Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with grievance policies and residents' rights to obtain written decisions regarding grievances.
Complaint Details
This was a complaint-related visit triggered by grievances filed by Resident #1's Health Care Proxy regarding inadequate responses to grievances about care and treatment. The grievance was substantiated as the facility did not provide written responses despite requests.
Findings
The facility failed to ensure that residents had the right to obtain written decisions regarding their grievances. Specifically, Resident #1's Health Care Proxy repeatedly requested written responses to grievances, but the facility only provided verbal outcomes and did not provide written results as required.
Deficiencies (1)
Failure to ensure residents had the right to obtain a written decision regarding their grievance.
Report Facts
Residents sampled: 3
Residents affected: 1
Grievance dates: 7
Business days to investigate grievance: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Service | Grievance officer responsible for investigating grievances and providing verbal outcomes | |
| Facility's Administrator | Responsible for grievance process and providing grievance results or resolution |
Inspection Report
Renewal
Capacity: 60
Deficiencies: 7
Date: Jan 9, 2025
Visit Reason
Summary of inspection history and citations from August 1, 2021 through July 31, 2025
Findings
A total of 7 violations were identified in one relicensure survey inspection, covering resident funds and valuables, personnel qualifications, environmental standards, and disaster and emergency planning.
Deficiencies (7)
487.6 (f) (1) — Resident funds and valuables
487.9 (a) (15) — Personnel
487.11 (h) (11) — Environmental standards
487.11 (k) (4) — Environmental standards
487.12 (a-b) — Disaster and emergency planning
487.12 (f) — Disaster and emergency planning
487.12 (g) — Disaster and emergency planning
Report Facts
Total inspections: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 16, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate an incident involving alleged physical abuse of a resident by nursing home staff.
Complaint Details
The visit was complaint-related, investigating an allegation of physical abuse. The facility determined the allegation was unsubstantiated as the admission Clerk #1 acted out of fright and reacted to Resident #1's aggressive behavior.
Findings
The facility did not ensure the residents' right to be free from physical abuse. An incident occurred on 10/25/2024 where admission Clerk #1 pushed Resident #1, causing the resident to fall and hit their head. The facility determined the occurrence was unsubstantiated for physical abuse, but the admission Clerk #1 was terminated for violating facility policy.
Deficiencies (1)
Failure to protect residents from physical abuse by staff, specifically an incident where admission Clerk #1 pushed Resident #1 causing injury.
Report Facts
Residents reviewed: 10
Residents affected: 1
Date of incident: Oct 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admission Clerk #1 | Named in physical abuse incident involving Resident #1; suspended and terminated for violating facility policy. | |
| Certified Nursing Assistant #1 | Witnessed Resident #1's aggressive behavior and fall; provided interview statements. | |
| Licensed Practical Nurse #1 | Called Doctor Strong code and provided interview statements regarding the incident. | |
| Certified Nursing Assistant #2 | Observed incident and provided interview statements about proper staff response to aggression. | |
| Registered Nurse Supervisor #1 | Reviewed video evidence and stated proper protocol for staff response to aggressive residents. | |
| Director of Nursing | Director of Nursing | Provided statements about staff protocol and investigation of the incident. |
| Administrator | Administrator | Reviewed video, initiated investigation, suspended and terminated admission Clerk #1, and provided statements about facility responsibilities. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 7, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 04/07/2024 to 04/12/2024 to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and hygiene, food safety and handling, garbage disposal, and infection control practices. Specific issues included failure to maintain resident dignity related to urine odor in a resident's room, inadequate grooming assistance, improper food storage and temperature monitoring, uncovered garbage dumpsters, and lapses in infection prevention such as failure to use enhanced barrier precautions during wound care and failure to sanitize blood pressure cuffs between residents.
Deficiencies (5)
Failure to ensure residents were treated with respect and dignity; resident room had strong urine odor due to inadequate management of incontinence and laundry of underwear.
Failure to provide appropriate care and assistance for activities of daily living; resident observed with long, untrimmed fingernails embedded with black matter.
Food safety violations including dishwashing machine not maintaining proper wash and rinse temperatures, dietary staff not properly covering hair, failure to check and record food temperatures prior to serving, and unlabeled food in pantry refrigerator.
Garbage and refuse not properly contained; dumpster was uncovered and overflowing with various types of garbage.
Infection prevention and control deficiencies including failure to use gowns during wound care as required by enhanced barrier precautions and failure to sanitize blood pressure cuff between residents during medication administration.
Report Facts
Residents reviewed for dignity: 5
Residents reviewed for activities of daily living: 10
Residents affected by dignity deficiency: 1
Residents affected by ADL deficiency: 1
Dishwasher temperature wash observed: 142
Dishwasher temperature rinse observed: 142
Dishwasher temperature final rinse observed: 188
Dishwasher temperature wash observed: 141
Dishwasher temperature rinse observed: 141
Dishwasher temperature final rinse observed: 193
Residents on Enhanced Barrier Precautions: 9
Residents on Enhanced Barrier Precautions: 9
Residents on Enhanced Barrier Precautions: 5
Residents on Enhanced Barrier Precautions: 18
Residents on Enhanced Barrier Precautions: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #5 | Interviewed regarding Resident #158's continence and urine odor in room | |
| Licensed Practical Nurse #1 | Interviewed regarding Resident #158's hygiene and urine odor in room | |
| Housekeeper #1 | Interviewed regarding urine odor in Resident #158's room and mattress changes | |
| Certified Nursing Assistant #7 | Interviewed regarding care of Resident #89 and nail trimming | |
| Registered Nurse Supervisor #1 | Charge Nurse | Interviewed regarding protocol for hand hygiene and nail care for Resident #89 |
| Certified Nursing Assistant #8 | Interviewed regarding care of Resident #89 and hand hygiene | |
| Director of Nursing | Interviewed multiple times regarding urine odor issue, ADL care, and infection control | |
| Director of Housekeeping | Interviewed regarding dumpster condition and garbage disposal | |
| Director of Dietary Department | Interviewed regarding dish machine temperatures, food safety, and garbage disposal | |
| Dietary Supervisor | Observed and interviewed regarding dietary staff hair covering and food handling | |
| Dietary Aide #1 | Observed and interviewed regarding food temperature checks and hygiene | |
| Dietary Aide #2 | Interviewed regarding garbage disposal practices | |
| Registered Nurse #6 | Observed and interviewed regarding wound care and use of enhanced barrier precautions | |
| Registered Nurse #7 | Interviewed regarding enhanced barrier precautions for wound care | |
| Infection Preventionist | Interviewed regarding implementation of enhanced barrier precautions | |
| Registered Nurse #2 | Observed and interviewed regarding failure to sanitize blood pressure cuff between residents | |
| Registered Nurse #1 | Supervisor | Interviewed regarding monitoring nurses for infection control compliance |
| Registered Nurse Educator | Interviewed regarding nurse education and competency on sanitizing equipment |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 11, 2022
Visit Reason
The inspection was a Recertification survey conducted to assess compliance with regulatory requirements including privacy, abuse reporting, MDS transmission, care planning, medication storage, and dental services.
Findings
The facility was found deficient in maintaining resident privacy and confidentiality, timely reporting of alleged abuse, timely transmission of MDS assessments, involving residents or representatives in care planning, secure storage of medications, and providing dental services for residents with missing dentures.
Deficiencies (6)
Did not ensure residents' personal and medical records were kept private and confidential; medication blister packs with identifying information were left unsecured in an unlocked office.
Failed to timely report suspected abuse involving a resident to the State Survey Agency within required timeframes.
Did not transmit a resident's Minimum Data Set (MDS) assessment to CMS within 14 days of completion.
Did not ensure that a resident and/or resident representative was invited to review the resident's plan of care with the interdisciplinary team during quarterly care plan meetings.
Did not ensure drugs and biologicals were stored in locked compartments; medication blister packs were observed unsecured in an unlocked office.
Did not ensure a resident with missing dentures was promptly referred for dental evaluation.
Report Facts
Residents reviewed: 39
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication storage, abuse reporting, and dental services deficiencies |
| RNSE | Registered Nurse Staff Educator | Used unsecured medication blister packs during orientation; unable to secure medication due to lack of office key |
| MDS Coordinator | MDS Coordinator (MDSC) | Interviewed regarding delayed MDS transmission |
| Regional MDS Coordinator | Regional MDS Coordinator (RMDSC) | Interviewed regarding computer glitch causing MDS submission failure |
| Social Worker | Social Worker (SW) | Interviewed regarding care plan meeting invitations |
| Social Worker Director | Social Worker Director (SWD) | Interviewed regarding care plan meeting invitation process |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) #1 | Interviewed regarding missing dentures of Resident #189 |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) #2 | Interviewed regarding responsibilities for identifying missing dentures |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jul 8, 2019
Visit Reason
The inspection was a Recertification survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including dignity and respect for residents, accommodation of resident needs, maintenance and environment of care, physician oversight of medications, staffing posting, food safety and temperature, and proper disposal of garbage and refuse.
Deficiencies (8)
Residents were observed dining at a table labeled 'FEEDER TABLE', which was deemed a dignity issue.
Call light was not kept within reach of a resident, impeding their ability to summon help.
Facility did not ensure a clean, comfortable, and homelike environment; issues included patched and mismatched wall paints, broken hand sanitizer canister, broken tiles, and leaking faucet.
Physician did not review resident's total care including medications and treatments at each required visit, leading to unnecessary medications.
Facility did not ensure that a Gradual Dose Reduction (GDR) was attempted for a resident prescribed psychotropic medication without behaviors supporting continued use.
Daily nurse staffing information was not posted in a prominent place readily accessible to residents and visitors.
Food and drink were not served at palatable and safe temperatures; sandwiches containing potentially hazardous foods were held at unsafe temperatures.
Garbage and refuse were not disposed of properly; uncovered garbage cans, foul liquid, and flies were observed in the outside garbage area.
Report Facts
Residents reviewed for Unnecessary Medications: 6
Residents sampled: 38
Temperature of tuna sandwich: 49
Temperature of pudding: 49
Temperature of no sugar added vanilla pudding: 46
Temperature of milk: 40
Temperature of stew: 152
Temperature of rice: 139
Temperature of vegetables: 151
Temperature of coleslaw: 36.2
Temperature of chicken salad sandwich: 47.7
Temperature of vanilla pudding: 35.2
Temperature of beef burger: 132
Temperature of mashed potatoes: 134.5
Temperature of carrots: 131
Temperature of hot water for tea: 122.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Qualified Dietitian | Qualified Dietitian (QD) | Interviewed regarding feeder table sign and meal service. |
| RN #2 | Registered Nurse on Unit B 4 | Interviewed about feeder table sign and resident seating. |
| CNA #1 | Certified Nursing Assistant | Interviewed about feeder table sign and dining room setup. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about feeder table sign and staffing posting. |
| Corporate Nursing Director | Corporate Nursing Director (CND) | Interviewed about feeder table sign and staff in-service. |
| CNA #3 | Certified Nursing Assistant | Interviewed about call bell accessibility for resident. |
| LPN #1 | Licensed Practical Nurse | Interviewed about call bell accessibility and rounds. |
| RN #3 | Registered Nurse | Interviewed about call bell accessibility and staff instructions. |
| RN #1 | Registered Nurse | Interviewed about maintenance requests and environment issues. |
| Housekeeping Associate | Housekeeping Associate (HA) | Interviewed about cleaning and maintenance reporting. |
| Director of Maintenance | Director of Maintenance (DM) | Interviewed about maintenance repairs and work orders. |
| CNA #4 | Certified Nursing Assistant | Interviewed about leaking bathroom pipe. |
| CNA #5 | Certified Nursing Assistant | Interviewed about leaking bathroom pipe and maintenance log. |
| RN #3 | Registered Nurse | Interviewed about maintenance reporting and follow-up. |
| Director of Maintenance | Director of Maintenance (DOM) | Interviewed about maintenance work orders and repairs. |
| Primary Medical Doctor | Primary Medical Doctor (PMD) | Interviewed about resident medication management and GDR. |
| Psychiatrist | Psychiatrist | Interviewed about resident medication dosage and GDR decisions. |
| Payroll and Staffing Coordinator | Payroll and Staffing Coordinator (PSC) | Interviewed about nurse staffing posting. |
| Regional Food Service Director | Regional Food Service Director (FSD) | Interviewed about food temperature and garbage disposal. |
| Consultant Registered Dietician | Consultant Registered Dietician (RD) | Interviewed about garbage disposal and refuse area. |
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