Inspection Report — Dec 16, 2024
Abbreviated Survey
Citations: 1
Date: Dec 16, 2024
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with regulations regarding resident safety and supervision following incidents involving two residents who fell and sustained injuries.
Complaint Details
The investigation concluded there was reasonable cause to suspect resident abuse, neglect, or mistreatment had occurred related to Resident #1's fall. For Resident #2, there was no reasonable cause to suspect abuse, neglect, or mistreatment.
Findings
The facility failed to ensure adequate supervision to prevent accidents, resulting in two residents falling with actual harm, including fractures and head injuries. Investigations revealed staff errors, lack of training, and policy deficiencies related to resident supervision and fall prevention.
Citations (1)
Failure to ensure adequate supervision to prevent resident falls resulting in actual harm.
Report Facts
Residents affected: 2
Fall risk score: 20
Fall risk score: 9
Medication dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Involved in transferring Resident #1 and took the wrong resident out of bed, leading to fall. | |
| Licensed Practical Nurse #1 | Charge nurse on shift, provided assignment to CNA #1, assisted Resident #1 after fall, cleaned Resident #1's cut. | |
| Nursing Supervisor #1 | Assessed Resident #1 after fall, assisted with mechanical lift, provided report to incoming shift. | |
| Certified Nurse Assistant #3 | Left Resident #2 unattended on toilet, resulting in fall. | |
| Licensed Practical Nurse #2 | Documented Resident #2's condition after fall and assisted with hospital transfer. | |
| Nursing Supervisor #2 | Assessed Resident #2 after fall, documented findings, and coordinated hospital transfer. | |
| Licensed Practical Nurse #3 | Responded to Resident #2's fall in bathroom and assisted with evaluation and transfer. | |
| Director of Nursing | Provided statements regarding incidents, staff training, and policy changes after falls. | |
| Medical Doctor | Assessed Resident #1 and Resident #2, ordered hospital transfers, did not recall incident details. |
Inspection Report — Dec 16, 2024
Complaint Investigation
Citations: 18
Date: Dec 16, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2024 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 54 complaints about this facility; 5 led to on-site inspections. Complaint-related citations totaled 4 during the reporting period.
Findings
Across 5 inspections, 22 citations were issued including 12 standard health and 10 Life Safety Code citations. The facility had 54 complaints with 5 on-site inspections and 2 enforcement actions totaling $28,000 in fines.
Citations (18)
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices found deficient causing actual harm.
Standard Health Citation — quality of care: Accounting And Records Of Personal Funds deficient with minor potential harm.
Standard Health Citation — quality of care: Department Criminal History Review cited with no harm potential.
Standard Health Citation — quality of care: Pain Management deficient with minor potential harm.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficient with minor potential harm.
Standard Health Citation — quality of care: Surety Bond-security Of Personal Funds deficient with minor potential harm.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extens deficient with minor potential harm.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure deficient with minor potential harm.
Standard Health Citation — quality of care: Baseline Care Plan deficient with minor potential harm.
Standard Health Citation — quality of care: Bedrails deficient with minor potential harm.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficient with minor potential harm.
Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary deficient with minor potential harm.
Standard Health Citation — quality of care: Physician Visits - Review Care/notes/order deficient with minor potential harm.
Life Safety Code Citation — NFPA requirements: Building Construction Type And Height deficient with minor potential harm.
Life Safety Code Citation — NFPA requirements: Exit Signage deficient with minor potential harm.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficient with minor potential harm.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficient with minor potential harm.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices deficient with minor potential harm.
Report Facts
Inspections on page: 5
Total violations/deficiencies cited: 22
Inspections with violations: 4
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 28000
Number of enforcement actions: 2
Total complaints: 54
On-site complaint inspections: 5
Complaint citations issued: 4
Inspection Report — Nov 7, 2024
Annual Inspection
Citations: 2
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey from 10/31/2024 to 11/07/2024 to assess compliance with regulatory requirements including abuse reporting and pain management.
Findings
The facility failed to timely report injuries of unknown origin to the New York State Department of Health for two residents, Resident #144 and Resident #130. Additionally, the facility did not provide appropriate pain management for Resident #3, who had a morphine pump with no documented evidence of cartridge replacement or pain management follow-up in over 12 months.
Citations (2)
Failure to timely report suspected abuse or injuries of unknown origin to the New York State Department of Health for Resident #144 and Resident #130.
Failure to provide safe, appropriate pain management for Resident #3, including lack of documented morphine pump cartridge replacement and pain management follow-up.
Report Facts
Residents reviewed for Abuse: 38
Residents reviewed for Pain: 6
Residents affected: 2
Residents affected: 1
Date of injury for Resident #144: Apr 29, 2024
Date of injury for Resident #130: Oct 23, 2023
Date of incident report submission for Resident #144: May 2, 2024
Date of incident report submission for Resident #130: Oct 25, 2023
Morphine pump cartridge last refilled: 2023-05
Morphine pump replacement interval: 5
Morphine pump cartridge replacement interval: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Interviewed regarding Resident #144's injury and pain management for Resident #3 |
| Director of Nursing | Director of Nursing | Interviewed regarding investigations and reporting for Resident #144 and Resident #130, and pain management for Resident #3 |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding transfer of Resident #130 |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding transfer of Resident #130 |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed hematoma on Resident #130 and notified supervisor |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Observed hematoma on Resident #130 and notified supervisor |
| Administrator | Administrator | Interviewed regarding reporting of Resident #144's injury |
| Attending Physician | Physician | Interviewed regarding Resident #3's pain management and morphine pump |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #3's pain and morphine pump |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding Resident #3's daily care and pain complaints |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding medication administration and awareness of Resident #3's morphine pump |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding awareness of Resident #3's morphine pump |
Inspection Report — Sep 26, 2022
Recertification Complaint
Citations: 5
Date: Sep 26, 2022
Visit Reason
The inspection was a Recertification and Complaint Survey conducted from 09/19/2022 to 09/26/2022 to assess compliance with care plan communication, comprehensive care planning, physician order review, and safe food handling.
Complaint Details
The visit was complaint-related as it included a complaint survey component addressing failure to provide a written summary of the baseline care plan to a resident's designated representative.
Findings
The facility failed to provide a written summary of the baseline care plan to a resident's designated representative, did not develop comprehensive care plans addressing side rail use for multiple residents, lacked physician orders for side rail use despite assessments and consents, did not assess or document risks and benefits of side rails for residents, and failed to ensure safe food handling by storing expired enteral feeding products.
Citations (5)
Did not ensure that a resident's designated representative was provided with a written summary of the baseline care plan.
Did not develop and implement a comprehensive care plan addressing residents' use of side rails as enablers.
Did not assess residents for risk of entrapment from bed rails prior to installation or use, nor obtained informed consent.
Physician did not review and place orders for resident's use of bed side rails despite rehab assessment and consent.
Stored expired enteral feeding products in the central supply storage room.
Report Facts
Residents reviewed for Care Plan: 40
Residents reviewed for Accidents: 40
Residents with side rail care plan deficiencies: 5
Expired enteral feeding boxes: 2
Cartons per expired box: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding baseline care plan provision |
| ADSW | Assistant Director of Social Work | Interviewed regarding baseline care plan distribution |
| SWD | Social Work Director | Interviewed regarding baseline care plan procedures |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding resident care and side rail use |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident care and side rail use |
| RN #2 | Registered Nurse in charge | Interviewed regarding resident care and side rail use |
| DOR | Director of Rehab | Interviewed regarding side rail assessment and orders |
| RN #1 | RN Nursing Supervisor | Interviewed regarding care plan initiation and side rail orders |
| DNS | Director of Nursing | Interviewed regarding side rail orders and care plan compliance |
| MD | Medical Director | Interviewed regarding physician order review and side rail orders |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding side rail use and resident consent |
| RN #5 | Registered Nurse | Interviewed regarding side rail use and orders |
| IT Nurse | Information Technology Nurse | Interviewed regarding care plan creation and siderail use |
| CSS | Central Supply Supervisor | Interviewed regarding enteral feeding inventory and expired product removal |
| DFS | Director of Food Service | Interviewed regarding enteral feeding usage and resident discharge |
| Central Supply Person | Interviewed regarding expired enteral feeding handling | |
| Director of Maintenance | Interviewed regarding siderail installation and safety checks |
Inspection Report — Dec 6, 2019
Annual Inspection
Citations: 6
Date: Dec 6, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents, inadequate resident participation in care planning meetings, failure to provide appropriate care for residents with limited range of motion, improper labeling and storage of medications, unsafe food handling practices, and lapses in infection prevention and control practices.
Citations (6)
Failure to develop and implement comprehensive care plans addressing residents' needs including anticoagulant, diuretic, diabetes, and hypertension medications.
Residents with intact cognition were not afforded the opportunity to participate in care planning meetings.
Residents with limited range of motion did not receive appropriate treatment; a resident with contractures was not observed wearing a prescribed hand splint device.
Medical supplies containing biologicals (insulin pens) were stored without appropriate pharmacy labels and lacked opened or discard dates.
Raw food (chicken and fish) was handled with bare hands without proper hand hygiene or glove use, violating food safety standards.
Housekeeping staff did not perform hand hygiene when removing waste from rooms of residents on Contact Precautions, violating infection control protocols.
Report Facts
Residents reviewed: 39
Residents affected: 2
Residents affected: 2
Residents affected: 1
Insulin pens observed: 2
Date of physician's order: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Unit Manager | Interviewed regarding missing care plans and responsibilities for care plan completion |
| Assistant Director of Nursing (ADON) | Interviewed regarding supervision of care plan development and staff responsibilities | |
| MDS Coordinator | RN - MDS Coordinator | Interviewed regarding responsibilities for care plan initiation and MDS assessments |
| Social Worker #3 | Social Worker | Interviewed regarding resident participation in care planning meetings |
| Social Worker #2 | Social Worker | Interviewed regarding resident and family invitations to care planning meetings |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Interviewed regarding provision of ADL care and application of splint devices |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Observed and interviewed regarding resident's splint device |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding medication storage and labeling practices |
| Registered Nurse (RN) #1 | Registered Nurse | Interviewed regarding medication cart checks and insulin pen labeling |
| Assistant Director of Nursing (ADN) | Interviewed regarding medication cart inspections and labeling requirements | |
| Cook #1 | Cook | Observed and interviewed regarding food handling and hand hygiene practices |
| Director of Nutrition (DON) | Director of Nutrition | Interviewed regarding staff training on handwashing and food safety |
| Housekeeper #1 | Housekeeper | Observed and interviewed regarding waste removal and infection control practices |
| Director of Housekeeping (DOH) | Director of Housekeeping | Interviewed regarding staff training and PPE use for biohazardous waste handling |
| Director of Nursing Services/Infection Control Manager | Director of Nursing Services/Infection Control Manager | Interviewed regarding infection control rounds and staff compliance |
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