Inspection Reports for
Highland Park Rehabilitation & Nursing Center
NY, 14895
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Inspection Report — Apr 26, 2024
Complaint Investigation State
Date: Apr 26, 2024
Visit Reason
State-compiled facility profile showing 11 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 46 complaints about this facility; 7 led to on-site inspections. Two citations resulted from those complaints.
Findings
Across 11 inspections, 9 resulted in citations totaling 19, including standard health and Life Safety Code violations. The facility had 46 complaints with 7 on-site inspections and one enforcement action recorded.
Citations (9)
Standard Health Citation — quality of care: Drug Regimen Is Free From Unnecessary Drugs was cited with minor potential harm.
Standard Health Citation — quality of care: License/comply W/ Fed/state/locl Law/prof Std was cited with potential for minimal harm.
Standard Health Citation — quality of care: Quality Of Care was cited with minor potential harm.
Life Safety Code Citation — NFPA requirements: Cooking Facilities was cited with minor potential harm.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste was cited with minor potential harm.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance was cited with minor potential harm.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress was cited with minor potential harm.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was cited with minor potential harm and widespread scope in multiple COVID19 surveys.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was cited with minor potential harm.
Report Facts
Inspections on page: 11
Total violations/deficiencies cited: 19
Inspections with violations: 9
Inspections without violations: 2
Total complaints: 46
On-site complaint inspections: 7
Enforcement actions: 1
Total fines: 2000
Citations from complaints: 2
Inspection Report — Apr 1, 2022
Routine CMS
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.
Citations (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 — Jun 21, 2019
Routine CMS
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.
Citations (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 |
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