Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better 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: Apr 11, 2025
Visit Reason
The inspection was conducted as a Recertification Survey from 04/07/2025 to 04/11/2025 to evaluate the facility's infection prevention and control program and overall compliance with regulatory requirements.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, specifically failing to place a resident with an unstageable pressure ulcer on enhanced barrier precautions and staff not wearing appropriate personal protective equipment during care. Multiple staff interviews confirmed that residents with wounds should be on enhanced barrier precautions, but several residents were missed.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program, including not placing Resident #25 on enhanced barrier precautions and staff not wearing appropriate PPE during wound and incontinence care.
Report Facts
Residents affected: 5
Residents recently identified not on enhanced barrier precautions: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Observed providing care without wearing gowns during wound and incontinence care | |
| Certified Nursing Assistant #1 | Observed providing care without wearing gowns during wound and incontinence care | |
| Certified Nursing Assistant #2 | Interviewed regarding enhanced barrier precautions for residents with wounds | |
| Licensed Practical Nurse #2 | Interviewed regarding enhanced barrier precautions and stated no residents were currently on them | |
| Infection Preventionist/Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about infection control policies and noted some residents were missed for enhanced barrier precautions |
| Director of Nursing | Director of Nursing | Interviewed and stated five residents were recently identified who should have been on enhanced barrier precautions but were not |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 11, 2025
Visit Reason
Infection prevention & control deficiency identified; no actual harm but potential for more than minimal harm; corrected by June 9, 2025.
Findings
Infection prevention & control deficiency identified; no actual harm but potential for more than minimal harm; corrected by June 9, 2025.
Deficiencies (1)
Infection prevention & control
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
Abuse reporting documentation deficiency noted.
Findings
Abuse reporting documentation deficiency noted.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 16, 2023
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home residents' rights and quality of care.
Findings
The survey identified deficiencies related to honoring residents' rights to request or refuse treatment and to formulate advance directives, specifically inconsistent application of DNR code status indicators. Additionally, deficiencies were found in providing adequate care for activities of daily living, including grooming and nail care for residents.
Deficiencies (2)
Failure to ensure residents' advance directive identifiers (DNR status) were consistently honored, with missing purple DNR stickers on wristbands or improper placement.
Failure to provide necessary services for activities of daily living, specifically residents observed with dirty and uncut nails.
Report Facts
Residents reviewed for advance directives: 32
Residents reviewed for activities of daily living: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Stated procedure for initiating CPR if no purple DNR sticker is present. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Unaware if wristbands included code status information. |
| Registered Nurse Manager #2 | Registered Nurse Manager | Explained DNR sticker placement and noted some residents do not wear wristbands. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Described location of DNR status information and procedure if resident becomes unresponsive. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Described locations of code status and procedure if resident becomes unresponsive. |
| Registered Nurse Manager #1 | Registered Nurse Manager | Described procedure for determining code status and initiating CPR. |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated that purple DNR stickers come off wristbands and staff cannot rely on them. |
| Director of Nursing | Director of Nursing | Unaware that purple DNR stickers were not adhering to wristbands; stated nail care should be done with shower and documented. |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Described nail care responsibilities and challenges with thick nails. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Described nail care routine and issues with thick nails. |
| Registered Nurse Manager #2 | Registered Nurse Manager | Described nail care standards and resident preferences. |
| Nurse Practitioner #1 | Nurse Practitioner | Evaluated resident's nails and noted inability to trim due to thickness. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 16, 2023
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements related to residents' rights, care, and services at Edna Tina Wilson Living Center.
Findings
The survey identified deficiencies in honoring residents' rights regarding Do Not Resuscitate (DNR) status identification and in providing adequate personal hygiene care, specifically nail care, to residents. Issues included missing purple DNR stickers on wristbands and residents having long, uncut, and dirty nails despite care plans.
Deficiencies (2)
Failure to ensure residents' DNR advance directive identifiers were consistent with their wishes, including missing purple DNR stickers on wristbands or alternative identifiers.
Failure to provide necessary services to maintain good grooming and personal hygiene, specifically residents observed with dirty and uncut nails.
Report Facts
Residents reviewed for DNR status: 32
Residents reviewed for activities of daily living: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Stated procedure for initiating CPR if no purple DNR sticker is found. |
| Licensed Practical Nurse #3 | LPN | Unaware if wristbands included code status information. |
| Registered Nurse Manager #2 | RNM | Explained DNR sticker usage and alternative placements. |
| Certified Nursing Assistant #1 | CNA | Described location of DNR status information and response to unresponsive residents. |
| Licensed Practical Nurse #1 | LPN | Described locations of code status and CPR initiation procedures. |
| Registered Nurse Manager #1 | RNM | Described procedures for determining code status and CPR initiation. |
| Assistant Director of Nursing | ADON | Stated that purple DNR stickers come off wristbands and staff cannot rely on them. |
| Director of Nursing | DON | Unaware of issues with purple DNR stickers not adhering to wristbands; stated nail care procedures. |
| Licensed Practical Nurse #6 | LPN | Described nail care responsibilities and challenges with thick nails. |
| Certified Nursing Assistant #3 | CNA | Described nail care routines and issues with thick nails. |
| Registered Nurse Manager #2 | RNM | Described nail care standards and observations of resident's nails. |
| Nurse Practitioner #1 | NP | Evaluated resident's nails and noted inability to trim due to thickness. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Jun 16, 2023
Visit Reason
Deficiencies in ADL care, treatment refusal and advance directives, and multiple life safety code issues including communication plan, electrical systems, fire alarm testing, and HVAC; all corrected by August 2023.
Findings
Deficiencies in ADL care, treatment refusal and advance directives, and multiple life safety code issues including communication plan, electrical systems, fire alarm testing, and HVAC; all corrected by August 2023.
Deficiencies (6)
ADL care provided for dependent residents
Request/refuse/dscntnue trmnt;formlte adv dir
Development of communication plan
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Hvac
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 17, 2021
Visit Reason
The Recertification Survey was conducted to assess compliance with regulatory requirements, including resident grievances and respiratory care.
Findings
The facility failed to make efforts to resolve a resident's grievance about wandering residents entering their room unannounced, and did not consistently provide or monitor oxygen therapy as ordered for another resident.
Deficiencies (2)
Facility did not make efforts to resolve Resident #41's grievance regarding other residents entering their room unannounced.
Facility did not ensure Resident #59 received consistent oxygen therapy as ordered and failed to monitor oxygen saturation levels adequately.
Report Facts
Days without documented oxygen monitoring: 9
Frequency of wandering resident entries: 4
Oxygen flow rate ordered: 4
Oxygen flow rate observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager | RNM | Reported residents complained about wandering residents entering rooms. |
| Director of Nursing | Described expectations for grievance resolution and documentation. | |
| Certified Nursing Assistant | CNA | Reported wandering residents entering Resident #41's room and notifying supervising nurse. |
| Licensed Practical Nurse | LPN | Described wandering residents behavior and oxygen flow rate verification for Resident #59. |
| Registered Nurse | RN | Stated oxygen orders and monitoring requirements. |
| RN Supervisor | Explained best nursing practices for oxygen monitoring and documentation. |
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