Inspection Reports for Daughters of Sarah Nursing & Rehabilitation Center
NY, 12203
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 9, 2024
Visit Reason
The inspection was a recertification survey to assess the facility's compliance with resident rights, specifically focusing on the facility's promotion and facilitation of resident self-determination through support of resident choice.
Findings
The facility did not promote and facilitate residents' right to self-determination by failing to provide accommodations for heating food brought in from outside, as evidenced by Resident #5's experience and facility policy restricting reheating of personal food. Staff interviews confirmed the policy and practice of not heating outside food due to safety concerns.
Deficiencies (1)
Facility did not provide accommodations for heating of food brought to residents from outside, limiting resident self-determination and choice.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #1 | Administrator | Stated facility policy not to heat food brought in from outside due to safety concerns; discussed concerns with Resident #5. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Stated microwave observed was for staff use only. |
| Registered Nurse #1 | Registered Nurse | Reported previous use and removal of microwave in office; stated staff no longer heat food brought in from outside. |
| Social Worker #1 | Social Worker | Reported facility policy preventing staff from heating food brought in from outside. |
| Director of Maintenance #1 | Director of Maintenance | Reported no work orders to remove microwaves; confirmed microwaves still present in facility. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 9, 2024
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements related to resident rights, medication management, infection control, and other care standards at the nursing facility.
Findings
The facility was found deficient in honoring residents' rights to dignity and self-determination, medication labeling and storage practices, infection prevention and control procedures, and accommodating residents' personal food heating needs. Several residents reported rude behavior by a Certified Nurse Aide, medication carts and refrigerators were not properly maintained, and staff did not consistently follow correct PPE protocols.
Deficiencies (4)
Failure to ensure treatment with respect, dignity, and care for residents, including rude behavior by Certified Nurse Aide #3 toward multiple residents.
Failure to promote and facilitate resident self-determination through support of resident choice, specifically not providing accommodations for heating personal food brought from outside.
Failure to ensure drugs and biologicals were labeled and stored according to professional standards, including unlabeled opened medications, pre-poured medication cups without covers, medication refrigerator temperature outside therapeutic range, and non-medication items stored in medication carts and rooms.
Failure to provide and implement an infection prevention and control program, specifically staff not putting on and taking off personal protective equipment correctly when entering and exiting the room of a COVID-19 positive resident.
Report Facts
Residents reviewed for dignity: 35
Residents affected by dignity deficiency: 3
Residents affected by other deficiencies: Few
Medication carts reviewed: 3
Medication storage rooms reviewed: 3
Temperature of medication refrigerator: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Certified Nurse Aide | Named in multiple findings related to rude behavior and resident complaints |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding knowledge of complaints and facility policies |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Reported complaints about Certified Nurse Aide #3 and resident interactions |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed about interactions with Certified Nurse Aide #3 and resident care |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding complaint knowledge and staff training |
| Administrator #1 | Administrator | Interviewed regarding complaint handling and facility policies |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding knowledge of complaints about Certified Nurse Aide #3 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about medication labeling and storage practices |
| Nurse Educator #1 | Nurse Educator | Interviewed about staff training and competencies |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about PPE use and infection control practices |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about PPE use and infection control practices |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about PPE use and infection control practices |
| Infection Preventionist #1 | Infection Preventionist | Interviewed about infection control training and PPE signage |
| Director of Maintenance #1 | Director of Maintenance | Interviewed about microwave ovens in the facility |
| Social Worker #1 | Social Worker | Interviewed about facility policy on heating personal food |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed incorrectly donning and doffing PPE |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed about medical equipment use and infection control |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Sep 9, 2024
Visit Reason
Complaint Survey with 6 Standard Health Citations and 1 Life Safety Code Citation, all Level 2 severity, no actual harm but potential for minor harm. Deficiencies included drug regimen, infection control, labeling drugs, personal food policy, resident rights, self-determination, and discharge from exits. Several corrected by October 2024.
Findings
Complaint Survey with 6 Standard Health Citations and 1 Life Safety Code Citation, all Level 2 severity, no actual harm but potential for minor harm. Deficiencies included drug regimen, infection control, labeling drugs, personal food policy, resident rights, self-determination, and discharge from exits. Several corrected by October 2024.
Deficiencies (7)
Drug regimen is free from unnecessary drugs
Infection prevention & control
Label/store drugs and biologicals
Personal food policy
Resident rights/exercise of rights
Self-determination
Discharge from exits
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Oct 2, 2023
Visit Reason
The inspection was conducted as an abbreviated survey focusing on compliance with resident dignity, treatment and care according to orders, and fall management.
Findings
The facility failed to ensure Resident #4 was treated with respect and dignity, as evidenced by forceful handling by LPN #3. The facility also failed to provide appropriate treatment and care for Resident #2 and Resident #4, including incomplete documentation and failure to remove all surgical staples. Additionally, the facility did not ensure an immediate assessment of Resident #4 after a fall before moving them off the floor.
Deficiencies (3)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, specifically forceful handling of Resident #4 by LPN #3.
Failure to provide appropriate treatment and care according to orders and comprehensive care plan for Residents #2 and #4, including incomplete documentation of surgical wounds and staples, and failure to remove all staples as ordered.
Failure to ensure immediate assessment of Resident #4 after a fall prior to moving the resident off the floor.
Report Facts
Residents reviewed: 4
Surgical wounds: 3
Staples: 8
Staples remaining: 4
Fall incident time: 1516
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Named in forceful handling and fall incident involving Resident #4 | |
| Caseworker (CW) #1 | Eyewitness and interviewee regarding forceful handling of Resident #4 | |
| Licensed Practical Nurse (LPN) #4 | Eyewitness and interviewee regarding forceful handling of Resident #4 | |
| Licensed Practical Nurse (LPN) #5 | Eyewitness and interviewee regarding forceful handling of Resident #4 and fall incident | |
| Registered Nurse Manager (RNM) #1 | Documented staple removal and interviewed about care planning for Resident #2 | |
| Registered Nurse Manager (RNM) #2 | Interviewed regarding forceful handling and fall incident of Resident #4 | |
| Administrator (ADMIN) | Interviewed regarding forceful handling and fall incident of Resident #4 | |
| Assistant Director of Nursing (ADON) | Interviewed regarding wound care and staple removal process | |
| Director of Nursing (DON) | Interviewed regarding staple removal process and documentation | |
| Nurse Practitioner (NP) #4 | Documented medical progress notes regarding staple removal for Resident #2 | |
| Nurse Practitioner (NP) #5 | Wrote discharge summary and interviewed regarding wound healing for Resident #2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Oct 2, 2023
Visit Reason
Complaint Survey with 2 Standard Health Citations related to quality of care and resident rights, both Level 2 severity, no actual harm but potential for minor harm. Both deficiencies corrected by November 2023.
Findings
Complaint Survey with 2 Standard Health Citations related to quality of care and resident rights, both Level 2 severity, no actual harm but potential for minor harm. Both deficiencies corrected by November 2023.
Deficiencies (2)
Quality of care
Resident rights/exercise of rights
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The inspection was conducted as a standard annual survey of the Daughters of Sarah Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Oct 18, 2021
Visit Reason
Complaint Survey with 4 Standard Health Citations and 2 Life Safety Code Citations, all Level 2 severity, no actual harm but potential for minor harm. Deficiencies included disposal of garbage, personal food policy, quality of care, dental services, fire alarm system, and sprinkler system maintenance. All corrected by November 2021.
Findings
Complaint Survey with 4 Standard Health Citations and 2 Life Safety Code Citations, all Level 2 severity, no actual harm but potential for minor harm. Deficiencies included disposal of garbage, personal food policy, quality of care, dental services, fire alarm system, and sprinkler system maintenance. All corrected by November 2021.
Deficiencies (6)
Dispose garbage and refuse properly
Personal food policy
Quality of care
Routine/emergency dental srvcs in snfs
Fire alarm system - testing and maintenance
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 12, 2021
Visit Reason
The inspection was a recertification survey conducted to assess compliance with professional standards of practice and regulatory requirements for nursing home care.
Findings
The facility failed to provide appropriate treatment and care according to orders and resident preferences for two residents, including failure to assess and address nutritional needs after loss of dentures and failure to properly evaluate and treat edema and weight gain. Additionally, the facility did not promptly refer a resident for dental services after loss of dentures, lacked a policy for assisting residents with food brought by visitors, and did not properly maintain the trash compactor area.
Deficiencies (4)
Failure to provide appropriate treatment and care according to orders and resident preferences, including inadequate assessment following loss of dentures and failure to address weight gain and edema.
Failure to provide routine and 24-hour emergency dental care by not promptly referring resident with lost dentures for dental services within 3 days.
Policy regarding use and storage of foods brought to residents by visitors did not include procedures to assist residents dependent on staff to access and consume food.
Failure to properly dispose of garbage and refuse; trash compactor and surrounding area were heavily soiled and not maintained.
Report Facts
Resident weights: 31.2
Weight gain percentage: 6.3
Weight gain percentage: 16.7
Weight measurements: 200
Weight measurements: 168.8
Weight measurements: 237
Weight measurements: 247
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding Resident #45's denture loss and weight loss |
| Registered Dietician #1 | Registered Dietician | Interviewed regarding Resident #45's nutritional status and denture loss |
| Director of Social Work | Director of Social Work | Interviewed regarding missing dentures and related reports |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding Resident #45's weight loss and denture loss |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Interviewed regarding Resident #55's edema care |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding Resident #55's edema monitoring |
| Dietician #2 | Dietician | Interviewed regarding Resident #55's weight gain and edema |
| Dietician #3 | Dietician | Interviewed regarding Resident #55's diet recommendations |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding edema monitoring system |
| Registered Nurse Unit Manager #3 | Registered Nurse Unit Manager | Interviewed regarding staff expectations for weight gain and edema monitoring |
| Director of Nursing | Director of Nursing | Interviewed regarding edema monitoring and documentation |
| Director of Social Work | Director of Social Work | Interviewed regarding missing dentures and dental referral process |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 24, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents, including specific interventions for psoriasis, edema, positioning, and communication deficits. Additionally, the facility did not maintain an effective infection prevention and control program, with observed breaches in standard precautions during wound care and oxygen tubing management.
Deficiencies (2)
Failure to develop and implement complete care plans with measurable objectives for residents' medical, nursing, and psychosocial needs.
Failure to maintain an infection prevention and control program to prevent disease transmission, including improper hand hygiene and contamination risks during wound care.
Report Facts
Residents reviewed: 35
Residents affected: 4
Residents reviewed: 7
Residents affected: 3
Wound measurements: 2.3
Wound measurements: 1.3
Wound measurements: 0.6
Wound measurements: 1
Wound measurements: 0.7
Wound measurements: 1.5
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Observed breaching infection control practices during wound dressing change for Resident #12 |
| LPN #1 | Licensed Practical Nurse | Observed breaching infection control practices during wound dressing change for Resident #174 |
| LPNUM #3 | Licensed Practical Nurse Unit Manager | Interviewed regarding care plan deficiencies for Residents #29, #145, and #173 |
| DON | Director of Nursing | Interviewed regarding expectations for care plans and facility awareness of deficiencies |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding care provided to Residents #29 and #145 |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding communication difficulties with Resident #173 |
| RN #1 | Registered Nurse | Interviewed regarding oxygen tubing management for Resident #299 |
| RN #2 | Registered Nurse | Interviewed regarding oxygen tubing management for Resident #299 |
| RNUM #3 | Registered Nurse Manager | Interviewed regarding infection control education and practices |
| RNM #4 | Registered Nurse Manager | Interviewed regarding nurse competencies and infection control training |
| Assistant Director of Nursing/Infection Control Nurse | Assistant Director of Nursing/Infection Control Nurse | Interviewed regarding infection control procedures and handwashing requirements |
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