Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
May 20, 2025
Visit Reason
Infection prevention & control deficiency corrected as of June 25, 2025.
Findings
Infection prevention & control deficiency corrected as of June 25, 2025.
Deficiencies (1)
| Description | Severity |
|---|---|
| Infection prevention & control | Level 2 |
Inspection Report
Routine
Deficiencies: 1
May 20, 2025
Visit Reason
The inspection was a Standard survey conducted to evaluate the facility's infection prevention and control program and compliance with related policies and procedures.
Findings
The facility failed to maintain an effective infection prevention and control program, specifically during incontinent care of Resident #60, where inadequate hand hygiene and reuse of washcloths were observed, posing a risk of cross contamination. Staff interviews confirmed these lapses despite training and policies requiring proper hand hygiene and use of clean linens.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide and implement an infection prevention and control program, including inadequate hand hygiene and reuse of washcloths during incontinent care of Resident #60. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Antibiotic orders: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in infection control finding for improper hand hygiene and reuse of washcloths during Resident #60's care | |
| Licensed Practical Nurse #1 | Unit Manager | Interviewed regarding infection control expectations and deficiencies related to Certified Nurse Aide #1 |
| Registered Nurse #1 | Infection Preventionist and Nurse Educator | Interviewed regarding infection control training and expectations for staff |
| Director of Nursing | Interviewed regarding infection control policies and staff training |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Aug 8, 2023
Visit Reason
Discharge summary deficiency corrected as of September 30, 2023.
Findings
Discharge summary deficiency corrected as of September 30, 2023.
Deficiencies (1)
| Description | Severity |
|---|---|
| Discharge summary | Level 2 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NY00319793) to determine if the facility ensured completion of discharge summaries that included a recapitulation of the residents' stay, a final summary, and a post-discharge plan of care for discharged residents.
Findings
The facility failed to ensure that three discharged residents (#1, #2, and #3) received complete discharge summaries including a recapitulation of their stay, a final summary of their status, and a post-discharge plan of care. Interviews with staff confirmed the lack of standardized discharge instructions and incomplete discharge paperwork.
Complaint Details
Complaint # NY00319793 was investigated and substantiated; the facility did not complete discharge summaries for three residents as required.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure completion of discharge summaries including a recapitulation of the residents' stay, a final summary, and a post-discharge plan of care for three residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 3
Discharge dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN UM #3 | Registered Nurse Unit Manager | Mentioned in relation to discharge instructions provided to residents. |
| SW #6 | Social Worker | Interviewed regarding nursing responsibility for discharge summaries. |
| Administrator | Interviewed regarding discharge packet contents and incomplete discharge instructions. | |
| Director of Nursing | DON | Interviewed regarding required discharge paperwork contents and incomplete discharge instructions. |
| Physician #7 | Physician | Completed discharge history and physical examinations for residents. |
Inspection Report
Routine
Deficiencies: 3
Mar 3, 2023
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident rights, care, food safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to make the most recent state survey results readily accessible to residents, inadequate care for a resident with limited range of motion due to improper use of hand devices, and food service safety violations including improper glove use and serving milk at unsafe temperatures.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility did not ensure results of the most recent NYSDOH survey were readily accessible to residents, family members, and legal representatives without having to ask staff. | Level of Harm - Potential for minimal harm |
| Facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion; hand devices were not utilized per plan of care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not prepare, distribute, and serve food in accordance with professional standards; staff did not change gloves or wash hands appropriately and milk was served at unsafe temperatures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Opportunities for lamb's wool palm protector use: 177
Opportunities for ABD pad use: 51
Milk temperature: 52.2
Milk temperature: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Manager #1 | RN Manager | Stated expectation that devices should be in place and signed off. |
| Licensed Practical Nurse (LPN) #1 | LPN | Responsible to ensure devices were in place and for signing off in TAR. |
| Occupational Therapist (OT) #1 | Occupational Therapist | Observed difficulty applying palm protector and worked to loosen resident's hands. |
| Occupational Therapist (OT) #2 | Occupational Therapist | Stated palm protector and ABD pad were for skin protection and wanted nurse to apply daily. |
| Director of Nursing (DON) | Director of Nursing | Stated devices should have been in place and staff should notify nurse manager or therapy if difficulty. |
| Dietary Manager | Dietary Manager | Observed food preparation and stated cook should have changed gloves after touching surfaces and food. |
| Dietary Supervisor | Dietary Supervisor | Explained milk and juice handling and temperature expectations. |
| Director of Dietary/Registered Dietitian (RD) | Director of Dietary/Registered Dietitian | Stated cook should have changed gloves and washed hands; milk temperature of 60°F was unacceptable. |
Inspection Report
Routine
Deficiencies: 1
Aug 18, 2021
Visit Reason
The inspection was conducted as a Standard Survey to assess compliance with nutritional guidelines and ensure the facility meets the nutritional needs of residents.
Findings
The facility failed to meet the nutritional needs of residents as two meals (lunch and dinner) did not provide adequate protein amounts according to established dietary guidelines. This deficiency involved Resident #6 and was attributed to use of prepared foods and staffing issues on the day of observation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Menus did not meet the nutritional needs of residents; two meals did not provide proper protein amounts to meet nutritional needs. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Protein per meal: 11
Residents on puree diet: 13
Serving size protein content: 2
Serving size protein content: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dietary | Observed meal preparation and explained menu changes due to staffing shortages. | |
| Registered Dietitian (RD) | Reviewed menus, nutritional facts, and stated protein levels were inadequate on the day of observation. | |
| Administrator | Confirmed expectation that dietary staff provide adequate nutrition daily. |
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