Inspection Reports for
Gold Crest Care Center
2316 Bruner Avenue, Bronx, NY, 10469
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Oct 3, 2024
Visit Reason
Complaint survey with multiple standard health and life safety code citations, all corrected by mid-November 2024.
Findings
Complaint survey with multiple standard health and life safety code citations, all corrected by mid-November 2024.
Deficiencies (6)
Bedrails
Develop/implement comprehensive care plan
Infection prevention & control
Right to be free from physical restraints
Fire alarm system - testing and maintenance
Standards of construction for new existing nh
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 3, 2024
Visit Reason
The inspection was conducted as a Recertification Survey from 09/26/2024 to 10/03/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints (bed side rails) without physician orders or consent, failure to develop comprehensive care plans for residents with osteomyelitis, lack of assessment and informed consent for bed rail use, and inadequate infection prevention practices during medication administration for residents with gastrostomy tubes.
Deficiencies (4)
Use of physical restraints (bed side rails) on Resident #60 without physician order, family consent, or proper documentation.
Failure to develop and implement comprehensive care plans for Residents #228 and #17 with osteomyelitis.
Failure to assess Resident #60 for risk of entrapment from bed rails, obtain informed consent, and conduct preventive maintenance on bed rails.
Failure to maintain enhanced barrier precautions during medication administration for residents with gastrostomy tubes (Residents #14 and #60).
Report Facts
Residents reviewed for physical restraints: 36
Residents sampled: 36
Residents observed for medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Interviewed regarding use of bed side rails for Resident #60. | |
| Certified Nursing Assistant #3 | Interviewed regarding use of bed side rails for Resident #60. | |
| Registered Nurse #4 | Unit Manager | Interviewed regarding bed side rail use policy and practice for Resident #60. |
| Occupational Therapist | Completed side rail assessment for Resident #60 and interviewed about recommendations. | |
| Director of Nursing | Interviewed regarding bed side rails and care plan responsibilities. | |
| Registered Nurse #1 | Nurse Manager | Interviewed regarding oversight of comprehensive care plans for Resident #228. |
| Registered Nurse #2 | Nursing Supervisor | Interviewed regarding admission and care plan development for Resident #228. |
| Assistant Director of Nursing | Interviewed regarding oversight of care plan for Resident #17. | |
| Licensed Practical Nurse #3 | Observed and interviewed regarding medication administration and enhanced barrier precautions. | |
| Registered Nurse #3 | Unit Manager | Interviewed regarding enhanced barrier precautions during medication administration. |
| Director of Maintenance | Interviewed regarding bed rail entrapment risk assessments and maintenance. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jul 29, 2024
Visit Reason
Complaint survey with standard health citations related to notice requirements before transfer/discharge and reporting of alleged violations, corrected by August 12, 2024.
Findings
Complaint survey with standard health citations related to notice requirements before transfer/discharge and reporting of alleged violations, corrected by August 12, 2024.
Deficiencies (2)
Notice requirements before transfer/discharge
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jul 29, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse and to assess compliance with timely notification requirements for resident transfers or discharges, particularly focusing on Justice Involved Residents.
Complaint Details
The visit included a complaint investigation regarding the failure to report an allegation of abuse involving rough handling of Resident #6. The allegation was unsubstantiated by the facility's internal investigation but was not reported to the state as required.
Findings
The facility failed to timely report an allegation of abuse involving rough handling of a resident to the New York State Department of Health. Additionally, the facility did not provide timely written transfer or discharge notices to Justice Involved Residents or notify the New York State Long Term Care Ombudsman office of these discharges. Interviews revealed that notices were often not given due to security reasons and short notice from authorities.
Deficiencies (2)
Failure to timely report suspected abuse involving rough handling of Resident #6 to the New York State Department of Health.
Failure to provide timely written notification of transfer or discharge and failure to notify the Office of New York State Long Term Care Ombudsman for 4 out of 5 Justice Involved Residents.
Report Facts
Residents sampled for abuse: 7
Justice Involved Residents affected: 4
Justice Involved Residents total: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Received abuse allegation call from Resident #6's adult child | |
| Licensed Practical Nurse #1 | Notified Director of Nursing and Administrator about abuse allegation | |
| Director of Nursing | Director of Nursing | Responsible for investigating incidents and reporting to authorities; stated abuse allegation was not reported due to belief of misunderstanding |
| Administrator | Administrator | Responsible for reporting incidents; stated abuse allegation was unsubstantiated and not reported |
| Director of Social Service | Director of Social Service | Stated notices of discharge/transfer were not given to Justice Involved Residents due to security and short notice; also stated Ombudsman not notified unless 30 days' notice given |
| Admission Director | Admission Director | Stated Ombudsman notified only for hospital transfers due to bed hold policy; not notified for community or other facility discharges |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 18, 2022
Visit Reason
The inspection was conducted as a Recertification Survey from 7/11/22 to 7/18/22 to assess compliance with Medicare and Medicaid regulations.
Findings
The facility was found deficient in multiple areas including failure to provide timely and proper Medicare Non-Coverage notices to residents and their representatives, failure to provide written summaries of baseline care plans to residents or their representatives within 48 hours of admission, improper labeling and storage of medications and biologicals, and incomplete documentation of toileting care in medical records.
Deficiencies (4)
Failure to provide timely and proper Notice of Medicare Non-Coverage (NOMNC) to Medicare beneficiaries and their representatives.
Failure to provide a written summary of the baseline care plan to residents or their representatives within 48 hours of admission.
Medication and biologicals were not labeled in accordance with professional principles; eye drops and inhalers lacked resident-specific labels on bottles/devices, and insulin pens were not stored to prevent cross-contamination.
Medical records were incomplete and inaccurately documented, specifically missing toileting documentation for a resident over multiple shifts.
Report Facts
Residents reviewed: 35
Residents affected: 2
Residents affected: 2
Units observed: 4
Insulin pens observed: 11
Missing toileting documentation days: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification processes, medication labeling, and toileting documentation. |
| MDS Coordinator | MDS Coordinator (MDSC) | Interviewed about Medicare Non-Coverage notice procedures. |
| Registered Nurse Manager #3 | Registered Nurse Manager (RNM) #3 | Interviewed about baseline care plan distribution. |
| Director of Social Work | Director of Social Work (DSW) | Interviewed about baseline care plan meetings and documentation. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) #2 | Interviewed about medication labeling practices. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about medication labeling and storage. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) #3 | Interviewed about care provided to Resident #22. |
| Registered Nurse Manager #2 | Registered Nurse Manager (RNM) #2 | Interviewed about toileting documentation and supervision. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 30, 2019
Visit Reason
The inspection was conducted as a recertification survey to ensure the facility's compliance with regulatory requirements, specifically to verify the accuracy of resident assessments.
Findings
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected a resident's dialysis treatment status. The MDS did not document dialysis for Resident #140 despite evidence from interviews, care plans, and physician orders confirming the resident's dialysis schedule.
Deficiencies (1)
Failure to ensure each resident receives an accurate assessment, specifically the MDS did not reflect resident's dialysis treatment.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse/ MDS Coordinator | Interviewed regarding MDS completion and acknowledged oversight in dialysis documentation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADNS) | Interviewed regarding responsibilities for MDS assessment and documentation accuracy |
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