4 Reports
Inspection Report — Jan 23, 2024
Annual Inspection CMS
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.
Citations (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 — Jan 23, 2024
Complaint Investigation State
Date: Jan 23, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2024 with deficiency and complaint history.
Complaint Details
The state logged 70 complaints about this facility; 4 led to on-site inspections. The facility received 30.4 complaints per 100 beds versus a statewide rate of 57.4, with 3 citations resulting from those complaints.
Findings
Across 4 inspections, 2 had no citations while 2 resulted in 16 citations total, mostly standard health citations with minor potential harm. The facility had 70 complaints with 4 on-site inspections and no formal enforcement actions.
Citations (16)
Standard Health Citation — quality of care: Criminal History Record Check Process was deficient.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve sanitary conditions were deficient.
Standard Health Citation — quality of care: Infection Control procedures were deficient.
Standard Health Citation — quality of care: Labeling and storage of Drugs and Biologicals was deficient.
Standard Health Citation — quality of care: Notice Requirements Before Transfer/discharge were deficient.
Standard Health Citation — quality of care: Personal Privacy and confidentiality Of Records was deficient.
Standard Health Citation — quality of care: Pharmacy Services, procedures, pharmacist, and records were deficient.
Standard Health Citation — quality of care: Posted Nurse Staffing Information was deficient.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was deficient.
Standard Health Citation — quality of care: Required Postings were deficient.
Standard Health Citation — quality of care: Requirements Before Submitting A Request For were deficient.
Standard Health Citation — quality of care: Right To Be Free From Physical Restraints was deficient.
Standard Health Citation — quality of care: Right To Survey Results and advocate Agency Info was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System was deficient.
Life Safety Code Citation — NFPA requirements: Emergency Lighting was deficient.
Standard Health Citation — quality of care: Free Of Accident Hazards, supervision, and devices was deficient.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 16
Inspections with violations: 2
Inspections without violations: 2
Total complaints: 70
On-site inspections from complaints: 4
Citations issued from complaints: 3
Total enforcement actions: 0
Inspection Report — Nov 4, 2021
Annual Inspection CMS
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.
Citations (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 — Apr 24, 2019
Annual Inspection CMS
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.
Citations (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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