Inspection Reports for
Hudson Park Rehabilitation and Nursing Center
325 Northern Boulevard, Albany, NY, 12204
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Inspection Report — Jun 12, 2024
Abbreviated Survey CMS
Date: Jun 12, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess housekeeping and maintenance services in the facility.
Findings
The facility failed to provide effective housekeeping and maintenance services on all resident units, the basement, and facility grounds, with issues including soiled floors, dirty window blinds, missing call bell light covers, hand-written room numbers, soiled dining tables, and littered grounds.
Citations (4)
Floors on multiple floors and basement were soiled with dirt, dust, and sticky residue; walls and doors had scrape, scuff, and smudge marks; dead flies found in corridor ceiling lights.
Window blinds were soiled with oily dust buildup in multiple rooms; corridor call bell light covers were missing in several rooms; some rooms lacked proper room number signs.
Underside of dining room tables was soiled with food particles and grime on multiple floors.
Facility grounds were littered with paper waste, used surgical gloves, and plastic wrapping.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Environmental Services #1 | Regional Director of Environmental Services | Interviewed regarding cleaning and maintenance practices and audits. |
| Administrator #1 | Administrator | Interviewed regarding plans to improve cleaning, repair missing call bell light covers, install new room number signs, and assign housekeeping to keep grounds litter-free. |
Inspection Report — Jun 12, 2024
Annual Inspection CMS
Date: Jun 12, 2024
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Hudson Park Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, medication self-administration assessment, housekeeping and maintenance, accident investigation, care plan development and revision, activity programming, wound care, hearing aid maintenance, respiratory care, food service safety, infection control, and handrail maintenance.
Citations (11)
Dining meals were served with disposable utensils in one dining room and a resident was found walking with pants falling down exposing incontinence brief without staff intervention.
Residents were not assessed by an interdisciplinary team to determine ability to safely self-administer medication when clinically appropriate.
Facility did not provide effective housekeeping and maintenance services; floors, window blinds, tables, ceiling light covers, room signs, and facility grounds were not clean or maintained.
Facility did not thoroughly investigate or prevent further accidents for a resident found on the floor with significant head injury; root cause analysis was not completed.
Comprehensive care plans were not reviewed and revised based on changing goals, preferences, and needs for several residents.
Facility did not provide an ongoing program to support residents in their choice of activities that met their preferences and cognitive abilities on two resident units.
Resident sustained a wound from a fall that was not tracked, monitored, or treated properly; wound care documentation was delayed and incomplete.
Residents requiring respiratory care were not provided oxygen therapy as ordered by the physician.
Food service safety deficiencies included malfunctioning dishwashing machine and unclean areas in main kitchen and unit kitchenettes.
Facility did not maintain an infection control program ensuring staff appropriately used and discarded personal protective equipment.
Handrails were loose and not securely attached to corridor walls on two resident units.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Stated plastic utensils should be in care plans; commented on resident dignity and fall incident | |
| Registered Nurse #5 | Stated plastic utensil use should be in care plans; commented on fall incident and care plan revisions | |
| Certified Nurse Aide #6 | Described procedure for addressing residents clothed inappropriately and commented on activities | |
| Registered Nurse #4 | Unit Manager | Commented on medication self-administration, hearing aid follow-up, and fall incident investigation |
| Administrator #1 | Commented on housekeeping, fall investigations, and handrail maintenance | |
| Regional Director of Environmental Services #1 | Commented on housekeeping cleaning and audits | |
| Registered Nurse #1 | Provided wound care and assessment information for Resident #524 | |
| Wound Nurse #1 | Provided wound assessment and care plan update information for Resident #524 | |
| Certified Nurse Aide #3 | Observed leaving soiled gloves and plastic bags on floor | |
| Certified Nurse Aide #4 | Observed entering contact precaution room without proper PPE | |
| Interim Food Service Director #1 | Commented on dishwashing machine and kitchen cleaning | |
| Regional Food Service Director #1 | Commented on dishwashing machine repair | |
| Activities Director #1 | Described activities assessment and programming |
Inspection Report — Jun 12, 2024
Certification/complaint State
Date: Jun 12, 2024
Visit Reason
State-compiled facility profile showing 24 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
Facility received 229 complaints with 25 on-site inspections conducted. Complaints resulted in 10 citations.
Findings
Across 24 inspections, 15 had no citations while 9 resulted in 26 total citations, mostly standard health and some life safety code violations. The facility had 229 complaints with 25 on-site inspections and 5 enforcement actions totaling $52,000 in fines.
Citations (25)
Standard Health Citation — quality of care: Activities did not meet interests or needs of each resident.
Standard Health Citation — quality of care: Care plans were not timely revised as required.
Standard Health Citation — quality of care: Corridors lacked firmly secured handrails.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving were not sanitary.
Standard Health Citation — quality of care: Infection prevention and control measures were inadequate.
Standard Health Citation — quality of care: Failed to investigate, prevent, or correct alleged violations.
Standard Health Citation — quality of care: Quality of care was deficient.
Standard Health Citation — quality of care: Resident rights were not fully exercised or protected.
Standard Health Citation — quality of care: Resident self-administered medications were not clinically appropriate.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were inadequate.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Standard Health Citation — quality of care: Treatment and devices to maintain hearing and vision were deficient.
Life Safety Code Citation — NFPA requirements: Exit signage was inadequate.
Life Safety Code Citation — NFPA requirements: Means of egress were not compliant.
Life Safety Code Citation — NFPA requirements: Roles under a waiver declared by Secretary were not met.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were deficient.
Standard Health Citation — quality of care: Free from misappropriation or exploitation was not ensured.
Standard Health Citation — quality of care: Drug regimen was not free from unnecessary drugs.
Standard Health Citation — quality of care: Residents were not free of significant medication errors.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Life Safety Code Citation — NFPA requirements: Electrical equipment power cords and extensions were not compliant.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Standard Health Citation — quality of care: Maintains effective pest control program was inadequate.
Standard Health Citation — quality of care: Infection prevention and control measures were inadequate.
Standard Health Citation — quality of care: Quality of care was deficient.
Report Facts
Inspections on page: 24
Total violations/deficiencies cited: 26
Inspections with violations: 9
Inspections without violations: 15
Total complaints: 229
On-site complaint inspections: 25
Citations from complaints: 10
Enforcement actions: 5
Total fines: 52000
Inspection Report — Apr 25, 2024
Abbreviated Survey CMS
Date: Apr 25, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of misappropriation of residents' property and exploitation involving three residents at Hudson Park Rehabilitation and Nursing Center.
Complaint Details
The visit was complaint-related, triggered by reports from Residents #1, #2, and #3 regarding suspicious activity and theft of their personal checks. Investigations substantiated misappropriation by Certified Nurse Aide #1 for Residents #1 and #2. Resident #3's involvement was inconclusive, with the interdisciplinary team determining likely complicity. Police reports were filed, and charges were pending.
Findings
The facility failed to protect residents from misappropriation of their personal funds and property, involving forged checks cashed by a Certified Nurse Aide. Investigations confirmed misappropriation for Residents #1 and #2, while Resident #3 was likely complicit. Corrective actions included termination of the staff member, police notification, resident support, staff reeducation, and provision of locked drawers for residents.
Citations (1)
Failure to protect residents from wrongful use of their belongings or money, including forgery and theft of personal checks.
Report Facts
Date of survey completion: Apr 25, 2024
Date of Resident #1 report: Sep 7, 2023
Date of Resident #2 report: Sep 7, 2023
Date of Resident #3 report: Oct 13, 2023
Amount misappropriated from Resident #3: 1750
Date Certified Nurse Aide #1 hired: Aug 14, 2023
Date Certified Nurse Aide #1 reported: Sep 8, 2023
Date of investigation conclusion: Sep 8, 2023
Date of staff reeducation completion: Sep 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Identified as responsible for forging checks and misappropriation of residents' funds; terminated and reported to the Office of the Professions. |
| Director of Nursing #1 | Director of Nursing | Provided interview confirming full investigation, police notification, termination of CNA #1, and staff reeducation. |
| Administrator #1 | Administrator | Provided interview summarizing investigation and corrective actions taken. |
| Assistant Administrator #1 | Assistant Administrator | Provided interview confirming familiarity with events and corrective actions. |
| Director of Social Work #1 | Director of Social Work | Provided interview detailing notification, police involvement, resident support, and interdisciplinary team actions. |
| Family Member #1 | Interviewed regarding Resident #3's financial matters and reimbursement efforts. |
Inspection Report — Apr 3, 2024
Abbreviated Survey CMS
Date: Apr 3, 2024
Visit Reason
The facility underwent an abbreviated survey to assess compliance with regulations related to environmental cleanliness, medication administration, and resident safety.
Findings
The survey found deficiencies in housekeeping and maintenance services, including soiled floors, heater/air conditioning units, windows, and other environmental concerns. Additionally, medication errors were identified involving administration of another resident's medication and incorrect dosing of fentanyl patches.
Citations (3)
Facility did not provide effective housekeeping and maintenance services on five resident units, including soiled floors, dirty heater/air conditioning units, soiled windows, dusty wall paneling, and heavily soiled mop buckets and wringers.
Resident #3 was administered Resident #9's medication in error when the nurse became distracted.
Resident #2 was given a 50 microgram fentanyl patch instead of the prescribed 12.5 microgram patch.
Report Facts
Resident rooms with soiled floors: 22
Resident rooms with soiled heater/air conditioning units: 16
Resident rooms with soiled windows: 34
Residents reviewed for medication errors: 5
Medication error incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #8 | Administered another resident's medication to Resident #3 in error | |
| Registered Nurse Unit Manager #3 | Notified about medication error involving Resident #3 and monitored the resident | |
| Licensed Practical Nurse #6 | Applied incorrect fentanyl patch dose to Resident #2 | |
| Registered Nurse Supervisor #2 | Notified about fentanyl patch medication error and contacted Medical Doctor | |
| Director of Nursing #1 | Provided information about medication errors and staff involved | |
| Interim Director of Housekeeping #1 | Discussed housekeeping deficiencies and corrective actions | |
| Administrator #1 | Discussed environmental cleanliness issues and ongoing improvement efforts |
Inspection Report — Sep 1, 2023
Abbreviated Survey CMS
Date: Sep 1, 2023
Visit Reason
The abbreviated survey was conducted to review alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property.
Findings
The facility failed to ensure timely reporting of a serious bodily injury of unknown origin within 2 hours as required by policy and regulations for Resident #2, who sustained an acute midshaft humeral fracture. The investigation concluded the injury was accidental with no evidence of abuse or neglect.
Citations (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for Resident #2 with a serious bodily injury of unknown origin.
Report Facts
Residents reviewed for injuries of unknown origin: 3
Residents affected: 1
Date of injury observation: May 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Assessed Resident #2's bruising and pain during the facility investigation |
| Nursing Home Administrator | Administrator | Responsible for reporting to the Department of Health and provided interview regarding reporting guidelines |
Inspection Report — Aug 8, 2023
Abbreviated Survey CMS
Date: Aug 8, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to assess the facility's pest control program and ensure a pest-free environment.
Findings
The facility failed to maintain an effective pest control program, with heavily soiled floors and dead cockroaches found in the main kitchen electrical closets, and insect traps missing from several resident rooms despite being documented as placed. Interviews revealed that insect traps were likely removed during floor maintenance and housekeeping actions.
Citations (1)
Failure to maintain a pest-free environment and effective pest control program, including heavily soiled floors and dead cockroaches in main kitchen electrical closets and missing insect traps in resident rooms.
Report Facts
Resident units affected: 1
Resident rooms with missing insect traps: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Stated the problem with insect infestation has been intermittent and insect traps may have been removed during floor maintenance | |
| Director of Maintenance | Stated maintenance does not check or clean above drop ceilings and housekeeping likely removed insect traps during floor waxing | |
| Director of Housekeeping | Stated staff picked up insect traps as a reaction to surveyor entering but did not know why |
Inspection Report — Mar 22, 2023
Abbreviated Survey CMS
Date: Mar 22, 2023
Visit Reason
The survey was a focused infection control survey conducted during an active Covid-19 outbreak in the facility to assess the infection prevention and control program and compliance with Covid-19 protocols.
Findings
The facility failed to maintain an effective infection prevention and control program, specifically failing to ensure staff wore PPE properly, performed hand hygiene when indicated, and followed infection control practices to prevent cross-contamination during an active Covid-19 outbreak with 11 active resident cases.
Citations (1)
Failure to ensure staff appropriately wore personal protective equipment (PPE), performed hand hygiene when indicated, and followed infection control practices and protocol to prevent cross-contamination during an active Covid-19 outbreak.
Report Facts
Active Covid-19 cases: 11
Total residents: 82
Residents tested positive since outbreak start: 26
Single serve coffee creamers dropped: 5
Date Resident #1 tested positive: Mar 13, 2023
Date Resident #1 scheduled to come off isolation: Mar 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated facility was in active outbreak with 82 residents and 26 positive cases; described PPE and infection control policies |
| LPN #2 | Licensed Practical Nurse | Interviewed about infection control guidelines and resident Covid-19 cases |
| Temporary Nurse Aide #2 | Temporary Nurse Aide | Observed and interviewed regarding infection control practices and meal service lapses |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Described outbreak protocols, testing frequency, and signage responsibilities |
| Director of Nursing | Infection Preventionist (IP) | Acted as Infection Preventionist; described staff education on PPE and hand hygiene |
Inspection Report — Nov 5, 2021
Annual Inspection CMS
Date: Nov 5, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Hudson Park Rehabilitation and Nursing Center.
Findings
The survey identified multiple deficiencies including failure to ensure residents' dignity, failure to notify physicians timely about medication issues, inadequate housekeeping and maintenance, incomplete investigations of bruising, incomplete baseline and comprehensive care plans, failure to implement appropriate care for elopement risk, environmental hazards, incomplete medication regimen review policies, and inaccurate medical record documentation.
Citations (10)
Failure to ensure Resident #90 was treated with dignity by preventing staff from accessing the resident's bathroom to assist with toileting.
Failure to immediately notify Resident #38's physician when two ordered medications were unavailable upon re-admission.
Failure to provide effective housekeeping and maintenance services; floors were soiled and baseboards missing.
Failure to thoroughly investigate bruises of unknown origin on Resident #56's bilateral inner thighs to rule out abuse or neglect.
Failure to develop and implement baseline care plans within 48 hours for multiple residents and to include necessary healthcare information.
Failure to develop and implement comprehensive care plans addressing residents' medical, nursing, and psychosocial needs including pain, elopement risk, communication, bruising, enteral feeding, and restorative nursing therapy.
Failure to provide appropriate treatment and care for Resident #41 identified as an elopement risk, resulting in elopement.
Environmental hazard due to missing end caps on handrails exposing sharp metal edges in hallways on 2 of 4 resident units.
Failure to develop and implement a medication regimen review policy including time frames for pharmacist actions when irregularities require immediate attention.
Failure to maintain medical records accurately documenting bruises on Residents #56 and #64; weekly skin checks did not reflect observed bruising.
Report Facts
Residents reviewed for baseline care plans: 17
Residents reviewed for comprehensive care plans: 30
Elopement risk score: 9
Elopement risk score: 5
Elopement risk score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Confirmed Resident #90's bathroom door could not open |
| CNA #4 | Certified Nurse Assistant | Reported Resident #90's bathroom door had been locked for over a month |
| MT #1 | Maintenance Technician | Reported all bathroom door locks were removed about seven years ago |
| Administrator | Stated facility policy was residents should have access to their bathroom | |
| RNUM #2 | Registered Nurse Unit Manager | Aware Resident #38's medications were unavailable and physician was notified |
| RNUM #1 | Registered Nurse Unit Manager | Stated RN responsible for re-admission assessment and medication reconciliation |
| DON | Director of Nursing | Stated nurses must notify physician if medication unavailable; care planning responsibilities |
| Corporate Clinical Consultant | Reported environmental concerns and maintenance resignation | |
| TNA #2 | Temporary Nurse Aide | Reported bruises on Resident #56 to LPN #8 |
| RNUM #2 | Registered Nurse Unit Manager | Started investigation of bruises on Resident #56 and identified lift pad as cause |
| LPN #2 | Licensed Practical Nurse | Completed skin check on Resident #56 and documented no new concerns |
| RNUM #2 | Registered Nurse Unit Manager | Acknowledged bruising documentation deficiencies and need for education |
| RNUM #1 | Registered Nurse Unit Manager | Described baseline care plan completion process |
| SW #1 | Social Worker | Stated care plans should be reviewed upon admission |
| RNUM #1 | Registered Nurse Unit Manager | Described care plan review and update process |
| PT #1 | Physical Therapist | Described restorative nursing therapy as nursing intervention performed by CNA staff |
| RN #5 | Registered Nurse | Intercepted Resident #41 during elopement and returned resident to facility |
| RC #1 | Reception Clerk | Reported lobby traffic during Resident #41's elopement |
| RN #4 | Registered Nurse | Interviewed Resident #41 after elopement |
| CNA #5 | Certified Nursing Assistant | Reported skin checks and notification process for bruises |
Inspection Report — Jun 24, 2019
Annual Inspection CMS
Date: Jun 24, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal and state regulations regarding resident care, safety, nutrition, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, housekeeping and maintenance, use of physical restraints, pressure ulcer care, nutrition and hydration monitoring, food palatability, food service safety, pest control, carbon monoxide detection, and equipment maintenance.
Citations (12)
Residents were not treated with dignity during dining, including use of Styrofoam plates and plasticware due to shortages and improper handling of spills and food.
Facility did not provide effective housekeeping and maintenance services; floors, furniture, windows, and closets were soiled on multiple floors and basement.
Use of physical restraints without physician order or care plan for Resident #54 using a zip-back jumpsuit.
Resident #95 with pressure ulcer did not receive proper infection control during dressing changes, including use of soiled gauze and cross-contamination of supplies.
Facility failed to maintain acceptable nutritional parameters for residents #18, 54, 95, and 104, including inadequate fluid intake monitoring, delayed nutritional assessments, lack of physician notification for weight loss, and incomplete nutrition care plans.
Pancakes served on the fifth floor were tough, rubbery, and not palatable, making them difficult for residents to eat.
Food service safety violations including unlabeled toxic chemicals, unclean food contact surfaces and floors, and improper glove use during food plating.
Facility lacked a policy regarding use and storage of foods brought to residents by family and visitors until shortly before the survey.
Carbon monoxide detectors in kitchen and boiler rooms were not hardwired or powered by 10-year batteries as required.
Essential equipment in the main kitchen was not maintained in safe operating condition; garbage disposal and floor/wall base coving tiles were in disrepair.
Facility did not maintain an effective pest control program; multiple sightings of drain flies in the main kitchen with staff treating drains instead of professional pest control.
Trash compactor area was unclean with litter and liquid on the ground, and seal around compactor was leaking.
Report Facts
Weight loss percentage: 11.28
Weight loss percentage: 14.3
Fluid intake days below 1500 mL: 20
Fluid intake days no evidence: 11
Fluid intake days 360 mL or less: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #3 | Dietary Aide | Mentioned in relation to shortage of plates and silverware |
| DA #4 | Dietary Aide | Mentioned in relation to use of Styrofoam and plasticware due to shortages |
| DA #13 | Dietary Aide | Mentioned in relation to use of plastic and Styrofoam when kitchen or dishwasher was short or not working |
| LPN #2 | Licensed Practical Nurse | Unaware resident was given spilled food; commented on dignity issues |
| Food Service Director | Food Service Director | Commented on ordering china plates, silverware, and proper dining staff behavior |
| RN #3 | Registered Nurse | Unaware of physical restraint use; commented on restraint orders and care plans |
| Director of Nursing | Director of Nursing | Commented on restraint orders and care plans |
| LPN #1 | Licensed Practical Nurse | Observed improper infection control during dressing change |
| Infection Control Nurse | Infection Control Nurse | Commented on improper infection control during dressing change |
| RNM #2 | Registered Nurse Manager | Commented on fluid intake monitoring and weight measurements |
| Registered Dietitian | Registered Dietitian | Commented on nutritional assessments and care plans |
| Clinical Nutritionist | Clinical Nutritionist | Commented on nutritional interventions and physician notifications |
| Administrator | Administrator | Commented on weight loss monitoring and physician notification |
| Director of Maintenance | Director of Maintenance | Commented on cleaning issues, pest control, carbon monoxide detectors, and equipment repairs |
| Dietary Employee | Dietary Employee | Observed plating food with gloves touching food delivery carts |
| MDS Coordinator #9 | MDS Coordinator | Commented on nutritional assessments upon re-admission |
| Registered Nurse #3 | Registered Nurse | Commented on dietary notification of resident weight changes |
| Director of Admissions and Concierge Services | Director of Admissions and Concierge Services | Commented on policy development for foods brought by visitors |
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