Inspection Reports for Hudson Hill Center for Rehabilitation and Nursing
65 Ashburton Avenue, Yonkers, NY, 10701
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
22.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
345% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Nov 26, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with care planning, supervision, infection control, and safety protocols, particularly focusing on residents at risk for elopement and respiratory infections.
Findings
The facility failed to timely develop and revise comprehensive care plans addressing elopement risks, did not ensure adequate supervision for residents at risk of elopement, delayed medical treatment and implementation of droplet precautions for a resident with Influenza A, and had deficiencies in the wander guard alarm system and staff adherence to supervision policies.
Deficiencies (5)
Failure to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions.
Failure to develop the complete care plan within 7 days of the comprehensive assessment and revise it to include measurable interventions for elopement risk.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including delayed initiation of Tamiflu and droplet precautions for Influenza A positive resident.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, including residents eloping while on one-to-one supervision and wander guard system failures.
Failure to provide and implement an infection prevention and control program, including delayed droplet precautions for a resident with Influenza A.
Report Facts
Residents reviewed for accidents: 3
Residents reviewed for respiratory infections: 3
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
One-to-one supervision monitoring period: 3
Tamiflu dosage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Named in care plan revision and supervision findings | |
| Registered Nurse #2 | Named in wander guard monitoring documentation findings | |
| Director of Nursing | Named in multiple interviews regarding care plan revisions, supervision failures, and infection control | |
| Medical Director | Named in interviews regarding delayed notification and treatment for Influenza A | |
| Registered Nurse Unit Manager #4 | Named in interviews regarding respiratory testing and infection control | |
| Patient Care Assistant #1 | Named in supervision failure leading to resident elopement | |
| Certified Nurse Aide #2 | Named in reporting missing resident and supervision | |
| Certified Nurse Aide #3 | Named in supervision failure during resident elopement | |
| Front Desk Personnel #1 | Named in wander guard system and alarm findings | |
| Administrator | Named in interviews regarding facility alarm system and security upgrades |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 4, 2025
Visit Reason
The visit was an abbreviated survey conducted to evaluate the facility's compliance with safety regulations following a fall incident involving Resident #1.
Findings
The facility failed to ensure a resident's environment was free from accident hazards, resulting in Resident #1 falling out of bed and sustaining a laceration to the left eyebrow. The fall occurred when a Certified Nurse Aide turned away to retrieve a mechanical lift pad, despite fall precautions being in place.
Deficiencies (1)
Failed to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Staff suspension duration: 3
Laceration size: 2.5
Resident assistance requirement: 2
Resident count reviewed for accidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in the fall incident and subsequent suspension related to Resident #1's accident. | |
| Registered Nurse Unit Manager/Supervisor #5 | Documented investigative summary and assessed Resident #1 after the fall. | |
| Certified Nurse Aide #2 | Assisted in placing Resident #1 back to bed via mechanical lift. | |
| Certified Nurse Aide #4 | Assisted in placing Resident #1 back to bed via mechanical lift. | |
| Registered Nurse #6 | Assisted Resident #1 after the fall. | |
| Physician #1 | Documented medical visit and emergency room evaluation of Resident #1 post-fall. | |
| Director of Nursing | Provided information about suspension of Certified Nurse Aide #1 and resident's condition post-fall. | |
| Assistant Director of Nursing #2 | Interviewed regarding reenactment of the fall incident. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Feb 25, 2025
Visit Reason
Complaint Survey with 5 Standard Health citations and no Life Safety Code citations. Deficiencies included administration, facility assessment, accident hazards, investigation, and QAPI program. All corrected by May 2025.
Findings
Complaint Survey with 5 Standard Health citations and no Life Safety Code citations. Deficiencies included administration, facility assessment, accident hazards, investigation, and QAPI program. All corrected by May 2025.
Deficiencies (5)
Administration — administrative issues
Facility assessment — quality of care
Free of accident hazards/supervision/devices — safety and supervision
Investigate/prevent/correct alleged violation — quality of care
Qapi prgm/plan, disclosure/good faith attmpt — quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Feb 25, 2025
Visit Reason
The abbreviated survey was conducted to investigate alleged violations related to resident safety and supervision, specifically concerning an incident where Resident #1 sustained burns from hot water obtained from a hot liquid cart on the unit.
Complaint Details
The visit was complaint-related, triggered by allegations concerning Resident #1's injury from hot water on 1/5/2025. The complaint was substantiated as the facility failed to prevent the incident and adequately investigate it.
Findings
The facility failed to ensure adequate supervision and safety measures to prevent Resident #1 from accessing hot water, resulting in second- and third-degree burns. The investigation and documentation of the incident were incomplete, and the facility lacked consistent monitoring of the hot liquid cart. The resident required hospitalization and skin graft surgery. The facility also failed to implement effective Quality Assurance and Performance Improvement plans following the incident and did not include patient care assistants in the facility-wide assessment.
Deficiencies (5)
Failure to respond appropriately to all alleged violations related to Resident #1's burn incident from hot water on 1/5/2025.
Failure to ensure the resident environment is free from accident hazards and provide adequate supervision to prevent accidents, resulting in immediate jeopardy due to Resident #1's burns.
Failure to administer the facility in a manner that enables effective and efficient use of resources, including lack of policy changes or action plans following the burn incident.
Failure to conduct and document a facility-wide assessment including all personnel such as patient care assistants and their training and competencies.
Failure to have a plan describing the process for conducting Quality Assurance and Performance Improvement (QAPI) activities, including lack of documented action plans to correct deficiencies related to the burn incident.
Report Facts
Date of incident: Jan 5, 2025
Date of survey completion: Feb 25, 2025
Burn wound measurements: 9
Burn wound measurements: 18
Burn wound measurements: 5
Burn wound measurements: 6
Burn wound measurements: 9
Burn wound measurements: 18
Temperature of hot liquids: 119
Temperature of hot liquids: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Witness to Resident #1's burn incident and reported observations to nursing staff. | |
| Registered Nurse #2 | Assessed Resident #1 after the incident and communicated with the attending physician. | |
| Licensed Practical Nurse #1 | Reported the incident and was the medication nurse for Resident #1 at the time. | |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Conducted investigation and fact-checked the incident involving Resident #1. |
| Director of Nursing | Director of Nursing | Oversaw incident investigations and Quality Assurance and Performance Improvement plans. |
| Administrator | Administrator | Informed about the incident and responsible for facility policy and Quality Assurance oversight. |
| Attending Physician | Physician | Provided medical care and follow-up for Resident #1's burns. |
| Director of Dietary Services | Director of Dietary Services | Responsible for hot liquid temperature monitoring and delivery. |
| Staffing Coordinator | Staffing Coordinator | Provided information about patient care assistants and their training. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 33
Date: Dec 18, 2024
Visit Reason
Complaint Survey with 18 Standard Health and 16 Life Safety Code citations. Numerous deficiencies related to accounting, assessments, ADLs, admissions, abuse prevention, drug labeling, pest control, resident rights, respiratory care, treatment of pressure ulcers, and multiple life safety code issues including cooking facilities, corridor doors, electrical equipment, fire alarm, sprinklers, and hazardous areas. Most corrected by early 2025.
Findings
Complaint Survey with 18 Standard Health and 16 Life Safety Code citations. Numerous deficiencies related to accounting, assessments, ADLs, admissions, abuse prevention, drug labeling, pest control, resident rights, respiratory care, treatment of pressure ulcers, and multiple life safety code issues including cooking facilities, corridor doors, electrical equipment, fire alarm, sprinklers, and hazardous areas. Most corrected by early 2025.
Deficiencies (33)
Accounting and records of personal funds — quality of care
Accuracy of assessments — quality of care
Activities daily living (adls)/mntn abilities — quality of care
Admissions policy — quality of care
Entering into binding arbitration agreements — quality of care
Free from misappropriation/exploitation — quality of care
Free of accident hazards/supervision/devices — quality of care
Label/store drugs and biologicals — quality of care
Maintains effective pest control program — quality of care
Notice requirements before transfer/discharge — quality of care
Personal privacy/confidentiality of records — quality of care
Physician visits - review care/notes/order — quality of care
Reporting of alleged violations — quality of care
Required in-service training for nurse aides — quality of care
Resident rights/exercise of rights — resident rights
Respiratory/tracheostomy care and suctioning — quality of care
Treatment/srvcs mental/psychoscial concerns — quality of care
Treatment/svcs to prevent/heal pressure ulcer — quality of care
Cooking facilities — life safety
Corridor - doors — life safety
Develop ep plan, review and update annually — life safety
Electrical equipment - power cords and extens — life safety
Emergency lighting — life safety
Ep training program — life safety
Fire alarm system - testing and maintenance — life safety
Fire drills — life safety
Hazardous areas - enclosure — life safety
Plan based on all hazards risk assessment — life safety
Portable space heaters — life safety
Smoking regulations — life safety
Sprinkler system - maintenance and testing — life safety
Sprinkler system - out of service — life safety
Stairways and smokeproof enclosures — life safety
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Dec 18, 2024
Visit Reason
The inspection was a recertification survey conducted from 12/11/2024 to 12/18/2024 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including mismanagement of resident funds, failure to ensure resident privacy and confidentiality, inadequate notification of resident discharge, inaccurate resident assessments, insufficient respiratory care, inadequate pressure ulcer prevention and care, lack of proper pest control, incomplete staff training, and failure to ensure residents' rights regarding binding arbitration agreements.
Deficiencies (15)
Facility did not ensure resident's right to manage personal funds; tax refund checks were deposited into facility account without resident's consent.
Facility staff opened residents' mail without consent, violating residents' right to privacy.
Facility did not ensure a resident's right to be free from misappropriation of property; tax refund checks were taken and deposited without resident's knowledge.
Facility failed to timely report a resident-to-resident altercation involving injury to the State Survey Agency.
Facility did not ensure admission policies protected residents from waiving rights or incurring personal financial liability; admission agreements included binding arbitration without explicit consent.
Facility failed to notify resident representative in writing of facility-initiated discharge.
Minimum Data Set assessments were inaccurate, including misreporting pressure ulcers, smoking status, and discharge destination.
Facility did not provide necessary care to ensure resident's ability to communicate needs; Spanish-speaking resident lacked interpreter services and staff were not trained on translation devices.
Facility failed to provide appropriate pressure ulcer care and prevention; lack of documented turning, repositioning, and use of heel booties contributed to avoidable wounds.
Facility did not ensure residents received necessary respiratory care; tracheostomy self-suctioning without order, incorrect oxygen flow rates, and lack of tubing changes were observed.
Physician did not review and address resident's total plan of care at each visit, missing dysphagia diagnosis and diet recommendations.
Facility did not ensure all drugs and biologicals were labeled and stored properly; expired insulin pen and controlled medication improperly stored.
Facility did not ensure residents and representatives were informed of their right to refuse binding arbitration agreements.
Facility did not maintain an effective pest control program; roach infestations were observed on multiple floors with inadequate documentation and follow-up.
Facility failed to provide required dementia management and abuse prevention training to Certified Nurse Aides.
Report Facts
Tax refund check amount: 1825.02
Tax refund check amount: 1957.42
Resident weight: 181
Braden Scale score: 17
Oxygen flow rate: 7
Oxygen flow rate: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #162 | Named in findings related to misappropriation of funds and unauthorized mail opening | |
| Business Office Manager | Named in findings related to mismanagement of Resident #162's funds and mail | |
| Administrator | Interviewed regarding multiple deficiencies including mail handling, admission agreements, and pest control | |
| Director of Nursing | Interviewed regarding reporting delays, care deficiencies, and staff training | |
| Social Worker #1 | Interviewed regarding discharge notification for Resident #255 | |
| Certified Nurse Aide #18 | Reported roach sightings and pest control issues on 4th Floor | |
| Certified Nurse Aide #31 | Reported roach sightings on 2nd Floor | |
| Housekeeper #32 | Reported roach sightings and pest control challenges | |
| Medical Doctor #1 | Attending Physician | Interviewed regarding Resident #271's care and death |
| Registered Nurse #6 | Reported Resident #168 self-suctioning tracheostomy | |
| Registered Nurse Unit Manager #6 | Interviewed regarding medication storage and oxygen flow rates | |
| Registered Nurse #21 | Reported controlled medication storage practices | |
| Nurse Educator | Interviewed regarding staff training deficiencies | |
| Speech Therapist | Interviewed regarding diet orders and resident assessments | |
| Dietary Technician | Interviewed regarding diet preferences and communication | |
| Certified Nurse Aide #4 | Reported lack of Spanish language proficiency and translation device training | |
| Director of Housekeeping | Interviewed regarding pest control program and exterminator activities | |
| Consultant Psychologist | Interviewed regarding psychology consults for Resident #220 |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Dec 18, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys from 12/11/2024 to 12/18/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, timely reporting of abuse, discharge notification, accuracy of Minimum Data Set assessments, communication services for non-English speakers, pressure ulcer prevention and care, respiratory care, accident prevention, physician oversight, and pest control. Specific issues included failure to change soiled linens timely, delayed abuse reporting, inadequate discharge notice to representatives, inaccurate resident assessments, lack of Spanish translation services, inadequate pressure ulcer prevention, improper oxygen administration, incomplete physician review of care, and persistent roach infestations.
Deficiencies (10)
Fitted mattress sheet on Resident #90's bed was stained and not changed for six days, violating resident dignity rights.
Failure to report a resident-to-resident altercation involving abuse within 2 hours to the State Survey Agency.
Resident #255's representative was not notified in writing of the facility-initiated discharge as required.
Minimum Data Set assessments were inaccurate for several residents, including incorrect documentation of pressure ulcers, smoking status, and discharge destination.
Resident #275, a Spanish speaker, was not provided with interpreter services as indicated in the care plan, and staff were not trained on translation device use.
Residents at risk for pressure ulcers did not receive necessary preventive care such as turning, repositioning, heel booties, or properly adjusted air mattresses.
Resident #271 with dysphagia was not provided a downgraded diet as recommended, and choking risk was not adequately managed or investigated after an incident.
Resident #168 self-suctioned tracheostomy without physician order or documented evaluation; Resident #194 received incorrect oxygen flow rates; Resident #69's oxygen tubing was not changed or dated as required.
Physician did not review or document resident #271's total plan of care including dysphagia and diet difficulties at each required visit.
Facility failed to maintain an effective pest control program; roach infestations were observed on multiple floors with inadequate documentation and follow-up.
Report Facts
Deficiencies cited: 10
Resident #90 mattress sheet not changed days: 6
Resident #42 to #273 altercation reporting delay hours: 3.5
Resident #115 weight pounds: 181
Resident #115 air mattress dial pounds: 350
Resident #276 Braden Scale score: 17
Resident #115 Braden Scale score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #29 | Interviewed regarding linen shortage and sheet changes for Resident #90 | |
| Registered Nurse #28 | Interviewed regarding awareness of soiled sheets on Resident #90 | |
| Director of Housekeeping | Interviewed regarding laundry services and linen delivery | |
| Director of Nursing | Interviewed regarding abuse reporting delay and discharge notification issues | |
| Social Worker #1 | Interviewed regarding discharge notice issuance and communication with resident representative | |
| Minimum Data Set Director | Interviewed regarding accuracy of Minimum Data Set assessments | |
| Certified Nurse Aide #2 | Interviewed regarding Spanish speaking resident care and translation device use | |
| Certified Nurse Aide #4 | Interviewed regarding Spanish speaking resident care and translation device use | |
| Registered Nurse Supervisor #1 | Interviewed regarding pressure ulcer prevention documentation and care | |
| Wound Nurse | Interviewed regarding pressure ulcer development and prevention | |
| Wound Care Physician | Interviewed regarding preventability of Resident #276's wounds | |
| Certified Nursing Assistant #11 | Interviewed regarding air mattress maintenance and resident weight | |
| Registered Nurse #7 | Interviewed regarding air mattress checks and oxygen therapy | |
| Certified Nurse Aide #18 | Interviewed regarding roach sightings and pest control reporting | |
| Certified Nurse Aide #31 | Interviewed regarding roach infestation on 2nd Floor | |
| Housekeeper #32 | Interviewed regarding roach infestation and pest control | |
| Registered Nurse #30 | 2nd Floor Nurse Manager | Interviewed regarding roach sightings and pest control documentation |
| Medical Doctor #1 | Interviewed regarding Resident #271's death and care oversight | |
| Medical Director | Interviewed regarding physician oversight of Resident #271's care | |
| Speech Therapist | Interviewed regarding diet orders and speech therapy services for Resident #271 | |
| Registered Nurse #36 | Interviewed regarding Resident #271's condition and meal supervision | |
| Certified Nursing Assistant #34 | Interviewed regarding Resident #271 found unresponsive and aspiration precautions | |
| Dietary Technician | Interviewed regarding Resident #271's diet preferences and communication with staff | |
| Registered Nurse #6 | Interviewed regarding observation of Resident #168 self-suctioning tracheostomy | |
| Registered Nurse Unit Manager #6 | Interviewed regarding oxygen flow rate for Resident #194 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Dec 9, 2024
Visit Reason
Complaint Survey with 5 Standard Health citations and no Life Safety Code citations. Deficiencies included definitions, abuse and neglect prevention, misappropriation, investigation, and quality of care. Most corrected by February 2025.
Findings
Complaint Survey with 5 Standard Health citations and no Life Safety Code citations. Deficiencies included definitions, abuse and neglect prevention, misappropriation, investigation, and quality of care. Most corrected by February 2025.
Deficiencies (5)
Definitions — quality of care
Free from abuse and neglect — resident rights
Free from misappropriation/exploitation — quality of care
Investigate/prevent/correct alleged violation — quality of care
Quality of care — quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Dec 9, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse, neglect, misappropriation of property, and to assess quality of care related to specific residents.
Complaint Details
The visit was complaint-related, triggered by allegations that a dialysis transportation worker misappropriated money from residents. The facility reported the incident to law enforcement but did not substantiate or unsubstantiated the allegation. There was no documented evidence of interviews with other residents or statements from the accused worker.
Findings
The facility failed to protect residents from abuse and misappropriation of property by a dialysis transportation worker who allegedly stole money from residents. Additionally, the facility did not ensure timely gynecological care for a resident with vaginal bleeding and delayed initiation of intravenous antibiotics for another resident.
Deficiencies (4)
Facility did not ensure residents were free from abuse, neglect, misappropriation of property, and exploitation related to a dialysis transportation worker withdrawing $5,900 from a resident's cash app account.
Facility failed to respond appropriately to alleged violations by not interviewing other residents transported by the dialysis transportation worker and not initiating an abuse care plan.
Facility did not provide timely gynecological care for a resident with vaginal bleeding and multiple fibroids, resulting in delayed hospital transfer and cancelled appointments due to transfer status.
Facility failed to initiate intravenous antibiotic treatment timely for a resident admitted with infection, despite family notification.
Report Facts
Amount stolen: 5900
Gynecology appointment scheduled: 1
Hemoglobin levels: 9.6
Hemoglobin levels: 11.5
Antibiotic dose: 1.5
Antibiotic administration date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated transportation worker did not work for the facility but for dialysis center; described actions taken after abuse allegations |
| Administrator | Administrator | Described staff in-service and changes to dialysis transportation procedures following abuse allegations |
| Registered Nurse #1 | Registered Nurse | Reported family notification about missed antibiotic and communication with physician |
| Primary Physician | Primary Physician | Discussed medication reconciliation and missed antibiotic order |
| Attending Physician | Attending Physician | Discussed Resident #1's gynecological care and hospital transfer considerations |
| Nurse Practitioner | Nurse Practitioner | Discussed gynecological appointments and clinical decisions regarding emergency department referral |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 24
Date: Sep 8, 2023
Visit Reason
Complaint Survey with 12 Standard Health and 13 Life Safety Code citations. Deficiencies included accuracy of assessments, PASARR coordination, abuse policies, garbage disposal, food sanitation, infection control, resident rights, nurse staffing, fire safety, electrical systems, and building maintenance. Most corrected by November 2023.
Findings
Complaint Survey with 12 Standard Health and 13 Life Safety Code citations. Deficiencies included accuracy of assessments, PASARR coordination, abuse policies, garbage disposal, food sanitation, infection control, resident rights, nurse staffing, fire safety, electrical systems, and building maintenance. Most corrected by November 2023.
Deficiencies (24)
Accuracy of assessments — quality of care
Coordination of pasarr and assessments — quality of care
Develop/implement abuse/neglect policies — quality of care
Dispose garbage and refuse properly — quality of care
Food procurement,store/prepare/serve-sanitary — quality of care
Free from abuse and neglect — resident rights
Increase/prevent decrease in rom/mobility — quality of care
Infection prevention & control — quality of care
Notice of bed hold policy before/upon trnsfr — quality of care
Posted nurse staffing information — quality of care
Resident rights/exercise of rights — resident rights
Development of ep policies and procedures — life safety
Discharge from exits — life safety
Electrical equipment - power cords and extens — life safety
Electrical systems - essential electric syste — life safety
Ep testing requirements — life safety
Fire alarm system - testing and maintenance — life safety
Fundamentals - building system categories — life safety
Gas equipment - cylinder and container storag — life safety
Hazardous areas - enclosure — life safety
Illumination of means of egress — life safety
Interior wall and ceiling finish — life safety
Maintenance, inspection & testing - doors — life safety
Sprinkler system - installation — life safety
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Sep 8, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 8/30/2023 to 9/8/2023 to assess compliance with regulatory requirements for Hudson Hill Center for Rehabilitation & Nursing.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified care during feeding, failure to protect residents from abuse, inadequate employee supervision pending criminal background checks, failure to notify residents and representatives of transfers and bed hold policies, inaccurate resident assessments, failure to coordinate PASARR assessments, inadequate care for residents with limited mobility, failure to post nurse staffing information daily, improper food safety practices, unsanitary trash compactor area, and deficiencies in infection prevention and control practices.
Deficiencies (12)
Residents were fed by staff while staff were standing over them, violating residents' right to a dignified existence.
Facility failed to protect residents from resident-to-resident abuse and did not implement interventions to prevent recurrence of altercations involving Resident #68.
An employee hired on a contingent basis worked without documented supervision pending criminal history record check completion.
Facility failed to provide timely written notification to residents, representatives, and Ombudsman of transfers/discharges to hospital for 6 residents.
Facility failed to notify residents or representatives in writing of the facility's bed hold policy for 6 residents.
Minimum Data Set assessments were inaccurate for 2 residents; weight loss not documented for Resident #67 and intermittent catheterization not documented for Resident #200.
Facility failed to coordinate PASARR Level II assessment for Resident #68; referral sent but no follow-up or completion documented.
Residents #67 and #174 did not receive appropriate care to maintain or improve range of motion and mobility; prescribed hand splints and knee braces were not applied as ordered.
Facility did not post accurate nurse staffing information daily from 8/17/2023 to 8/30/2023 as required.
Food contact surfaces were not maintained in a sanitary condition; sanitizer solution in three bay sink was below required concentration; multiple cold foods were held above safe temperatures.
Trash compactor area was unsanitary with litter, pests, and pooling liquid with foul odor; no cleaning logs or schedules documented.
Facility failed to maintain an effective infection prevention and control program; Foley catheter drainage bags were observed on the floor or on uncovered mattress; Water Management Plan was outdated; dirty linen cart was touching clean linen carts.
Report Facts
Sanitizer concentration: 0
Cold food temperature: 50
Cold food temperature: 50
Cold food temperature: 60
Weight loss: 10
Dates without nurse staffing posted: 14
Employee unsupervised days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Observed feeding residents while standing; aware of dignity feeding policy |
| LPN #2 | Licensed Practical Nurse | Observed feeding residents while standing; aware of dignity feeding policy |
| RN #5 | Registered Nurse | Observed feeding resident while standing; unaware of dignity feeding policy |
| Director of Nursing | Director of Nursing | Stated staff should be seated while feeding residents; discussed supervision of Resident #68 |
| CNA #1 | Certified Nurse Aide | Worked without supervision pending CHRC; fearful of Resident #68; refused 1:1 supervision |
| RN #3 | Registered Nurse | Provided information on Resident #68 behavior and supervision |
| Social Worker | Social Worker | Discussed Resident #68 behavior and PASARR referral |
| MD #1 | Medical Doctor | Discussed Resident #68 aggression and hospitalizations |
| NP #1 | Nurse Practitioner | Discussed Resident #68 medications and supervision recommendations |
| Administrator | Administrator | Acknowledged failure to notify residents and representatives of transfers and bed hold policy |
| RN #1 | Registered Nurse | Acknowledged failure to provide notices of transfer and bed hold policy |
| MDS Nurse | MDS Nurse | Acknowledged nutritional status section of MDS completed by dietitian |
| Registered Dietitian | Registered Dietitian | Acknowledged error in documenting resident weight on MDS |
| RN #7 | Registered Nurse | Acknowledged resident self-catheterization not coded in MDS |
| MD #2 | Medical Doctor | Confirmed resident self-catheterization and order |
| Director of Rehabilitation | Director of Rehabilitation | Stated Resident #174 should wear bilateral knee braces at all times |
| RN #6 | Registered Nurse | Aware of Resident #174 adaptive equipment and care plan |
| CNA #5 | Certified Nurse Aide | Aware of Resident #174 plan of care and adaptive equipment |
| Dietary Aide #1 | Dietary Aide | Observed improper food contact surface use |
| Pot Washer | Pot Washer | Observed sanitizer concentration test strips showing no sanitizer |
| Dietary Supervisor | Dietary Supervisor | Unaware of sanitizer concentration issue |
| Housekeeping Employee | Housekeeping Employee | Reported trash compactor liquid and cleaning schedule |
| Dietary Director | Dietary Director | Acknowledged no cleaning documentation for trash compactor area |
| LPN #2 | Licensed Practical Nurse | Observed urinary drainage bags on floor and mattress |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Stated drainage bags should not be on floor or mattress |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
The inspection was conducted as a recertification survey and abbreviated surveys to assess compliance with regulations regarding resident safety and protection from abuse.
Findings
The facility failed to protect residents from resident-to-resident abuse involving Resident #68, who had multiple physical altercations with other residents between 11/8/22 and 7/14/23. Despite documented incidents and hospitalizations, the facility did not update care plans or implement adequate supervision and monitoring to prevent recurrence.
Deficiencies (1)
Failure to protect residents from resident-to-resident abuse and psychological harm, with inadequate interventions and supervision following multiple altercations involving Resident #68.
Report Facts
Residents affected: 4
Incident dates: 4
Medication dosage: 10
Medication dosage: 500
Acetaminophen dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding Resident #68's behavior, supervision, and medication adjustments |
| SW | Social Worker | Interviewed about incidents involving Resident #68 and Resident #80, and facility interventions |
| MD #1 | Medical Doctor | Interviewed about Resident #68's aggression, hospitalizations, and medication management |
| NP #1 | Nurse Practitioner | Interviewed about Resident #68's medications and recommended supervision |
| DON | Director of Nursing | Interviewed about facility's efforts to manage Resident #68's aggression and supervision failures |
| CNA #1 | Certified Nurse Aide | Interviewed about Resident #68's behavior, elevator use, and refusal to provide one-on-one supervision |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Jun 12, 2023
Visit Reason
Complaint Survey with 3 Standard Health citations and no Life Safety Code citations. Deficiencies included discharge planning, investigation, and reporting of alleged violations. All corrected by August 2023.
Findings
Complaint Survey with 3 Standard Health citations and no Life Safety Code citations. Deficiencies included discharge planning, investigation, and reporting of alleged violations. All corrected by August 2023.
Deficiencies (3)
Discharge planning process — quality of care
Investigate/prevent/correct alleged violation — quality of care
Reporting of alleged violations — quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jun 12, 2023
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse and mistreatment, as well as to review discharge planning and ensure compliance with regulatory requirements.
Complaint Details
The visit was complaint-related, triggered by an allegation from Resident #1 that a staff member hit them in the stomach on 05/12/2023. The facility did not report the incident to the NYSDOH within the required 2 hours and did not conduct a thorough investigation. The allegation was dismissed based on staff denials and the resident's history of accusatory behavior.
Findings
The facility failed to timely report an alleged abuse incident to the New York State Department of Health within 2 hours, did not thoroughly investigate the abuse allegation, and failed to develop a discharge plan addressing all post-discharge care needs, specifically dialysis care for a resident with End Stage Renal Disease.
Deficiencies (3)
Failure to timely report suspected abuse to the state within 2 hours of occurrence.
Failure to thoroughly investigate an incident of physical abuse to rule out abuse, neglect, or mistreatment.
Failure to develop a discharge plan that addressed all post discharge care needs, specifically dialysis care for a resident with ESRD.
Report Facts
Residents reviewed for abuse and mistreatment: 3
Residents affected: 1
Dialysis frequency: 3
Dialysis missed date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | DNS | Named in relation to abuse allegation reporting and investigation |
| Social Worker | SW | Named as alleged perpetrator in abuse allegation |
| Certified Nursing Assistant | CNA #1 | Witness present during alleged abuse incident |
| Registered Nurse | RN #1 | Provided statement regarding incident and resident behavior |
| Director of Social Services | SWD | Involved in investigation and interviews related to abuse allegation |
| Administrator | ADMN | Responsible for oversight of abuse investigations and reporting |
| Dialysis Administrative Assistant | DAA | Provided information on dialysis care coordination post discharge |
| Dialysis Social Worker | DSW | Involved in dialysis care coordination and communication with facility social worker |
| Facility Social Worker | FSW | Responsible for resident's home discharge planning and dialysis care setup |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 6, 2023
Visit Reason
Covid-19 Survey with 1 Standard Health citation related to reporting to the national health safety network. Citation not corrected as of report.
Findings
Covid-19 Survey with 1 Standard Health citation related to reporting to the national health safety network. Citation not corrected as of report.
Deficiencies (1)
Reporting - national health safety network — quality of care
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 5, 2022
Visit Reason
Complaint Survey with 2 Standard Health citations related to ADL care and comprehensive care plan. Both corrected by December 2022.
Findings
Complaint Survey with 2 Standard Health citations related to ADL care and comprehensive care plan. Both corrected by December 2022.
Deficiencies (2)
ADL care provided for dependent residents — quality of care
Develop/implement comprehensive care plan — quality of care
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 13, 2021
Visit Reason
Covid-19 Survey with 1 Standard Health citation related to reporting to the national health safety network. Citation not corrected as of report.
Findings
Covid-19 Survey with 1 Standard Health citation related to reporting to the national health safety network. Citation not corrected as of report.
Deficiencies (1)
Reporting - national health safety network — quality of care
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Nov 3, 2021
Visit Reason
Complaint Survey with 1 Standard Health citation for accident hazards and 2 Life Safety Code citations for electrical equipment. All corrected by December 2021.
Findings
Complaint Survey with 1 Standard Health citation for accident hazards and 2 Life Safety Code citations for electrical equipment. All corrected by December 2021.
Deficiencies (3)
Free of accident hazards/supervision/devices — quality of care
Electrical equipment - other — life safety
Electrical equipment - power cords and extens — life safety
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 5, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in allowing residents to participate in care planning, timely provision of prescribed vision devices, and maintaining proper sanitizing equipment for food service safety.
Deficiencies (3)
Facility did not ensure that each resident was invited to participate in the care planning process, evidenced by Resident #402 attending only one care plan meeting since admission.
Facility did not ensure that a device to correct visual impairment was provided to Resident #64 in a timely manner as prescribed by the Optometrist.
Facility did not maintain sanitizing equipment in accordance with professional standards; the low temperature dishwasher final rinse did not maintain proper chemical sanitizer concentration.
Report Facts
Residents reviewed for resident rights: 9
Residents reviewed for vision: 4
Sanitizer concentration: 50
Sanitizer concentration: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work | Interviewed regarding resident participation in care planning meetings | |
| Registered Nurse Manager (RN #1) | Interviewed regarding awareness of resident's missing glasses and optometry recommendations | |
| Registered Nurse (RN #2) | Interviewed regarding resident transfer and optometry consult recommendations | |
| Supervisor, Registered Nurse (RN #3) | Interviewed regarding follow-up on optometry consult and oversight of bifocal glasses recommendation | |
| Food Service Manager (FSM) | Reported dishwasher type and sanitizer concentration; scheduled service call | |
| Dietary Aide (DA) | Responsible for checking sanitizer concentration and reported actions taken | |
| Director of Maintenance | Called to correct dishwasher sanitizer issue but was unable to do so |
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