Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Sep 14, 2023
Visit Reason
Complaint survey with 11 standard health citations and 2 life safety code citations, all Level 2 severity, corrected by late 2023.
Findings
Complaint survey with 11 standard health citations and 2 life safety code citations, all Level 2 severity, corrected by late 2023.
Deficiencies (13)
Develop/implement comprehensive care plan
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Grievances
Nutritive value/appear, palatable/prefer temp
Personal food policy
Quality of care
Resident rights/exercise of rights
Right to survey results/advocate agency info
Safe/clean/comfortable/homelike environment
Elevators
Gas equipment - cylinder and container storag
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Sep 14, 2023
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 09/07/2023 through 09/14/2023 to assess compliance with regulatory requirements for Greene Meadows Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including timely meal service and dignity in care, posting of survey results, housekeeping and maintenance issues, grievance handling, comprehensive care planning, medication administration, accident prevention, food service quality and safety, food storage, and garbage disposal.
Deficiencies (11)
Residents in dining rooms waited up to 31 minutes for meals; personal care was provided with an open door exposing a resident.
Facility did not ensure survey results were posted in a place accessible to residents and staff.
Housekeeping deficiencies including numerous stained ceiling tiles and soiled windows throughout the facility.
Facility did not promptly resolve a grievance regarding missing hearing aids for a discharged resident.
Comprehensive care plans did not address use of psychotropic medications and were not person-centered for some residents.
Physician ordered wound treatment was not consistently applied and documented; physician was not notified of missed treatments.
Missed medication and treatment administration due to staffing shortages without proper notification or documentation.
Food and beverages were served at suboptimal temperatures, were not palatable, and food temperatures were not consistently obtained prior to serving.
Food was not stored or labeled properly in resident kitchenettes, with unlabeled or undated food items found.
Food service areas including main kitchen and kitchenettes were not properly cleaned; sanitizer test papers were missing.
Dumpster cover was open exposing kitchen food waste, cover was heavily soiled, and grounds around dumpster were littered.
Report Facts
Residents affected: 2
Residents affected: 6
Ceiling tiles stained: 111
Residents affected: 1
Missed medication/treatment occasions: 5
Food temperature measurements: 142
Food temperature measurements: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) #2 | Interviewed regarding meal service delays and dignity issues | |
| Certified Nurse Aid (CNA) #1 | Interviewed regarding meal tray organization and personal care incident | |
| Director of Nursing (DON) | Interviewed regarding meal service issues, grievance handling, and missed treatments | |
| Facility Administrator | Interviewed regarding food service issues and grievance resolution | |
| Regional Manager | Interviewed regarding meal service and food temperature standards | |
| Social Worker (SW) #1 | Grievance Officer interviewed regarding missing hearing aids grievance | |
| Licensed Practical Nurse Unit Manager (LPNUM) #3 | Interviewed regarding missed medication and treatment documentation | |
| Certified Nursing Assistant (CNA) #2 | Interviewed regarding food temperature checks post-incident |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Sep 14, 2023
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 9/7/2023 through 9/14/2023 to assess compliance with regulatory requirements for Greene Meadows Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including timely and dignified meal service, proper posting of survey results, housekeeping deficiencies with stained ceiling tiles and soiled windows, failure to promptly resolve a grievance regarding missing hearing aids, incomplete care plans for psychotropic medication use, missed wound care treatments, inadequate supervision leading to a resident burn injury, and serving food at unsafe and unappetizing temperatures.
Deficiencies (9)
Residents in dining rooms waited up to 31 minutes for meals after dining mates were served; personal care was provided with an open door exposing a resident.
Facility did not ensure survey results were posted in a place readily accessible to residents and staff.
Housekeeping services were ineffective with numerous ceiling tiles stained by water and windows soiled with water stains and debris.
Facility did not promptly resolve a grievance regarding missing hearing aids for a discharged resident.
Care plans did not address use of psychotropic medications for two residents and were not person-centered.
Physician ordered wound treatment was not administered on five occasions and physician was not notified.
Missed wound care treatments due to staffing shortages were not reported to supervisors.
Resident suffered first degree burns from hot soup served without temperature testing; staff lacked training and thermometers to test food temperature.
Food and beverages were served at suboptimal temperatures, were bland or unpalatable, and food temperatures were not consistently obtained prior to serving.
Report Facts
Missed wound treatment administrations: 5
Meal serving delay: 31
Ceiling tiles stained: 111
Meal temperatures: 120.9
Meal temperatures: 56.3
Meal temperatures: 75.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed heating food improperly and lacked training on heating food for residents; involved in incident of resident burn |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Interviewed regarding meal service delays and privacy issues during care |
| SW #1 | Social Worker / Grievance Officer | Involved in grievance process for missing hearing aids; acknowledged grievance process was not followed |
| LPNUM #1 | Licensed Practical Nurse Unit Manager | Described proper procedure for missing items and grievance reporting |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies in meal service, grievance follow-up, care plans, and missed treatments |
| Regional Manager | Provided information on meal cart delivery process and food temperature standards | |
| Administrator | Acknowledged issues with food service and grievance follow-up; described corrective actions | |
| Director of Building and Grounds | Explained causes of stained ceiling tiles and plans for repair |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
Covid-19 survey with one standard health citation related to reporting to the national health safety network, Level 2 severity, not corrected as of report.
Findings
Covid-19 survey with one standard health citation related to reporting to the national health safety network, Level 2 severity, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 11, 2022
Visit Reason
Complaint survey with one standard health citation for notification of changes (injury/decline/room, etc.), Level 2 severity, corrected by December 9, 2022.
Findings
Complaint survey with one standard health citation for notification of changes (injury/decline/room, etc.), Level 2 severity, corrected by December 9, 2022.
Deficiencies (1)
Notify of changes (injury/decline/room, etc. )
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 18, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Greene Meadows Nursing and Rehabilitation Center.
Findings
The survey identified deficiencies including failure to ensure residents' advance directives were addressed, pharmaceutical service issues related to medication availability and communication, food service safety violations including improper sanitization and labeling, and lack of policy for safe handling of foods brought by visitors.
Deficiencies (4)
Failure to ensure resident or representative was informed and provided written information regarding advance directives; advance directives or code status not addressed upon admission or during stay for Resident #51.
Failure to provide pharmaceutical services to meet needs of residents; medication for diabetic neuropathy not available for Resident #53 and failure to notify nursing administration when narcotic renewal order did not arrive for Resident #57.
Failure to store, prepare, distribute and serve food in accordance with professional standards; dishwashing machine not operating within manufacturer's specifications, chemical sanitizer concentration too high, unlabeled spray bottles and food containers, soiled equipment and surfaces, and kitchen floor and wall in disrepair.
Lack of policy regarding use and storage of foods brought to residents by family and visitors; no procedure to assist residents in accessing and consuming visitor-brought food and no information provided to families on safe food handling.
Report Facts
Residents reviewed for Advance Directives: 2
Residents reviewed for pharmaceutical services: 4
QAC concentration: 500
Dishwashing machine final rinse water pressure: 30
Medication doses missed: 8
Medication renewal delay: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #3 | Social Worker | Reviewed advance directives and code status with Resident #51 and spouse; completed Health Care Proxy and MOLST forms |
| Director of Nursing | Director of Nursing (DON) | Stated expectation to have code status prior to date; involved in medication reorder process and identified pharmacy order communication issues |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Unable to find Resident #51's code status in records |
| Registered Nurse/Unit Manager #2 | Registered Nurse/Unit Manager (RNUM) | Unable to find code status for Resident #51; communicated with Social Worker #3 |
| Licensed Practical Nurse #4 | Licensed Practical Nurse (LPN) | Ordered medication for Resident #53 but order did not go through due to computer error |
| Registered Nurse/Unit Manager #3 | Registered Nurse/Unit Manager (RNUM) | Described medication reorder process and communication issues |
| Pharmacist #7 | Pharmacist | Provided details on medication supply and ordering process |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported software communication issues affecting medication orders |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Reported medication for Resident #57 not arrived from pharmacy |
| Pharmacist #3 | Pharmacist | Reported no renewal order for Resident #57 in system |
| Registered Nurse #1 | Registered Nurse (RN) | Reported system problems with medication orders |
| RN #2 | Registered Nurse (RN) | Would be notified by medication nurse if medication delay occurs |
| Physician #4 | Physician | Reported problems with electronic interface for orders |
| Dietary Supervisor #1 | Dietary Supervisor | Reported issues with dishwashing machine and kitchen maintenance |
| Food Service Director | Dietary Manager | Stated no information provided to families on safe food handling for visitor-brought food |
| Administrator | Administrator | Stated facility provides food safety information upon request and plans to update Welcome Booklet |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Aug 14, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with Medicare and Medicaid regulations, including review of notifications to residents, care planning, medication management, safety, food service, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicaid/Medicare coverage notices, failure to provide written transfer/discharge notifications and bed hold policy notices, incomplete baseline care plans, incomplete and unrevised comprehensive care plans, unsecured wardrobes posing accident hazards, improper medication management related to anticoagulation therapy, unclean kitchen exhaust areas, and inadequate infection control practices during dressing changes.
Deficiencies (9)
Failure to provide timely and specific notification to residents or representatives regarding Medicare Part A coverage termination and beneficiary liability.
Failure to provide written notification to residents, representatives, and ombudsman before transfer or discharge including appeal rights.
Failure to notify residents or representatives in writing of the nursing home's bed hold policy upon hospital transfer.
Failure to develop and implement baseline care plans within 48 hours of admission for multiple residents.
Failure to review and revise comprehensive care plans as necessary after changes in resident condition or events.
Unsecured wardrobes in resident rooms posed accident hazards due to risk of toppling.
Failure to ensure resident's drug regimen was free from unnecessary drugs; specifically, continued Heparin injections without adequate indication and despite resident refusal.
Failure to maintain clean food preparation and serving areas; greasy ceiling tiles and exhaust fan guards in the main kitchen.
Failure to maintain infection prevention and control practices during dressing changes; improper glove use and failure to change gloves after touching contaminated surfaces.
Report Facts
Residents reviewed for baseline care plans: 24
Residents reviewed for comprehensive care plans: 24
Heparin doses refused: 53
Resident rooms with unsecured wardrobes: 5
Wardrobe units inspected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #3 | Social Worker | Responsible for issuing Medicare Part A coverage notifications and bed hold policy notices; interviewed regarding notification deficiencies. |
| MDS Coordinator #5 | MDS Coordinator | Interviewed regarding timing and issuance of Medicare Part A coverage notifications. |
| Registered Nurse Manager #2 | Registered Nurse Manager | Interviewed regarding transfer/discharge notifications and bed hold policy notices. |
| Registered Nurse Unit Manager #4 | Registered Nurse Unit Manager | Interviewed regarding transfer/discharge notifications and bed hold policy notices. |
| Director of Resident and Family Services | Director of Resident and Family Services | Interviewed regarding transfer/discharge notifications and bed hold policy notices. |
| Administrator | Administrator | Interviewed regarding notification deficiencies and baseline care plan implementation. |
| Registered Nurse Unit Manager #8 | Registered Nurse Unit Manager | Interviewed regarding baseline care plan development and review. |
| Social Worker #3 | Social Worker | Interviewed regarding baseline care plan completion. |
| Registered Nurse Manager #2 | Registered Nurse Manager | Interviewed regarding care plan revision practices. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan revision and medication refusal documentation. |
| Director of Maintenance | Director of Maintenance | Interviewed regarding unsecured wardrobes and plans to secure them. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding resident refusal of Heparin injections. |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding resident refusal of Heparin injections and medication monitoring. |
| Medical Director | Medical Director | Interviewed regarding resident refusal of Heparin and medication discontinuation. |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding medication use and resident refusal. |
| Director of Food Service | Director of Food Service | Interviewed regarding kitchen cleanliness and maintenance. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed and interviewed regarding improper glove use during dressing change. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed and interviewed regarding improper glove use during dressing change. |
| Registered Nurse Manager #4 | Registered Nurse Manager | Interviewed regarding infection control practices during dressing changes. |
| Staff Educator #3 | Staff Educator | Interviewed regarding plans for inservice training on proper dressing change procedures. |
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