2 citations.
Findings
Across 8 inspections, 15 citations were issued including 14 standard health and 1 life safety citation. Two enforcement actions totaling $20,000 in fines were recorded, and multiple citations remain uncorrected from COVID19 surveys.
Citations (10)
Standard Health Citation — quality of care: Baseline Care Plan was deficient.
Standard Health Citation — quality of care: Failed to develop and implement a comprehensive care plan.
Standard Health Citation — quality of care: Issues with entering into binding arbitration agreements.
Standard Health Citation — quality of care: Facility was not free of accident hazards and lacked proper supervision/devices.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Standard Health Citation — quality of care: Failed to provide right to survey results and advocate agency information.
Standard Health Citation — quality of care: Routine/emergency dental services in nursing facility were deficient.
Standard Health Citation — quality of care: Treatment/services to prevent or heal pressure ulcers were deficient.
Life Safety Code Citation — NFPA requirements: Means of egress were not compliant with general requirements.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient and not yet corrected (multiple inspections).
Report Facts
Inspections on page: 8
Total citations: 15
Total complaints: 50
On-site complaint inspections: 2
Enforcement actions: 2
Total fines: 20000
Citations issued from complaints: 2
Inspection Report — Apr 12, 2024
Abbreviated Survey CMS
Date: 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.
Citations (2)
Failure to timely report suspected abuse involving Resident #80 and Resident #119 to the New York State Department of Health.
Inadequate supervision and failure to provide required 2-person assistance to Resident #80, resulting in a fall and left distal femoral neck fracture.
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 — Apr 12, 2024
Annual Inspection CMS
Date: 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.
Citations (8)
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.
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.
Baseline care plan was not developed within 48 hours of admission and a copy was not provided to the resident.
Comprehensive care plan was not developed and implemented for a resident's use of antipsychotic medication.
Resident was observed without ordered bilateral heel float boots to prevent pressure ulcers.
Resident received inadequate supervision resulting in a fall and fracture due to failure to provide 2-person assistance as required.
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.
Binding Arbitration Agreement did not grant the resident or representative the right to rescind the agreement within 30 calendar days of signing it.
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 — Mar 30, 2022
Annual Inspection CMS
Date: 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 — Aug 5, 2019
Annual Inspection CMS
Date: 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.
Citations (5)
Failure to ensure a resident was free from physical restraints without proper assessment and monitoring.
Failure to timely submit Minimum Data Set (MDS) assessments within required timeframes.
Failure to develop and implement a complete care plan for a resident using a lap tray.
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.
Failure to maintain infection control practices related to oxygen tubing being left on the floor.
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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