Inspection Reports for Highbridge Woodycrest Center
936 Woodycrest Avenue, Bronx, NY, 10452
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 16, 2024, identified deficiencies related to the facility’s water management plan for Legionella and the qualifications of the designated Infection Preventionist. Earlier inspections also noted issues with infection preventionist qualifications and infection control, as well as life safety code concerns that were corrected promptly. Prior reports cited accident hazards and infection preventionist training gaps, along with medication management and storage issues in 2019. Complaint investigations were unsubstantiated or involved deficiencies that were corrected in a timely manner. The facility’s record shows recurring themes around infection preventionist qualifications and infection control, with some improvements in addressing life safety and hazard issues over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 16, 2024
Visit Reason
The inspection was conducted as a Recertification Survey to evaluate the facility's compliance with infection prevention and control requirements, including review of the Water Management Plan for Legionella and the qualifications of the designated Infection Preventionist.
Findings
The facility failed to maintain a facility-specific water management plan for Legionella with all required components and did not ensure that the designated Infection Preventionist had completed specialized infection prevention and control training as required.
Deficiencies (2)
The facility did not have a facility-specific water management plan for Legionella including required components such as a description of the water distribution system, temperature profile, personnel roles, and control measures.
The designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training.
Report Facts
Contact hours of infection control training: 4
Duration Infection Preventionist out sick: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acting Infection Preventionist | Stated that the full-time Infection Preventionist had been out sick for 4 months and both had taken 4 contact hours of infection control training |
| Administrator | Interviewed regarding the water management plan and Infection Preventionist training requirements |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 16, 2024
Visit Reason
Deficiencies in infection control, infection preventionist qualifications, and life safety code issues including fire alarm system, HVAC, and illumination of means of egress; all corrected by September 2024 or earlier.
Findings
Deficiencies in infection control, infection preventionist qualifications, and life safety code issues including fire alarm system, HVAC, and illumination of means of egress; all corrected by September 2024 or earlier.
Deficiencies (1)
Infection control; Infection prevention & control; Infection preventionist qualifications/role; Fire alarm system - testing and maintenance; HVAC; Illumination of means of egress
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 6, 2022
Visit Reason
The inspection was a Recertification survey conducted from 09/29/22 to 10/06/22 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found to have a tampered bathroom doorknob in a shared resident room that posed an accident hazard, and the facility did not have a qualified Infection Preventionist with specialized training as required. The bathroom door handle was replaced during the survey, and interviews revealed lack of awareness about infection prevention training requirements.
Deficiencies (2)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents related to a tampered bathroom doorknob that could not be opened in an emergency.
Designate a qualified infection preventionist to be responsible for the infection prevention and control program in the nursing home; facility did not have a qualified IP with specialized education, training, experience, or certification.
Report Facts
Residents sampled: 25
Residents affected by bathroom door hazard: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse, Infection Preventionist | Named as facility IP responsible for infection control but lacking required training and certification |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding infection prevention and bathroom door incidents; identified as facility IP without required training |
| Maintenance Director | Maintenance Director | Interviewed about bathroom door issues and replacement |
| Administrator | Administrator | Interviewed about infection preventionist qualifications and training awareness |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed bathroom door and provided information about door condition |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about opening bathroom doors with a coin |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 6, 2022
Visit Reason
Deficiencies in care plan timing and revision, accident hazards supervision, infection preventionist qualifications, and multiple life safety code issues including egress doors, electrical systems, emergency lighting, physical environment, sprinkler system installation and maintenance; all corrected by late 2022 or early 2023.
Findings
Deficiencies in care plan timing and revision, accident hazards supervision, infection preventionist qualifications, and multiple life safety code issues including egress doors, electrical systems, emergency lighting, physical environment, sprinkler system installation and maintenance; all corrected by late 2022 or early 2023.
Deficiencies (1)
Care plan timing and revision; Free of accident hazards/supervision/devices; Infection preventionist qualifications/role; Egress doors; Electrical systems; Emergency lighting; Physical environment; Plan based on all hazards risk assessment; Smoking regulations; Sprinkler system installation; Sprinkler system maintenance and testing
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 14, 2022
Visit Reason
Deficiencies related to abuse and neglect prevention, reporting of alleged violations, and reporting of reasonable suspicion of a crime; all corrected by May 2022.
Findings
Deficiencies related to abuse and neglect prevention, reporting of alleged violations, and reporting of reasonable suspicion of a crime; all corrected by May 2022.
Deficiencies (1)
Free from abuse and neglect; Reporting of alleged violations; Reporting of reasonable suspicion of a crime
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 5, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements related to medication use, specifically focusing on unnecessary use of antipsychotic medications in residents.
Findings
The facility failed to ensure that a physician reviewed and documented the clinical rationale for continued use of an antipsychotic medication for Resident #31. The resident was prescribed Zyprexa for an unclear diagnosis, with conflicting documentation regarding the diagnosis of dementia versus psychosis. The physician disagreed with pharmacist recommendations but did not document clinical rationale. Non-pharmacological interventions were used, and no inappropriate behaviors were observed. Additionally, expired influenza vaccines were found in the medication refrigerator.
Deficiencies (4)
Failure to ensure physician review and documentation of clinical rationale for continued antipsychotic medication use for Resident #31.
Failure to ensure licensed pharmacist monthly drug regimen review responses included clinical rationale when disagreeing with recommendations.
Failure to implement gradual dose reductions and non-pharmacological interventions prior to continuing psychotropic medication for Resident #31.
Failure to ensure drugs and biologicals were stored in accordance with regulations; expired influenza vaccine syringes found in medication refrigerator.
Report Facts
Residents reviewed for unnecessary medication: 5
Expired influenza vaccine syringes: 4
Days past expiration: 156
Mini-Mental Status Exam score: 25
Montreal Cognitive Assessment score range: 9-20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PNP | Psychiatric Nurse Practitioner | Conducted psychiatric assessments and recommended continuation of Zyprexa for Resident #31. |
| MD | Medical Doctor | Oversaw Resident #31's care, disagreed with some medication regimen recommendations, and did not document clinical rationale. |
| DON | Director of Nursing | Provided information on medication regimen review process and responsibilities. |
| CNA #1 | Certified Nursing Assistant | Reported no inappropriate behaviors or hallucinations for Resident #31. |
| LPN #2 | Licensed Practical Nurse | Reported Resident #31's behavior and cognitive status during rounds. |
| SW | Social Worker | Provided background on Resident #31's psychiatric history and behavior. |
| LPN #1 | Licensed Practical Nurse | Administers influenza vaccines and confirmed use of current season vaccine. |
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