Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
122% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jan 23, 2024
Visit Reason
The inspection was conducted as a recertification survey from 01/16/2024 to 01/23/2024 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to post required contact information and survey results accessibly, breaches of resident privacy, improper use of physical restraints, delayed reporting of abuse allegations, failure to notify the Ombudsman of resident discharge, improper posting of nurse staffing data, failure to maintain accurate controlled drug records, improper labeling and storage of medications, and unsafe food storage practices.
Deficiencies (11)
Failure to post names, addresses, and telephone numbers of State Survey Agency and Ombudsman in accessible locations.
Failure to post the results of the most recent survey in a place readily accessible to residents and family members.
Violation of resident privacy and confidentiality by discussing probation status with door open in public area.
Use of physical restraints without proper assessment, monitoring, or care planning for 4 residents.
Failure to timely report suspected abuse to the New York State Department of Health within 2 hours.
Failure to notify the Ombudsman Office of resident discharge.
Failure to post nurse staffing information in a location accessible to residents and visitors.
Failure to maintain and reconcile controlled drug records for Fentanyl patches.
Failure to label opened insulin vial with date opened and expiration date.
Certified Nursing Assistant transported medications without licensed nurse supervision.
Failure to store food at proper temperature and presence of unlabeled, undated food in pantry refrigerator.
Report Facts
Residents sampled: 35
Residents reviewed for physical restraints: 5
Residents affected by physical restraint deficiency: 4
Residents reviewed for abuse: 4
Residents affected by abuse reporting deficiency: 2
Fentanyl patches counted: 9
Fentanyl patches documented: 10
Temperature of 3rd Floor pantry refrigerator: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Did not reconcile Fentanyl patch count and failed to document administration |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Transported medications without licensed nurse supervision |
| Director of Nursing | Interviewed regarding multiple deficiencies including restraint use, abuse reporting, and medication practices | |
| Administrator | Interviewed regarding posting of information and Ombudsman notification | |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication administration and medication blister pack handling |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Instructed CNA #5 to bring medication blister packs to Nursing Office |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 23, 2024
Visit Reason
The inspection was conducted as a Recertification and Complaint survey to investigate allegations related to resident privacy violations and timely reporting of suspected abuse.
Complaint Details
The complaint investigation found that the Director of Social Services violated Resident #222's privacy by discussing probation status in an open office. Additionally, the facility failed to report a physical altercation between Residents #106 and #167 within the required 2-hour period, as mandated by facility policy and state regulations.
Findings
The facility failed to ensure a resident's right to privacy during a conversation in an open office setting and did not report a resident-to-resident physical altercation to the New York State Department of Health within the required 2-hour timeframe.
Deficiencies (2)
Facility did not ensure a resident's right to privacy and confidentiality; conversation about Resident #222 was overheard in an open Social Work Office.
Facility did not timely report suspected abuse involving Residents #106 and #167 to the New York State Department of Health within 2 hours of occurrence.
Report Facts
Residents sampled: 35
Residents affected: 1
Residents affected: 2
Residents reviewed for abuse: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Named in privacy violation finding for discussing resident probation status with door open | |
| Director of Nursing | Interviewed regarding privacy violation and reporting of abuse incidents | |
| Registered Nurse #4 | Witnessed conversation violating resident privacy |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Jan 23, 2024
Visit Reason
Complaint survey with 13 health citations and 2 life safety code citations, all corrected by March 21, 2024.
Findings
Complaint survey with 13 health citations and 2 life safety code citations, all corrected by March 21, 2024.
Deficiencies (15)
Criminal history record check process — quality of care
Food procurement, store/prepare/serve-sanitary — quality of care
Infection control — quality of care
Label/store drugs and biologicals — quality of care
Notice requirements before transfer/discharge — quality of care
Personal privacy/confidentiality of records — quality of care
Pharmacy services/procedures/pharmacist/records — quality of care
Posted nurse staffing information — quality of care
Reporting of alleged violations — quality of care
Required postings — quality of care
Requirements before submitting a request for — quality of care
Right to be free from physical restraints — quality of care
Right to survey results/advocate agency info — quality of care
Electrical systems - essential electric system — life safety
Emergency lighting — life safety
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 27, 2022
Visit Reason
Complaint survey with one health citation related to accident hazards, corrected by July 27, 2022.
Findings
Complaint survey with one health citation related to accident hazards, corrected by July 27, 2022.
Deficiencies (1)
Free of accident hazards/supervision/devices — quality of care
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as a re-certification (annual) survey to assess compliance with Minimum Data Set (MDS) assessment and transmission requirements, and to ensure accurate resident assessments.
Findings
The facility failed to transmit a discharge MDS assessment within the required 14 days for one resident, and failed to accurately capture key resident information such as use of lap trays, left hand splints, and anticoagulant medication on MDS assessments for other residents. These deficiencies were identified through record review, observation, and staff interviews.
Deficiencies (2)
Failure to transmit Minimum Data Set (MDS) 3.0 discharge assessment within 14 calendar days from completion date for Resident #1.
Failure to ensure MDS assessments accurately reflected resident status, including omission of lap tray restraint, left hand splint, and anticoagulant medication for Residents #149 and #71.
Report Facts
Residents reviewed: 35
Residents affected: 1
Residents affected: 3
Days late for MDS transmission: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN #3) | Registered Nurse | Responsible for transmitting MDS documents; interviewed regarding late transmission of Resident #1's discharge MDS |
| Director of MDS | Director of MDS | Interviewed about MDS transmission process and responsibilities |
| MDS Coordinator (MDSC) | MDS Coordinator | Interviewed regarding MDS assessment completion and failure to capture splint, anticoagulant, and lap tray on MDS |
| Physical Therapist (PT) | Physical Therapist | Interviewed about responsibility for coding splint on MDS |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding MDS accuracy and documentation of restraints |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Nov 4, 2021
Visit Reason
Complaint survey with 2 health citations and 9 life safety code citations, all corrected by January 2, 2022.
Findings
Complaint survey with 2 health citations and 9 life safety code citations, all corrected by January 2, 2022.
Deficiencies (11)
Accuracy of assessments — quality of care
Encoding/transmitting resident assessments — quality of care
Corridor - doors — life safety
Electrical equipment - testing and maintenance — life safety
Electrical systems - other — life safety
Emergency lighting — life safety
Means of egress - general — life safety
Physical environment — life safety
Sprinkler system - maintenance and testing — life safety
Stairways and smokeproof enclosures — life safety
Vertical openings - enclosure — life safety
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 24, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with Medicare/Medicaid regulations and to evaluate the facility's adherence to regulatory requirements.
Findings
The facility was found deficient in providing appropriate Medicare beneficiary notices at the termination of Medicare Part A benefits, ensuring accurate resident assessments, and providing appropriate care to maintain or improve range of motion for residents with contractures. Deficiencies involved failure to provide Skilled Nursing Facility Advance Beneficiary Notices, inaccurate Minimum Data Set assessments, and failure to consistently apply physician-ordered gauze hand rolls to a resident with contractures.
Deficiencies (3)
Failure to provide residents with Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN-form CMS-10055) at the termination of Medicare Part A benefits.
Resident's Minimum Data Set (MDS) assessment did not include the active diagnosis of Paranoid Schizophrenia.
Resident with limited Range of Motion (ROM) and mobility did not receive appropriate treatment; gauze hand rolls were not consistently provided as per physician order.
Report Facts
Residents reviewed for Beneficiary Protection Notification Rights: 3
Residents reviewed for Unnecessary Medication and Dementia Care: 5
Residents reviewed for Range of Motion: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Director of Social Services | Acknowledged failure to provide SNF ABN notices to residents #15 and #371. |
| Rehab Director | Rehab Director | Described communication process for Medicare notices and stated SNF ABN is only given when Medicare days are exhausted. |
| MDS Coordinator | MDS Coordinator | Responsible for completing MDS assessments; acknowledged omission of Paranoid Schizophrenia diagnosis on resident #209's assessment. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Responsible for placing gauze rolls in resident #100's hands; admitted possible failure to apply gauze rolls consistently. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed gauze rolls were not applied to resident #100 on the morning of 4/23/19. |
| Registered Nurse #1 | Registered Nurse | Described procedures for device application and monitoring; noted resident #100 should have gauze rolls in place but did not during multiple observations. |
| Registered Occupational Therapist | Registered Occupational Therapist | Explained purpose of gauze rolls for resident #100 and importance of continued use even on hospice care. |
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