Inspection Reports for
Hopkins Center For Rehabilitation And Healthcare
NY, 11217
Back to Facility ProfileInspection Report — Apr 12, 2024
Annual Inspection
Citations: 2
Date: Apr 12, 2024
Visit Reason
The inspection was conducted as a Recertification Survey from 04/07/2024 through 04/12/2024 to assess compliance with regulatory requirements including staffing data submission and infection control practices.
Findings
The facility failed to timely submit required direct care staffing data for the quarter 10/01/2023 - 12/31/2023, and did not ensure proper infection control practices during dining, specifically a Certified Nursing Assistant did not perform hand hygiene between assisting multiple residents.
Citations (2)
Failure to electronically submit complete and accurate direct care staffing information based on payroll data timely for the quarter 10/01/2023 - 12/31/2023.
Failure to ensure infection control practices were followed; specifically, a Certified Nursing Assistant did not perform hand hygiene between residents during dining assistance.
Report Facts
Fiscal quarter: 1
Date of failed submission: Feb 15, 2024
Observation time: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Observed not performing hand hygiene between residents during dining assistance |
| Assistant Director of Nursing #1 | Assistant Director of Nursing / Infection Preventionist | Interviewed regarding infection control practices and hand hygiene requirements |
| Administrator | Responsible for submitting staffing data; acknowledged late submission |
Inspection Report — Apr 12, 2024
Complaint Investigation
Citations: 9
Date: Apr 12, 2024
Visit Reason
State-compiled facility profile showing 7 inspections from 2022 to 2024 with citation and complaint history.
Complaint Details
The state logged 137 complaints about this facility; 4 led to on-site inspections. No citations resulted from those complaints.
Findings
Across 7 inspections, 5 resulted in citations totaling 9 deficiencies, including standard health and life safety code violations. The facility had 137 complaints with 4 on-site inspections but no formal enforcement actions.
Citations (9)
Infection Prevention & Control: Standard Health Citation for quality of care related to infection prevention and control issues.
Payroll Based Journal: Standard Health Citation for quality of care related to payroll based journal reporting.
Discharge From Exits: Life Safety Code Citation for NFPA requirements regarding discharge from exits.
Hazardous Areas - Enclosure: Life Safety Code Citation for NFPA requirements related to hazardous area enclosures.
Stairways And Smokeproof Enclosures: Life Safety Code Citation for NFPA requirements concerning stairways and smokeproof enclosures.
Reporting - National Health Safety Network: Standard Health Citation for quality of care related to reporting deficiencies noted in multiple COVID19 surveys.
Reporting - National Health Safety Network: Standard Health Citation for quality of care related to reporting deficiencies noted in multiple COVID19 surveys.
Reporting - National Health Safety Network: Standard Health Citation for quality of care related to reporting deficiencies noted in multiple COVID19 surveys.
Reporting - National Health Safety Network: Standard Health Citation for quality of care related to reporting deficiencies noted in multiple COVID19 surveys.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 9
Inspections with violations: 5
Inspections without violations: 2
Total complaints: 137
On-site complaint inspections: 4
Enforcement actions: 0
Inspection Report — Mar 15, 2022
Annual Inspection
Citations: 6
Date: Mar 15, 2022
Visit Reason
The inspection was conducted as part of the recertification and abbreviated survey to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate assistance with activities of daily living, improper application of therapeutic devices, inadequate supervision to prevent accidents related to smoking materials, unsafe food handling and storage practices, expired emergency water supplies, and incomplete and inaccurate medical record documentation.
Citations (6)
Failure to provide assistance with toileting and personal hygiene for Resident #44 as per care plan.
Resident #144 with left-hand contracture was not provided with splint device/rolled gauze as ordered.
Multiple residents (including #62, #65, #80, #119, #203) were found with smoking materials in their possession contrary to facility policy, posing accident hazards.
Expired food items (bologna and sandwiches) found in kitchen refrigerator beyond safe use date.
Emergency water supply included 5-gallon bottles expired as early as 2016, stored in an area also used for expired residents.
Certified Nursing Assistants documented application of rolled gauze to Resident #144's left hand when it was not provided.
Report Facts
Residents reviewed for ADL assistance: 38
Residents reviewed for accident hazards: 38
Expired 5-gallon water bottles: 51
Expired 5-gallon water bottles observed: 52
Smoking materials observed in Resident #119's room: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed regarding lack of awareness of rolled gauze application for Resident #144 |
| CNA #5 | Certified Nursing Assistant | Interviewed about smoking observations for Residents #62 and #119 |
| CNA #8 | Certified Nursing Assistant | Interviewed about Resident #44 toileting assistance |
| CNA #9 | Certified Nursing Assistant | Interviewed about Resident #44 toileting assistance and refusal |
| RN Manager #7 | Registered Nurse Manager | Interviewed about supervision of CNAs and resident care |
| CNA #4 | Certified Nursing Assistant | Interviewed about Resident #65 smoking habits |
| LPN #5 | Licensed Practical Nurse | Interviewed about Resident #65 smoking materials |
| RN #4 | Registered Nurse | Interviewed about smoking policy and resident supervision |
| DSW | Director of Social Work | Interviewed about smoking agreements and resident supervision |
| SW #1 | Social Worker | Interviewed about smoking assessments and resident compliance |
| SG | Security Guard | Interviewed about smoking material control and resident supervision |
| AFSD | Acting Food Service Director | Interviewed about expired food and food safety practices |
| DOM | Director of Maintenance | Interviewed about emergency water storage and expired bottles |
| Administrator | Facility Administrator | Interviewed about smoking policy enforcement and emergency water concerns |
| Infection Preventionist | Infection Preventionist | Interviewed about food storage and emergency water safety |
| RNS #1 | Registered Nurse Supervisor | Interviewed about resident #144 care and supervision |
| DON | Director of Nursing | Interviewed about resident splint device supervision and smoking policy |
Inspection Report — Aug 1, 2019
Annual Inspection
Citations: 7
Date: Aug 1, 2019
Visit Reason
The inspection was a recertification survey conducted to assess compliance with federal regulations for nursing homes, including resident rights, care planning, infection control, environmental conditions, and pest control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding Foley catheter privacy, inadequate resident notification of complaint rights, improper posting of survey results, unsanitary conditions with persistent urine odor and pest infestation, incomplete person-centered care planning for dementia, and lapses in infection control practices such as oxygen tubing touching the floor and improper use of personal protective equipment.
Citations (7)
Resident's Foley catheter bag and tubing were left uncovered and exposed to public view, violating dignity rights.
Residents were not informed orally and in writing about their right to file a complaint with the state survey agency and provided with contact information.
Survey results were not posted in a place readily accessible to residents and representatives without having to ask for them.
Facility did not ensure necessary housekeeping services to maintain a clean, sanitary, and comfortable interior; strong urine odor and presence of flies noted in resident room and common areas.
Care plan for a resident with dementia lacked individualized, person-centered interventions with measurable goals and time frames.
Infection control practices were not maintained: oxygen tubing touching the floor, CNA entering contact precaution room without PPE, and RN not performing hand hygiene before connecting enteral feeding.
Facility did not maintain an effective pest control program; numerous flies observed in a resident's room despite weekly extermination visits.
Report Facts
Residents reviewed: 38
Residents observed for environmental conditions: 8
Residents affected by dignity deficiency: 1
Residents affected by complaint notification deficiency: 11
Residents affected by survey posting deficiency: 11
Residents affected by environmental odor and pest deficiency: 1
Residents affected by care plan deficiency: 1
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed about Foley catheter care and oxygen tubing |
| RN #1 | Registered Nurse | Interviewed about Foley catheter care and oxygen tubing supervision |
| Director of Nursing Services | Director of Nursing | Interviewed about facility policy on Foley catheter privacy |
| Medicaid Coordinator | Interviewed about resident complaint information in admission packets | |
| Administrator | Facility Administrator | Interviewed about complaint rights notification and survey results posting |
| CNA #5 | Certified Nursing Assistant | Interviewed about environmental odor and pest control in resident room |
| Housekeeper Staff #5 | Housekeeper | Interviewed about cleaning routines and pest control |
| Director of Facilities Management | Director of Facilities Management | Interviewed about cleaning and pest control procedures |
| CNA #4 | Certified Nursing Assistant | Interviewed about resident behavior and care for dementia resident |
| CNA #5 | Certified Nursing Assistant | Interviewed about dementia resident care and behavior |
| RN #3 | Registered Nurse | Interviewed about dementia resident care and use of dolls for engagement |
| RN #2 | Registered Nurse | Observed and interviewed about enteral feeding and hand hygiene |
| CNA #3 | Certified Nursing Assistant | Observed and interviewed about failure to wear PPE in contact precaution room |
| Infection Control Nurse | Interviewed about oxygen tubing infection control practices | |
| Housekeeper Staff #8 | Housekeeper | Observed performing room sanitization |
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