Inspection Reports for Highland Park Rehabilitation & Nursing Center
NY, 14895
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
No detailed data available for this inspection on the page.
Findings
No detailed data available for this inspection on the page.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Apr 26, 2024
Visit Reason
Multiple standard health and life safety code citations including drug regimen, licensing compliance, quality of care, cooking facilities, electrical systems, fire alarm system, and illumination of means of egress. All deficiencies corrected by June or July 2024.
Findings
Multiple standard health and life safety code citations including drug regimen, licensing compliance, quality of care, cooking facilities, electrical systems, fire alarm system, and illumination of means of egress. All deficiencies corrected by June or July 2024.
Deficiencies (7)
Drug regimen is free from unnecessary drugs
License/comply w/ fed/state/locl law/prof std
Quality of care
Cooking facilities
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Illumination of means of egress
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NY00315852) to determine if the facility ensured that each resident's drug regimen was free from unnecessary drugs, specifically focusing on monitoring of Prothrombin Time/International Normalized Ratio (PT-INR) for residents on anticoagulant therapy.
Complaint Details
Complaint #NY00315852 triggered the investigation. The complaint involved inadequate monitoring of PT-INR levels for Resident #130 on Warfarin, which was substantiated by findings of lapses in communication and failure to follow facility policies, resulting in a supratherapeutic INR and hospitalization.
Findings
The facility failed to adequately monitor the PT-INR levels for Resident #130 on anticoagulant therapy, resulting in adverse consequences including hospitalization for a supratherapeutic INR level. There was a lack of documented evidence that PT-INR tests were completed or communicated to providers between 4/3/23 and 4/30/23, despite orders and policies requiring such monitoring.
Deficiencies (1)
Failure to ensure adequate monitoring of Prothrombin Time/International Normalized Ratio for Resident #130 on anticoagulant therapy, leading to adverse consequences.
Report Facts
Prothrombin Time: 16.3
International Normalized Ratio: 1.4
International Normalized Ratio: 8.5
Warfarin dosage: 5
Date of PT-INR lab order: Apr 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant #1 | Medical Provider | Provided statements regarding lack of PT-INR monitoring and communication lapses |
| Registered Nurse #3 | Former Unit Manager | Initialed lab results on 4/7/23 and provided statements about monitoring expectations |
| Licensed Practical Nurse #6 | Documented blood in Resident #130's stool and notified provider | |
| Licensed Practical Nurse #7 | Documented Resident #130's hospital admission for coagulation disorder | |
| Registered Nurse Supervisor #1 | Former Director of Nursing | Provided statements about expectations for monitoring PT-INR and medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation focusing on treatment and care related to skin conditions, drug regimen monitoring, and compliance with safety regulations.
Complaint Details
Complaint #NY00315852 triggered the investigation into the facility's drug regimen monitoring practices, specifically regarding anticoagulant therapy.
Findings
The facility failed to provide appropriate treatment and care for residents with skin ulcers, did not adequately monitor anticoagulant therapy resulting in adverse consequences, and did not maintain carbon monoxide detectors according to state fire code requirements.
Deficiencies (3)
Lack of assessment and treatment initiation for a newly developed skin ulcer and failure to follow wound consultant recommendations for two residents.
Failure to ensure each resident's drug regimen was free from unnecessary drugs, specifically inadequate monitoring of PT-INR for a resident on anticoagulant therapy resulting in adverse consequences.
Failure to comply with the 2020 Fire Code of New York State requiring carbon monoxide detection and maintenance in all rooms and sleeping areas with fuel-burning appliances.
Report Facts
Deficiencies cited: 3
Ulcer size: 3.5
Ulcer size: 2
Ulcer size: 1
Warfarin dose: 5
Prothrombin Time: 16.3
INR level: 1.4
INR level: 8.5
Carbon monoxide alarm testing period: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Unit Manager | Named in relation to failure to initiate incident report and notify medical provider about Resident #39's ulcer |
| Licensed Practical Nurse #3 | Named in relation to Resident #39's wound treatment and documentation | |
| Nurse Practitioner #1 | Named in relation to wound care orders and communication | |
| Registered Nurse #1 | Named in relation to observation and reporting of Resident #39's skin ulcer | |
| Registered Nurse Supervisor #1 | Named in relation to wound care and treatment of Resident #5 | |
| Wound Consultant Medical Doctor #1 | Medical Doctor | Named in relation to wound care recommendations for Resident #5 |
| Physician Assistant #1 | Named in relation to anticoagulant therapy monitoring for Resident #130 | |
| Registered Nurse #3 | Former Unit Manager | Named in relation to anticoagulant therapy monitoring for Resident #130 |
| Registered Nurse Supervisor #1 | Former Director of Nursing | Named in relation to anticoagulant therapy monitoring for Resident #130 |
| Maintenance Director | Named in relation to carbon monoxide detector maintenance and testing |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jun 20, 2023
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity. Not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 2, 2022
Visit Reason
Citation for reporting of alleged violations with isolated scope and level 2 severity. Corrected as of December 22, 2022.
Findings
Citation for reporting of alleged violations with isolated scope and level 2 severity. Corrected as of December 22, 2022.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Certification Survey
Capacity: 60
Deficiencies: 6
Date: Apr 1, 2022
Visit Reason
Multiple standard health and life safety code citations including ADL care, infection control, notice requirements, posted nurse staffing info, electrical systems, and sprinkler system. Deficiencies mostly level 1 or 2 severity and corrected by May 23, 2022.
Findings
Multiple standard health and life safety code citations including ADL care, infection control, notice requirements, posted nurse staffing info, electrical systems, and sprinkler system. Deficiencies mostly level 1 or 2 severity and corrected by May 23, 2022.
Deficiencies (6)
ADL care provided for dependent residents
Infection control
Notice requirements before transfer/discharge
Posted nurse staffing information
Electrical systems - essential electric syste
Sprinkler system - maintenance and testing
Inspection Report
Routine
Deficiencies: 3
Date: Apr 1, 2022
Visit Reason
The inspection was conducted as a Standard survey from 3/28/22 to 4/1/22 to assess compliance with regulatory requirements related to resident notification of transfers/discharges, provision of activities of daily living (ADL) care, and posting of nurse staffing information.
Findings
The facility failed to notify the resident's representative and the Office of the State Long Term Care Ombudsman of a resident's hospital transfer, did not ensure adequate nail care for a cognitively impaired resident requiring total assistance, and did not post daily nurse staffing information in a location accessible to residents and visitors.
Deficiencies (3)
Failure to provide timely notification to the resident's representative and Ombudsman before transfer or discharge.
Failure to provide necessary care and assistance for activities of daily living, specifically grooming and nail care for a resident unable to perform ADLs.
Failure to post nurse staffing information daily in a location readily accessible to residents and visitors.
Report Facts
Residents reviewed for hospitalization: 1
Residents reviewed for ADLs: 2
Residents affected by ADL deficiency: 1
Dates of survey: 2022-03-28 to 2022-04-01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Unit Manager | Stated failure to notify resident's family of hospital transfer |
| Director of Nursing | Interviewed regarding notification policies and nail care expectations | |
| Social Worker | Responsible for notifications to Ombudsman, unaware of hospital transfer notification requirement | |
| Business Office Manager | Confirmed resident discharge to hospital | |
| Certified Nurse Aide #1 | CNA | Described responsibilities for nail care |
| Licensed Practical Nurse #1 | LPN | Described CNA responsibilities and refusal of care documentation |
| Registered Nurse #1 | RN | Described shower schedule and nail care expectations |
| Human Resource Director | Described location of daily staffing sheets |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 21, 2019
Visit Reason
The inspection was a Standard survey conducted to assess compliance with regulatory requirements related to resident rights and medication management.
Findings
The facility was found deficient in honoring residents' rights to self-determination, specifically regarding smoking privileges for a grandfathered resident without evidence of unsafe smoking. Additionally, deficiencies were found in the management of psychotropic medications, including failure to implement gradual dose reductions and lack of documentation supporting medication use for two residents.
Deficiencies (3)
Failure to ensure resident's right to choose activities and health care consistent with interests and plan of care, specifically revocation of smoking privileges without evidence of unsafe smoking for Resident #53.
Failure to implement gradual dose reduction of Seroquel as ordered for Resident #12.
Administration of Seroquel to Resident #37 without documentation of behaviors or specific condition to support use and no medical work-up prior to medication start.
Report Facts
Deficiencies cited: 3
Medication dosage: 25
Medication dosage: 12.5
Medication dosage: 75
Medication dosage: 50
Medication dosage: 37.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #2 | Attending Physician | Agreed to gradual dose reduction order for Resident #12 but order was not implemented |
| Director of Social Work | Provided information about smoking policy changes and corporate decisions | |
| Director of Activities | Reported corporate decision to end grandfathered smoking privileges | |
| Registered Nurse #2 | Unit Manager | Reviewed physician order and confirmed agreement to dose reduction |
| LPN #2 | Explained responsibility for entering physician orders and lack of order implementation | |
| RN #3 | Supervisor/Charge Nurse | Described process for entering new orders and lack of knowledge about signed dose reduction |
| RN #4 | Former B Wing Unit Manager | Described responsibility for entering new orders and lack of knowledge about weekend orders |
| Physician #1 | Provided clinical expectations for antipsychotic medication use | |
| Director of Nursing | Acknowledged lack of system for confirming new orders and need for improved behavioral charting |
Viewing
Loading inspection reports...
