Inspection Reports for
Elmhurst Care Center, Inc
100-17 23 Avenue, East Elmhurst, NY, 11369
Back to Facility Profile5 Reports
Inspection Report — Jul 3, 2024
Complaint Investigation State
Date: Jul 3, 2024
Visit Reason
State-compiled facility profile showing 7 inspections from 2022 to 2024 with deficiency and enforcement history.
Complaint Details
The state logged 45 complaints about this facility; 9 led to on-site inspections.
Findings
Across 7 inspections, 3 resulted in citations totaling 25 deficiencies including standard health and life safety code violations. One enforcement action with fines was recorded, and multiple complaints led to on-site inspections.
Citations (24)
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficiencies noted in multiple inspections.
Standard Health Citation — quality of care: Infection Control issues identified.
Standard Health Citation — quality of care: Posted Nurse Staffing Information not properly maintained.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights violations found.
Standard Health Citation — quality of care: Right To Survey Results/advocate Agency Info deficiencies widespread.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment issues noted.
Standard Health Citation — quality of care: Sufficient Nursing Staff not ensured.
Life Safety Code Citation — NFPA requirements: Alcohol Based Hand Rub Dispenser (abhr) issues found.
Life Safety Code Citation — NFPA requirements: Discharge From Exits violations noted.
Standard Health Citation — quality of care: Accuracy Of Assessments deficiencies identified.
Standard Health Citation — quality of care: Encoding/transmitting Resident Assessments issues found.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility not properly addressed.
Standard Health Citation — quality of care: Respect, Dignity/right To Have Prsnl Property violations noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiencies found.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General issues widespread.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation violations noted.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies found.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier widespread issues.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier pattern violations noted.
Standard Health Citation — quality of care: Care Plan Timing And Revision deficiencies identified.
Standard Health Citation — quality of care: Free From Abuse And Neglect violations causing actual harm.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices issues found.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficiencies noted.
Standard Health Citation — quality of care: Reporting Of Reasonable Suspicion Of A Crime violations found.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 25
Inspections with violations: 3
Inspections without violations: 4
Total complaints: 45
On-site complaint inspections: 9
Plan of correction counts: Not explicitly stated
Total fines: 4000
Number of enforcement actions: 1
Inspection Report — Jul 3, 2024
Annual Inspection CMS
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as a Recertification and Abbreviated survey from 06/26/2024 to 07/03/2024 to assess compliance with staffing requirements and nurse staffing information posting.
Findings
The facility was found to have insufficient nursing staff on weekends, with documented call outs resulting in only one Certified Nurse Assistant for a 40-bed unit. Additionally, nurse staffing information was not posted in a prominent, readily accessible area for residents and visitors due to construction.
Citations (2)
Insufficient nursing staff to meet the needs of every resident, with short staffing on weekends and only one Certified Nurse Assistant working on a 40-bed unit during call outs.
Nurse staffing information was not posted in a prominent area readily accessible to residents and visitors.
Report Facts
Certified Nurse Assistants scheduled: 5
Certified Nurse Assistants scheduled: 4
Certified Nurse Assistants scheduled: 3
Certified Nurse Assistants working: 1
Call outs: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #4 | Reported staffing shortages and inadequate assistance on night shifts | |
| Certified Nurse Assistant #7 | Reported working alone on overnight shift and limited ability to care for residents | |
| Licensed Practical Nurse #1 | Reported assisting Certified Nurse Assistants during call outs | |
| Staffing Coordinator | Provided information on staffing goals and challenges with call outs | |
| Director of Nursing | Discussed staffing goals, incentives, and agency use to address call outs | |
| Administrator | Discussed ongoing staffing challenges, call outs, and efforts to improve staffing |
Inspection Report — Jul 3, 2024
Annual Inspection CMS
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations regarding resident dignity, environment, care planning, and resident rights.
Findings
The facility was found deficient in ensuring resident dignity, maintaining a safe and clean environment, posting survey results accessibly, and developing comprehensive care plans for residents. Specific issues included a physical therapist assistant holding up a resident's oversized pants, poor housekeeping and maintenance conditions across multiple units, inaccessible survey results, and lack of a care plan for antibiotic therapy for one resident.
Citations (4)
Failure to ensure residents were treated with dignity, evidenced by a physical therapist assistant holding up a resident's oversized pants during ambulation.
Failure to post survey results in a place readily accessible to residents and family members; survey results were on a high shelf with no signage.
Failure to maintain housekeeping and maintenance services, including stained furniture, holes in ceilings and walls, wobbly dining tables, missing window panels, dirty mechanical lifts and scales, and torn wheelchairs.
Failure to develop and implement a comprehensive care plan for a resident receiving antibiotic therapy.
Report Facts
Residents sampled: 38
Residents affected: 1
Residents affected: 1
Resident units affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapist Assistant #6 | Physical Therapist Assistant | Observed holding up resident's pants and interviewed about dignity issue |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding resident clothing concerns |
| Registered Nurse #1 | Registered Nurse | Interviewed about daily rounds and resident care |
| Director of Nursing | Director of Nursing | Interviewed about staff education and care plan deficiencies |
| Housekeeper #1 | Housekeeper | Interviewed about housekeeping routines and maintenance reporting |
| Director of Maintenance | Director of Maintenance | Interviewed about maintenance responsibilities and environmental safety |
| Registered Nurse #6 | Registered Nurse | Interviewed about lack of antibiotic care plan for Resident #134 |
Inspection Report — Sep 27, 2022
Annual Inspection CMS
Date: Sep 27, 2022
Visit Reason
The inspection was a Recertification Survey conducted from 9/19/22 to 9/27/22 to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering Foley catheter bags, late submission of Minimum Data Set (MDS) assessments, inaccurate MDS assessments, incomplete comprehensive care plans especially regarding pacemaker care, and failure to provide appropriate assistive devices such as ankle foot orthosis (AFO) and orthotic devices as per physician orders.
Citations (5)
Resident's Foley catheter bag and tubing were not covered, exposing the resident and violating dignity rights.
Thirty-two Resident MDS assessments were submitted late, exceeding the 14-day submission requirement.
The most recent MDS did not accurately document a resident's diagnosis of Psychotic Disorder.
A Comprehensive Care Plan did not include measurable objectives or interventions to address a resident's pacemaker.
Resident with limited range of motion and mobility did not receive appropriate assistive devices (AFO and orthotic devices) as ordered by physician.
Report Facts
Resident MDS Assessments submitted late: 32
Residents reviewed for dignity: 38
Residents reviewed for unnecessary medication: 6
Residents reviewed for position, mobility, and activities of daily living: 34
Residents affected by dignity deficiency: 1
Residents affected by MDS late submission: 32
Residents affected by inaccurate MDS: 1
Residents affected by incomplete care plan: 1
Residents affected by assistive device deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Foley catheter privacy bag for Resident #67. |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding Foley catheter privacy bag for Resident #67. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding Foley catheter privacy bag for Resident #67 and care plan initiation. |
| MDS Coordinator (MDSC) | MDS Coordinator | Interviewed regarding late MDS submissions and staffing issues. |
| Administrator | Facility Administrator | Interviewed regarding MDS assessor staffing and consultant hiring. |
| MDS Assessor (MDSA) | Director of MDS | Interviewed regarding accuracy of MDS assessments. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding awareness of resident's pacemaker and assistive devices. |
| Registered Nursing Supervisor (RNS) | Registered Nursing Supervisor | Interviewed regarding care plan initiation and assistive device lists. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding provision of assistive device lists to nursing. |
| Physical Therapist (PT) | Physical Therapist | Interviewed regarding resident compliance with AFO device. |
| Certified Nursing Assistant (CNA #4) | Certified Nursing Assistant | Interviewed regarding knowledge of resident's AFO device. |
| Registered Nurse (RN #2) | Registered Nurse | Interviewed regarding documentation and application of assistive devices. |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding missing AFO device and CNA documentation. |
Inspection Report — Dec 5, 2019
Annual Inspection CMS
Date: Dec 5, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with professional standards of quality, care, and safety in the nursing facility.
Findings
The facility failed to ensure professional standards of quality in care, including improper administration of insulin to Resident #200 and giving water by mouth to Resident #221 who had a gastrostomy tube and a Nothing by Mouth (NPO) order. Additionally, the facility did not maintain a safe environment, as evidenced by broken floor tiles posing a hazard to Resident #93.
Citations (3)
Insulin was not administered as ordered to Resident #200; seven missed evening doses led to elevated blood glucose levels.
Resident #221 with a gastrostomy tube and NPO order was given water by mouth, risking aspiration.
Floor tiles at the foot of Resident #93's bed were lifting and uneven with a hole, creating an accident hazard.
Report Facts
Missed insulin doses: 7
Blood glucose levels (mg/dL): 232
Blood glucose levels (mg/dL): 185
Blood glucose levels (mg/dL): 277
Blood glucose levels (mg/dL): 241
Blood glucose levels (mg/dL): 300
Blood glucose levels (mg/dL): 157
Blood glucose levels (mg/dL): 200
Hole size: 3
Hole circumference: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed about withholding insulin doses for Resident #200 |
| RN supervisor #1 | Registered Nurse Supervisor | Interviewed regarding communication about insulin withholding |
| RN Supervisor #2 | Evening Registered Nurse Supervisor | Interviewed by phone about insulin withholding communication |
| CNA #1 | Certified Nurse Aide | Observed giving water to Resident #221 and interviewed about the incident |
| LPN #1 | Licensed Practical Nurse | Charge nurse who authorized giving water to Resident #221 |
| RN #1 | Registered Nurse | Supervised nurses and commented on care related to Resident #221 |
| Speech Therapist | Speech Therapist | Evaluated Resident #221 and provided expert opinion on dysphagia and aspiration risk |
| Physician | Physician | Interviewed about Resident #221's NPO status and aspiration risk |
| CNA #2 | Certified Nurse Aide | Noticed broken floor tiles in Resident #93's room but did not report |
| Housekeeper #6 | Housekeeper | Reported broken floor tiles to maintenance supervisor |
| Director of Environmental Services | Director of Environmental Services | Interviewed about maintenance and repair processes for facility environment |
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